Neither Rain Nor Snow

My phone rang as I was driving to the Langham in Pasadena. Coris USA, a travel insurer, had another housecall. Since I was on the freeway, I couldn’t write, so I asked for the address, planning to collect the remaining information from the patient. I hate to be late, so I told the dispatcher I might not arrive for several hours. 

The Langham guest had a sore throat, an uncomplicated visit. I reached the Coris destination, a private house in Hollywood, an hour after the call. The gate in the surrounding fence was locked. The buzzer felt loose in its housing, giving the impression that it was broken. This seemed the case because no one appeared.

What to do… Usually I phone the patient, but I didn’t have a number. I considered phoning Coris, but whoever answered would ask for the patient’s name which I also didn’t have. She might or might not succeed in tracking down the original dispatcher, but it was guaranteed I’d spend a long time on hold in a chilly drizzle.

The railing was my height, and there were footholds. Passerbys certainly wondered at an elderly man in a suit struggling over a fence, but I succeeded without tearing my clothes.

The woman who answered the door denied that anyone wanted me. It turned out this was not a private house but a youth hostel. The woman consulted other residents; one remembered someone who wanted a doctor, but she had left. 

The resident didn’t have her phone number but offered to leave a message on Facebook. I called Coris to warn them that matters were not looking well.

Then the door burst open, revealing the patient, gasping for breath after running several blocks. The visit itself was uncomplicated. 

Three More Great Sins of the Medical Profession

4.  Doctors spend too little time explaining how to relieve stress.

     Probably… Stress makes everything worse but doesn’t cause anything. Seeing a doctor for stress results from what I call the “medicalization of society” - the notion that life’s difficulties (a hateful job, unsatisfying sex life, shyness) represent a medical problem. There’s no harm in this; a good doctor can listen sympathetically and make sensible suggestions which require no medical training.

5.  Doctors don’t pay much attention to diet, rest, exercise, and other natural methods of treating illnesses.

     True and proper. Diet, rest, etc. play an essential part in preventing disease but drop to minor roles once you get sick... A perfect example were tuberculosis sanitariums, the oldest government supported medical program. They began appearing in the nineteenth century. Patients received nutritious food and plenty of rest in a healthy, rural environment.  They were discharged (sometime after years) when their TB became inactive. No one was cured, and many relapsed. When drugs appeared after 1945 sanitariums vanished. Nowadays doctors encourage TB patients to eat a nutritious diet, but they’ll get better even if they don’t – provided they take their drugs.

6.  Doctors ignore alternative and folk medical practices.

     I notice enthusiasts treat folk medicine with respect, but no one advocates folk dentistry...

     In fact, many alternative practices work but less dramatically than advocates claim.  Acupuncture definitely relieves pain. Unfortunately, its action is unpredictable and not always complete. Despite vivid reports, Chinese surgeons rarely use it in place of anesthesia... Chiropractic manipulation relieves some backaches for a limited time.

     The better doctors handle a problem, the less you’ll read about “alternative” treatments. Your local health food store doesn’t sell an herbal remedy for appendicitis. Don’t laugh. Appendicitis is fatal; until a century ago victims died after weeks of agony. Then we discovered that snipping off the appendix (something any bright high school student can do) cured it. Today no one searches for an alternative treatment of appendicitis. 

     On the other hand, doctors don’t do so well treating obesity, arthritis, aging, or senility. So if you want to find an alternative remedy that doctors have stupidly ignored, you’ll find plenty.  Good luck with them.

Three Great Sins of the Medical Profession

We’re guilty of them all, but there are extenuating circumstances.

1.  Doctors give treatments that relieve symptoms but don’t cure the underlying problem.

     Sometimes this is the best we can do.  The cure for severe menstrual cramps is menopause, hysterectomy, or pregnancy.  Drugs only relieve the pain, but patients appreciate them.  No doctor cures migraine, asthma, emphysema, osteoporosis, or the flu, but we relieve a great deal of misery.

2.  Doctors order too many tests and prescribe too many drugs.

     Correct, but partly we’re responding to pressure. Most patients with a painful injury assume they need an X-ray, but they don’t.  Those with a high fever, sore throat, swollen glands, cough, or clogged sinuses assume they need an antibiotic, but they usually don’t.  Doctors hate to disappoint patients, so they lean over backwards to “do” something like order a test or prescribe.

3.  Doctors order too few tests and prescribe too few drugs.

     We can’t win.  Some clinics, hospitals, and insurance plans restrict tests and drugs doctors can order.  This infuriates doctors as well as patients, but the sad fact is that experts set up these guidelines to discourage needless tests and wrong or unnecessarily expensive drugs. Mostly, guidelines fail. Even the guilty doctors agree that we do too much.

I’ll reveal three more sins next time.

Taking Things Out of an Ear

Cleaning his ear, a guest removed the Q-tip and discovered that the cotton tip had disappeared.

Extracting objects from an ear is a satisfying experience everyone involved. Over thirty years, I’ve removed ten cotton balls and one bug.

Mostly, of course, I remove wax. I’ve done this 110 times. Using a sharp curette, one can scoop it out in seconds. Ear-nose-threat specialists use a curette, but I don’t have the nerve, having seen bloody results from attempts by other GPs. I use a large syringe.

All hotel rooms have an ice bucket. I fill it with warm water and set it on the bathroom sink. Warned they are about to get wet, guests remove expensive clothing, drape a towel over their shoulders, and lean over. After filling the syringe, I pull the ear back, rest the tip just inside the opening, and squirt. Most impactions require a dozen attempts or less. A few specks flowing out herald the great moment, and the plug itself may pause coyly at the opening.

