The No-Housecall Mode

Several times per year, a hotel guest suffers a bloody nose. I don’t make housecalls for nosebleeds because there’s nothing I can do. Treatment is to pinch the nose, releasing pressure every five minutes to check if bleeding has stopped. I tell guests to repeat until they get bored. If bleeding persists, the next step is cautery or nasal packing, both of which require expertise.

I regularly hear “I can move it, so I know it’s not broken…” but this is as true as most popular medical theories.  Examining a wrist, finger, ankle, foot, or ribs I can suspect a fracture, but I’m never certain. Most common fractures aren’t urgent, so I tell guests it’s OK to wait to see if there’s quick improvement. If not, they need an X-ray.

All insect bites look the same, bee stings included. Redness and itching spread, peaking at two days before slowly fading. I explain this over the phone, but guests often want me to take a look.

When a guest suggests he has bronchitis, I immediately go into no-housecall mode because this is a fake diagnosis doctors use when they prescribe an antibiotic as a placebo (other fake diagnoses are “sinus infection” and “bacterial infection” and sometimes “strep”). You may be surprised to read that bronchitis is not a disease but a medical term for coughing. 

Amazing Medical Maxims

What many laymen believe are serious signs are not.  Here are examples.

1. Local pain is worrisome; widespread pain is reassuring.

When a guest suffers abdominal pain, I ask to see where it hurts. When he or she indicates the entire abdomen, I relax a little. The common stomach virus produces widespread pain. When the patient’s finger rests on a small area, I worry about conditions like gallstones, appendicitis, or diverticulitis whose pain is usually localized.

2. One allergy can be serious; many allergies: not so much.

An allergy is a specific immunological reaction that can be fatal, but most drug reactions are not allergies. If a medicine upsets your stomach or gives you a headache that’s usually what we call “drug intolerance.” If you’re willing, it’s OK to continue it, something we never do with an allergy. However, doctors use “allergy” indiscriminately, and laymen add their own diagnoses, so many patients confront us with a long list of forbidden drugs, foods, and environment stuff. The major consequence is not illness but expense. If you say you’re allergic to penicillin (90 percent of those who say so are wrong), for example, an alternative costs fifty times more.

3. Things don’t turn into other things.

Mostly this comes up with viral upper respiratory infection (cough, congestion, sore throat, fever).  Everyone knows that antibiotics are useless for viruses, but if a doctor diagnoses a virus, many patients believe they’ve wasted the trip. This is where the maxim comes into play.

“If I don’t get something it turns into… “bronchitis…strep…pneumonia…a bacterial infection….”  It doesn’t. In otherwise healthy people, illnesses don’t change into other illnesses, and experts persistently warn doctors that giving antibiotics to prevent complications is positively harmful. They wouldn’t keep warning us if we didn’t keep doing it.

No Income Today

A guest dropped an ice bucket on her toe. Pain was excruciating, and blood oozed out. Holding the toe under the tap didn’t help.

Over the phone, I explained that running water won’t stop bleeding. She should apply pressure and add ice to dull the pain. When I called an hour later, she was having dinner in the hotel restaurant.

A man had developed a slight cough, in his opinion a prelude to full-blown bronchitis. He wanted something to knock it out. I explained that, in a healthy person, viruses cause almost all coughs. I could come, but I couldn’t promise an antibiotic. The man said he would get a second opinion.

A toddler bumped his head against a bedpost and developed a lump the size of an egg. He felt fine, but the parents asked that I check him for brain injury. That requires a CT scan, I explained. He would certainly get one if he went to an emergency room, but the injury didn’t seem serious enough for that. It was OK to wait.

A guest had missed his flight because of an upset stomach. He was well now but needed a doctor’s note to avoid an expensive ticket-exchange fee. These requests put me in a difficult position. I can’t write “The patient was unable to travel because of an upset stomach” because I don’t know if that’s true (sometimes the patient admits that it isn’t). So I offer to write the truth: “The patient states that he suffered an upset stomach and could not travel.” I sweeten the pot by offering to fax it to the hotel at no charge.

Guests usually accept. To date, no one has complained, so it’s possible that the note works.

