A Weird Letter from My Doctor

I take good care of myself, but the best life-style only postpones the inevitable.

I was seeing a cardiologist at the Pacific Heart Institute in Santa Monica. He was excellent. I would be seeing him still but for a strange letter I received.

Insurance companies and Medicare have been reducing payments, the letter began, and more cuts are threatened. In response other cardiology groups were lowering the quality of their care. Pacific Heart Institute vowed to maintain its standards. But how to do that while continuing to accept insurance?

The solution, according to Pacific Heart Institute, was an “Enhanced Access Program.” An accompanying sign-up sheet listed three levels of benefits.

For an extra $500 a year I could choose the “SELECT” level. Among its features were priority in appointments, prompt notification of test results, waiver of miscellaneous office fees, a special internet portal, and a customized wallet card with my EKG tracing.

$1800 per year would bump me to “PREMIER” status: same day appointments, direct e-mail and phone access to my cardiologist, and a free vascular risk assessment (whatever that is…).

At $7,500 a year (that’s not a typo), the deluxe “CONCIERGE” level gives 24 hour access to my “personal” cardiologist, same day visits, same day tests, and a call from my personal cardiologist to discuss results.

I could check a fourth box that merely stated “I choose not to participate… No fee.” The doctor would continue to see me if I decided not to pay up. It didn’t say he would consider me a cheapskate, but why wouldn’t he?

Paying extra to get the doctor’s attention is routine where doctor incomes are low. It was the norm in the old Soviet Union and remains so in Russia, China, and Eastern Europe.

American doctors are the world’s richest, but they didn’t get that way by ignoring sources of income. If you follow the news, you know that cash-only or “concierge” practices are a growing niche. They’re so popular that professional organizations such as the AMA have set up ethical guidelines. This strikes me as similar to setting up ethical guidelines for operating a Mexican cancer clinic, but mine is a minority view.

Seriously Burned

I awoke at my usual time, wrote for a few hours, ate breakfast, and went back to bed. Having made a wee-hour visit to a distant hotel, I was sleepy.

When business is slow, I take actions that encourage calls such as going to a movie or trying to take a nap. Unfortunately, this works when I don’t want it to, so the phone rang as I drifted off. It was a lady at the Custom hotel whom I’d seen the day before for a bad stomach virus. She was better and desperate to return home, but her insurance insisted on another exam before allowing her to travel. Making visits to guests who aren’t sick is a perk of hotel doctoring, and I was happy to comply.

Returning home I headed straight for bed, but the phone rang as my head touched the pillow. A lady at Le Parc explained that had undergone eyebrow waxing, and a clumsy cosmetologist had inflicted serious burns. I suggested that serious burns around the eye require more care than I could deliver on a housecall, but she demanded a visit.

I consoled myself with the knowledge that guests often exaggerate their problems. This proved to be the case when she showed me several pink spots over her forehead. These were mild, first-degree burns, I explained, similar to sunburn. I handed over a tube of soothing cream and assured her that they would heal completely in a week.

I was wrong, she insisted. Because of her extremely delicate skin, she would be scarred for life.

An Odd Foreign Custom

When I finish caring for American guests, I accept their thanks and money and then leave. With guests from another country, I often find myself discouraging them from accompanying me to the elevator or down to the lobby or (if it’s a private house) to my car.

I mentioned this excessive politeness to a colleague from South America.

“They probably thought you were in a hurry to get away,” he said.

When I protested, he explained.

“When I first came to the US and visited an acquaintance, I was disturbed when he shut the door behind me after I left. Did I offend him, I wondered. Is he happy to get rid of me….? In my country, you always accompany an honored guest when he leaves and make sure he is safely on his way. To stay behind is not courteous. But this is what Americans do.”      

Another Freebie

A guest at the Georgian hotel in Santa Monica wanted a housecall, said the desk clerk. She had a urine infection.

That was good news. The Georgian was not far, and urine infections are easy.

“The guest has gone to dinner,” the clerk added. “She’d like you to come at 9 o’clock.”

I hate it when hotels make an appointment without consulting me. I want to talk to guests before a visit. They need to know how much I charge and that they’ll have to pay directly. Learning this, some guests reconsider. A few guests assume the doctor is in the hotel, so it’s no big deal if they’re late or decide to skip the consultation entirely. Finally, it’s stressful to kill time at home, hoping another call doesn’t arrive to complicate matters.

Sure enough, at 8:30, as I was about to leave, the phone rang. A guest at the Airport Hilton was vomiting. Vomiters don’t like to wait. There was no way to contact the Georgian guest to suggest a delay, but I decided I could make the visit and reach the Hilton in an hour. I hurried off.

