Losing Two Out of Three

A guest at the Hollywood Heights with an upset stomach requested my services. I had barely hung up when an Englishman at the Shangri-La wanted a doctor for a respiratory infection. These hotels were not convenient – the Hollywood Heights is ten miles east, the Shangri-La in Santa Monica five miles west. But two visits make for a good day, so I drove off in a pleasant mood.

As I approached Hollywood, the phone rang. My heart sank when I learned the caller was the Sheraton in Pasadena, twenty miles away – thirty from Santa Monica.  
  

Having visits pile up, especially those with long drives, oppresses me, so this was one I’d prefer to skip.

This guest’s husband, who was driving to the hotel from the airport, was suffering a cough and sore throat and wanted a doctor when he arrived. Launching my no-visit effort, I explained that viral infections cause these symptoms in almost all cases, so a doctor can do little except relieve symptoms. I suggested that she discuss this with her husband when he arrived. She agreed. With that weight off my shoulders, I continued on to the Hollywood Heights.

After finishing, I reversed my course and headed for Santa Monica. As I neared the hotel my phone rang. “A friend of mine found a bottle of amoxicillin,” said the Shangri-La guest. “I think I’ll give it a try and save you the trip.”

Having lost that visit, I immediately called the Pasadena Sheraton. The husband had arrived, and they had decided to wait.

An Unwelcome Visitor from the Past

A young man at the Chateau Marmont had been coughing for two weeks. He had a fever, and my stethoscope revealed lung noises typical of pneumonia.

I enjoy diagnosing pneumonia because, in an otherwise healthy person, it’s the only common illness with a cough that doctors can cure. Everything else is a virus. 

I didn’t like this particular diagnosis. It takes a tough germ to cause pneumonia in most people, so unpleasant symptoms begin quickly. This man’s cough had persisted for some time. Furthermore, he was gay and admitted to having unprotected sex. I suspected that he had a pneumocystis infection. Pneumocystis is a fungus so benign that it lives in the lungs of most of us, causing no trouble.

Until forty years ago, it was rare, affecting patients already sick with cancer or serious diseases requiring drugs that suppressed immunity. Doctors were mystified when Pneumocystis began attacking previously healthy young men during the 1980s. It turned out to be the most common sign of AIDS.

It’s rare again today because we track immune cells of HIV patients and prescribe preventive drugs when the numbers drop. This young man had not been tested, but he was no fool. He cut short his visit and returned home.

Lost in Translation Again

“Bom dia” said the woman who opened the door.

“Bomn dia,” I responded. That’s the limit of my conversational Portuguese. My heart sank as I looked around the room which contained a toddler but no adult male. When I see a couple from a foreign country, the husband is likely to speak some English.

The mother pointed at her child, made coughing noises, tapped his chest, and produced a thermometer which she waved significantly. Once she understood that I needed more information, she took up her cell phone. 

After some effort because her husband was in a meeting she delivered a long recitation before handing me the phone.

I heard “He have cough. He have flu. He need medicine.”

In response to my question, the father insisted that this was everything she had said, but I knew he was summarizing. I asked more questions and received short versions of her long answers. The child looked happy and not at all sick, and my examination was normal. He had a cold. He’d coughed for four days and might cough for a few more, I explained. She was already giving him Tylenol, and no other medicine is safe for a two year-old. Luckily, he didn’t need medicine or bed rest or a special diet. It wasn’t even necessary to stay in the room.

If I had handed over a bottle of medicine, every mother from Fiji to Mongolia to Nigeria would understand that I was behaving like a doctor. But I wasn’t. What was going on?

I’ve encountered this hundreds of times, so I work very, very hard to communicate that the child has a minor illness (husband’s translation: “Doctor says child is OK…”), that no treatment will help (husband’s translation: “Doctor does not want to give medicine…”) and that being stuck in a hotel room is boring, so she should try to enjoy herself (husband’s translation: “Doctor says go out; child is OK…”).

Tap, tap, tap…. The mother beat a tattoo on he child’s chest in a wordless appeal. Everyone knows that a sick child must be confined and given medicine. Why did the doctor keep saying that he wasn’t sick?

I repeated my reassurance, and the husband translated. When, at the end, I asked if she understood she knew the proper answer: yes. She remembered her manners as I left and thanked me effusively.