“Get ready for the big show!” I announce before delivering the final spray. Guest invariably recoil with horror as a soggy brown lump, often the size of a kidney bean, flies into the sink.

Sometimes I pay a heavy price. Guests who work hard with a Q-tip (a device designed for pushing wax) confront me with a solid wall of material resting deep inside. Time passes as I refill the bucket and work the syringe. Water drips from the guest. My thumb aches from pushing the plunger. At intervals I stop, either because the guest begs for a rest or to peer inside with my otoscope to check the waxy wall, now glistening but stubbornly immobile. I often joke that when doctors die and go to Hell, they receive a syringe and a patient with an ear sealed with concrete.

During training, doctors learn a rule for procedures that aren’t working (difficult spinal taps, searches for slivers): keep trying. So I persevere, ignoring my throbbing thumb. On two visits, I stopped at the guest’s request. All other ear washes succeeded although a few exceeded fifteen minutes.

Taking Things Out of an Eye

Few actions bring a hotel doctor more pleasure than removing something from a guest’s eye. Patients have kissed my feet in gratitude.

It’s easy. With one hand, I lay a Q-tip horizontally across the upper lid. With two fingers of the other hand, I grasp the eyelashes and fold the lid back over the Q-tip, exposing its underside. That’s usually where a speck lies. Experts warn never to try to remove something on the eyeball itself, but I’ve never encountered this. 

This agreeable experience doesn’t happen often: thirteen times according to my records. Mostly, guests who think they have something in their eye are suffering a corneal abrasion. This was the case fifty-four times.

The cornea is extremely sensitive; injuries produce intense discomfort, but minor ones heal in a day or two. I prescribed antibiotic drops and an oral pain remedy. Patients yearn for the anesthetic drops I use during the examination, but they damage the eye when used regularly. No doctor should prescribe them.

The Same Thing

“My wife had strep last week. Now I have the same thing.”

I receive one “same thing” phone call per week. Naturally, guests hope I’ll agree.

This is not the traditional warning against self-diagnosis, because the guests are usually right. If necessary, I’m happy to phone a pharmacy with the appropriate prescription.

Everyone with an upset stomach suspects food poisoning. If your dinner companions are also sick, it’s a possibility, but if you’re the only one, you probably suffer the common stomach virus which makes you miserable for a day or two. Most guests with vomiting or diarrhea don’t want to travel to a pharmacy. For those willing, I sometimes provide symptomatic remedies. Sadly, in the US no common intestinal infection is curable with antibiotics.

Other illnesses are tricky, but a young woman who’s had several bladder infections knows when she has another. This is perhaps the only infection where it’s acceptable to prescribe an antibiotic over the phone.

Inevitably, respiratory infections produce the most “same thing” calls. These are stressful calls because many guests proceed to tell me what they need, and they’re wrong.

As I repeat with boring regularity, many doctors, perhaps a majority, prescribe useless antibiotics for viral respiratory infections. That includes yours. That doesn’t mean you have a bad doctor; prescribing useless antibiotics is so common that competent doctors do it.

When, after hearing the symptoms, I explain that this doesn’t describe anything that antibiotics cure, guests assume there will be no antibiotic unless I make a housecall and collect a fat fee. In fact, I do everything possible to avoid a housecall because not giving an antibiotic guarantees an unhappy patient. If I yield to his entreaties, I hate myself.

A Doctor's Routine

“Under your tongue… under your tongue… close your mouth… don’t bite!”

Seeing a thermometer, the guest had unbuttoned his shirt and lifted his arm. Over much of the world, doctors take a temperature in the armpit. It’s often a struggle to make them understand.

Once the thermometer is in place, I announce that I will wash my hands. This produces minor panic, and someone rushes to the bathroom to tidy up. After returning and announcing the temperature, I sometimes take the blood pressure. It’s not useful for most ailments, but patients, especially the elderly, often expect it.

After the examination, I announce the diagnosis and hand over an appropriate medicine. Then I give advice. You probably think it differs from patient to patient, but this is only partly true. I give several bits of advice regularly. These include:

“Rest doesn’t make this go away any quicker.”

Despite the universal belief, this is true for almost every illness, and it’s miserable to be confined to a hotel room during a vacation. I encourage sick guests to get out.

“You’ll feel bad for a few days, and then you’ll feel better.”

Once a doctor performs his magic, patients often expect immediate results. I receive plenty of calls the next day from guests wondering why they’re still sick.

“If you call, I answer in person.”

I demonstrate by holding up my cell phone. Of course, your doctor also encourages you to call, but have you tried? You reach voicemail or, if you’re lucky, a receptionist, and then you leave a message and wait. I want to spare patients this hassle. But I also don’t want them to call the hotel to let them know they’re not feeling better.

Jumping to Conclusions

Midafternoon is a slow time, so I take a history class at UCLA, and I’m rarely disturbed. But my phone buzzed.

“This is International Assistance about the patient you saw today. She has begun to vomit and wants another visit.”

That morning I had given ibuprofen to a woman with a headache. She was in Hollywood, a tedious eight mile drive through city streets with the rush hour beginning. After twenty minutes of stop-and-go, a sense of unease grew. Ibuprofen shouldn’t cause such a violent reaction. Then I remembered that the Hollywood patient was not from International Assistance but World Assistance.

International Assistance had called the previous night at 1 a.m. and sent me to the Airport Hilton for a guest suffering a backache. I’d given an injection and left strong pain pills for later. I checked caller ID on my cell phone and, sure enough, I’d jumped to the wrong conclusion.

The Hilton was in the opposite direction. It took another twenty minutes to reach the freeway and join the rush hour creep.