Freeway traffic stopped cold at my exit. Santa Monica was holding an arts festival. The streets were jammed.  Normally, I would park and walk the six blocks to the hotel, but this would make me outrageously late for the poor vomiter at the Hilton.

Guests usually agree to wait when I explain the problem. The Georgian guest was back in her room.

“I just flew in from London. There’s no way I can stay awake,” she said on hearing that I’d like to return later that evening.

In the end, I phoned a prescription for a urine infection into a nearby pharmacy and then drove to the airport.

Major and Minor Tranquilizers

Guests often ask for something to calm them, and I try to comply by stocking Valium.

Tranquilizers relieve anxiety but not the pain of a terrible event such as a family death. Unhappy victims regularly ask for something to “put me to sleep,” but only general anesthesia does that. Even sleeping pills merely produce drowsiness; if you’re miserable, sleep comes hard.

I give a Valium injection if asked, but I have a low opinion of its tranquilizing properties. Valium pills work better because the more you take, the drowsier you get. The effect of the maximum Valium injection does not impress me. I prefer Thorazine.

Valium and its relatives are minor tranquilizers; the Thorazine family belongs to the major tranquilizers. “Major” and “minor” have nothing to do with strength; they refer to the seriousness of problem they treat. Thorazine helps schizophrenia, a major mental illness. The first of a numerous class of drugs called phenothiazines, its US approval in 1954 marked a huge advance because it calmed schizophrenics enough so most could leave mental hospitals and live on the street, thus saving tax money.

People who deny that schizophrenia is a brain disease claim Thorazine works because it makes patients somnolent. In fact, many newer phenothiazines aren’t sedating but work as well. Thorazine and its family turn off the positive symptoms of schizophrenia:  hallucinations, delusions, bizarre behavior. Movie schizophrenics seem to enjoy themselves, but hearing a voice inside your head frightens most people even if it’s God.

Despite their dramatic effects, phenothiazines don’t cure schizophrenia because they don’t eliminate the negative symptoms such as apathy, social withdrawal, and self-neglect. Being around a well-behaved schizophrenic remains an uncomfortable experience. Something is missing.

Isn't Science Wonderful - Continued

As I wrote last time, doctors treat strep throat with an antibiotic. Does it work?

That seems a no-brainer because antibiotics definitely kill strep bacteria. But the answer turns out to be….maybe. In scientific studies, giving antibiotics to patients with strep throat is not dramatically effective. Some doctors suspect they don’t work. This contrasts vividly with treating strep infections in other areas such as the skin where it’s often obviously lifesaving.

“Wait a minute!!” assert experts including my professors in medical school. It’s true that strep throat goes away in three to five days even if not treated, but doctors must treat in order to prevent rheumatic fever, a disease that can produce devastating heart disease. Scientists don’t understand why, but a small percentage of strep victims go on to develop rheumatic fever. Antibiotics lower the risk.

Are they right? Again science delivers the answer: maybe. Evidence for preventing rheumatic fever in America comes from a study conducted sixty-five years ago when rheumatic fever was common. It’s rare now. I’ve never seen a case. Everyone agrees it wasn’t a terrific study.

Some doctors believe that rheumatic fever is so rare in the US that giving an antibiotic is more likely to cause harm (yes, antibiotics can cause harm) than benefit.

While it’s fun to make controversial statements in this blog, with patients I stick to the standard of practice. This means I sometimes give treatments whose scientific basis is weak. If you prefer therapy that’s guaranteed, you must stop seeing scientific practitioners like me and seek out alternative or complementary healers. Google “alternative medicine.”  You’ll notice that their treatments always work.

Isn't Science Wonderful!

“He has pus on his tonsils, so it’s probably strep,” said a guest, calling about her teenage son. I hear this phrase regularly. It causes me some stress because I know that later I might find myself delivering a why-antibiotics-won’t-help explanation to a sullen audience. 

One popular (i.e. wrong) medical belief is that pus on tonsils is a sign of strep throat. In fact, this is true only about ten percent of the time. Viral infections produce identical exudates.

Arriving in the room, I discovered that the boy had pus on his tonsils but also a fever, swollen, painful glands in his neck, and no cough. Good scientific studies show that the presence of these four signs: pus on tonsils, fever, swollen neck glands, and NO cough raise the odds of strep to over fifty percent, so prescribing an antibiotic is appropriate. I prescribed an antibiotic. The family made it clear they were in the presence of a doctor who knew his business.

Isn’t science wonderful? It is. But it’s wonderful in ways that are often not satisfying. More in my next post.