Good Doctors Do It

“I’m coughing my head off. My head is plugged. I have a fever. I’m on vacation, and I need something.”

I’ve seen over 4,000 guests with respiratory infections. To the average hotel doctor, this is an easy visit. He arrives, performs the traditional exam, prescribes the traditional antibiotic, and accepts his fee and the guest’s thanks. What’s not to like?

That the antibiotic is unnecessary doesn’t bother the doctor, but it would bother me. Despite my colleagues’ insistence that patients demand an antibiotic, most of mine don’t. A small minority appear disappointed when I don’t prescribe one, and a tiny number make it painfully clear that I’ve missed the boat.

For decades, solemn editorials in medical journals have urged us to stop prescribing useless antibiotics, warning that they’re poisoning the environment, producing nasty, drug-resistant germs that are already killing thousands. 

Despite this, giving antibiotics for viral respiratory infections remains almost universal. Almost every doctor whose prescribing habits I know – admittedly a limited sample – does it. None believe they help. All tell me that patients expect them.

“I don’t want an antibiotic if I don’t need it,” patients often tell me. “But how do I know?”

“You don’t, but bacterial respiratory infections are rare in healthy people.”

“What if it’s bronchitis? I get that a lot.”

“Antibiotics don’t help bronchitis.”

“That’s what my doctor gives me. Are implying he’s incompetent?”

“No. Prescribing unnecessary antibiotics is so common that one could call it the standard of practice – meaning competent doctors do it.”

Medical Myths That Doctor's Believe

Here are myths that most laymen take for granted. A more serious problem is that many doctors also believe them. 

1.  If it hurts, it needs an x-ray.

Excellent for detecting fractures, X-rays are surprisingly unhelpful in other painful conditions.  Almost everyone suffering an excruciating headache, backache, bellyache, or hacking cough wants to know what’s going on inside, and they assume that, like Superman’s X-ray vision, a film reveals this, but it doesn’t.

2.  If your sputum turns green you need an antibiotic.

Your respiratory tract produces a quart of mucus every day.  When irritated, it produces more and the sputum may turn yellow, green, or brown. In an otherwise healthy person, this has no significance.

3. If one medicine isn’t working, you need a better medicine.

Understandable in a layperson but doctors should know better. In medical school, students are drilled in the rule:  if a drug isn’t working, switching is almost never the solution. Find out why the patient isn’t improving. It’s more likely that the diagnosis is wrong.

4.  Spicy food irritates your stomach.  Fats are hard to digest.  Tasteless and colorless (i.e. bland) food is soothing.

All proven false by good studies. 

5. High blood pressure causes headaches or dizziness.

Ordinary high blood pressure causes no symptoms.

6. Bronchitis requires an antibiotic.

Almost anything that causes coughing can be called “bronchitis.”  The most common is a viral infection; antibiotics don’t work.

7. Injections work faster than pills,

Sometimes, sometimes, not.  Doctors can charge for an injection. If they write a prescription, the pharmacist gets the money.

Addicted to Gratitude

“You saw me at the Marriott yesterday. I still don’t feel good.”

“I’m sorry,” I said. “I did mention that you’d be under the weather a few days.”

“I still have a temperature. The Tylenol only works a few hours. The cough medicine isn’t doing much. I need something stronger.”

“I would love to make you better, but, as I explained, there’s no cure for these respiratory viruses.”

“What if it’s bronchitis? My doctor tells me I have a lot of bronchitis.”

“‘Bronchitis’ is just another word for coughing. It’s a virus that runs its course.”

“I guess I just have to be sick. Thank you, Doctor Oppenheim,” she said before hanging up. There was sarcasm in her tone. I felt bad.

I also felt a surge of anger at my fellow doctors, most of whom prescribe antibiotics for viral infections. No doctor believes they work, but prescribing them guarantees a patient’s gratitude; doctors are addicted to your gratitude. 

My practice is to prescribe antibiotics when they’ll help and to not prescribe them when they won’t except when it’s clear that the patient will blow his top if I don’t. This turns out to work pretty well. About ninety percent of patients seem genuinely grateful. Most of the remainder are dissatisfied, but they remember their manners. Perhaps one percent make it clear that I have failed them.