I left feeling as discouraged as the woman. She was in a strange country, trapped in a hotel room with a sick child. Despite her best efforts, the foreign doctor didn’t understand that her son needed help.

I Don't Like Coughing

“I’ve been hacking up stuff for a couple days, and it’s turning green.”

“It sounds like the virus that’s going around,” I said. “It’ll last three or four or five or six more days. Medical science doesn’t do anything dramatic.”

“At home I’d tough it out. But I have meetings all week, and I need something to knock it out. When can you get here?”

If you read this blog you know my heart sinks when I hear “I need something to knock it out….” It guarantees an unsatisfying visit. Either the guest will feel resentful if he doesn’t get an antibiotic, or I’ll give an antibiotic (if it seems like he’ll blow his top, and sometimes I’m too slow), and I’ll leave hating myself.

Now, readers, you’re probably thinking: “Yes, isn’t it disgraceful that doctors give useless antibiotics so often that patients expect them. But sometimes you need an antibiotic. How can you tell?...”  The answer is so surprising that you and your doctor may not believe it. In an otherwise healthy person (infants and the elderly excepted) the only common disease with a cough that antibiotics cure is pneumonia. Everything else is a virus. ..in my opinion (my lawyer insisted I add that).

Be Careful What You Ask For

He had been coughing for several days, a guest explained, adding that he probably needed a Z-pak. When a patient suggests he needs an antibiotic, a doctor feels one of two emotions.

(1) Pleasure because this guarantees an easy visit. Give the antibiotic, and the patient will make it clear that the doctor has done what a good doctor does. I doubt most of you realize the importance of your gratitude. No matter how you try to conceal it, if you’re disappointed, we feel depressed.

(2) Depression. In an otherwise healthy person, the only common illness with a cough that antibiotics cure is bacterial pneumonia which is not common. All others are viral infections. These affect fifteen percent of everyone who consults a doctor, so they are no trivial matter.

Over the phone, I quizzed him about his symptoms and then explained that he was suffering a self-limited illness requiring only over-the-counter remedies. When he insisted that he needed a doctor, I directed him to a nearby urgent care clinic where he would get his antibiotic.

Lost In Translation

“Bom dia” said the woman who opened the door.

“Bom dia,” I responded. That’s the limit of my conversational Portuguese. My heart sank as I looked around the room which contained a toddler but no adult male. Among foreign couples, the husband is much more likely to speak English.

The mother pointed at her child, made coughing noises, tapped his chest, and produced a thermometer which she waved significantly. Once she understood that I needed more information, she took up her cell phone. 

After some effort because her husband was apparently in a meeting she delivered a long recitation before handing me the phone.

“He have cough. He have the flu. He need something. She wants you to examine him.”

In response to my question, the father insisted that this was everything she had said, but I knew he was summarizing. This is a chronic problem with amateur interpreters. I asked more questions and received short versions of her long answers. The child looked happy and not at all sick, and my examination was normal. He had a cold. He’d coughed for four days and might cough for a few more, I explained. She was already giving him Tylenol, and no other medicine is safe for a two year-old. Luckily, he didn’t need medicine or bed rest or a special diet. It wasn’t even necessary to stay in the room.

If I had handed over medicine, every mother from Fiji to Mongolia to Nigeria would understand that I was behaving like a doctor. But I wasn’t. What was going on?

I’ve encountered this hundreds of times, so I work very, very hard to communicate that the child has a minor illness (husband’s translation: “Doctor says child is OK…”), that no treatment will help (husband’s translation: “Doctor does not want to give medicine…”) and that being stuck in a hotel room is boring, so she should try to enjoy herself (husband’s translation: “Doctor says go out; child is OK…”).

Tap, tap, tap…. The mother beat a tattoo on he child’s chest in a wordless appeal. Everyone knows that a sick child must be confined and given medicine. Why was I implying that he wasn’t sick?

I knew what she was thinking. I repeated my reassurance, and the husband translated. When, at the end, I asked if she understood she knew the correct answer: yes. She remembered her manners as I left and thanked me effusively.

I left feeling as discouraged as the woman. She was in a strange country, trapped in a hotel room with a sick child. Despite her best efforts, the foreign doctor didn’t understand that her son was sick.