Japanese Never Travel Alone

The room contained four young Asian men and extra beds, on one of which lay my patient looking miserable with a wet washrag on his forehead.

At my first question, several pulled out Japanese-American phrase books, a bad sign. It’s a fact that all Japanese study English in school, but all Americans study American history, and how much do they learn?...

Answers to my questions were on the order of “please perform a diagnostic evaluation” or “the reading of the thermometer seems excessive.” I had reluctantly decided to call their travel insurer’s 800 number (phone interpreting is tedious) when the tour leader entered. His English was rudimentary, and, being Asian, he was too polite to tell me when he didn’t understand, but I managed to confirm my suspicion that the young man had influenza, not life-threatening but a terrible illness for young people who take for granted they’ll never be ill.

Disappointment

Loews guest was suffering flu symptoms, but mostly he worried about his temperature. I explained that the fever was not an ominous sign. If he wanted to check, he could buy a thermometer. Or I could come to the hotel. He opted for the visit. I told him how much it would cost.

“Oh… I thought it was free,” he said.

I’d heard that before. Your doctor doesn’t answer when you dial, but I do. Naïve guests think I’m downstairs awaiting their call.

He was from Chile. Did he buy travel insurance before coming to the US, I asked. He did. I explained that travel insurance pays for housecalls, and most insurance agencies call me. However, he must phone the insurance first to obtain approval. He promised to do so. 

Half an hour later my phone rang. It wasn’t Loews but the Doubletree. An elderly man had undergone electrical cardioversion for atrial fibrillation – an irregular heartbeat – a month earlier, and he was worried. His heart didn’t feel right. I asked him to count his beats; he counted 80 per minute. That is not particularly fast. I assured him that he wasn’t describing anything dangerous. He wanted me to check him.

These are the best visits. A guest is worried, and I’m already convinced that there’s nothing to worry about. Sure enough, the exam was normal. He was delighted at the news, and I was delighted to deliver it. Everyone was happy.

I was even more delighted to drive to the Doubletree because it’s only a few blocks from Loews. At any minute, I expected a call from the Loews guest’s insurance agency for another easy visit. But it never came.

Humor in Medicine

I had cared for a ten year-old with fever who had vomited twice. It was the usual stomach virus that might last a day. I reassured his mother and gave anti-nausea pills.

“I’m concerned about his fever. How often should I measure it?”

“Whenever you want.”

“I’m not comfortable with that. How often?”

“Are you worried about his fever?” I asked.

“Of course.”

“In that case don’t take his temperature.”

This is my usual drole response to patients frightened by fevers. It startles them, but my explanation reassures them. This lady was not startled but offended.

“I work in the medical profession, doctor, and that is dangerous advice.”

“Actually not.” I explained that when otherwise healthy people get seriously sick, they look sick. If they don’t look sick, they’re probably not sick, and having a fever doesn’t change matters. Infants and the elderly are exceptions; otherwise this is a good rule. People worry too much about fevers.

“I’ve heard different. Fever can kill.”

“You see life-threatening fevers in diseases like meningitis and rabies, but these patients look very bad. I haven’t seen a life-threatening fever in thirty years. Sick people look sick. Make your decision on calling a doctor on that basis. Never mind the fever.”

“We’re done here.” She held out her credit card.  

The Evils of Common Sense

Everyone yearns to understand their medical problem. In the absence of evidence, they use common sense which turns out to be a terrible way to get at the truth. It’s a good rule that any common sense explanation of a medical problem is wrong. Here are others that I hear all the time.

“I can walk on it, so I know it’s not broken.”

It turns out that the fibula, one of two bones in the lower leg, doesn’t bear weight. You walk on your tibia.

“I can move it, so I know it’s not broken.” You may know, but I’m not so sure.

“I have to let this run its course…”

Seeing smoke pour out of your car’s exhaust, no one explains that the engine is repairing itself by expelling bad things. Yet plenty of patients believe vomiting or diarrhea is the body’s attempt to cleanse itself. In fact, it’s a malfunction. It’s OK to suppress it although exceptions exist for a few serious diseases.

“Fever is your body’s way of fighting an infection.”

Google “does fever treatment help” for an avalanche of praise for fever's healing properties from doctors and medical sites as well as laymen – a good sign that it’s nonsense.

Here are questions that you might ask.

1. In what specific infections is lowering the fever harmful? I can’t think of any.

2. What infections do doctors treat by giving patients a fever?  The answer is none (doctors tried this about a century ago, but it wasn’t helpful).

3. Every day, across the world, a hundred million people take medicine for fever. How many end up at the doctor who explains that they made the problem worse?

Worry, Part 2

I drove to the Magic hotel in Hollywood where a Danish couple’s 18 month-old was vomiting. He looked fine, and looking is essential:  sick children look sick. Nothing abnormal turned up on an exam, so my diagnosis was a common stomach virus. I told the parents it might last a few days and gave the usual dietary advice.

I check on patients before going to bed, but the Danish parents beat me to it. The child had vomited once again, they reported. He was still in no distress, so I told them it was OK to wait.

My assurance was proper, but patients occasionally deliver unpleasant surprises, so I worried a little as I went to bed.

I phoned the Danes the following day to learn that the child hadn’t vomited but was now feverish. This was to be expected, I explained, and I approved their decision to give Tylenol.

The Danish child was still feverish, his parents reported the next day, and now he had diarrhea. I gave dietary advice.

There was no answer the following morning. From the front desk I learned that they had checked out. I had just returned from seeing a young man with abdominal pain at a youth hostel. He was worried about appendicitis; my exam made that unlikely. Since he had no health insurance, I did not want to make my life easier by sending him to an emergency room where a workup including CT scans would run to about $5,000. His symptoms hadn’t improved when I called, but they still didn’t seem like appendicitis. He promised to phone if there was any change. I worried a little as I went to bed.

Phrases Patients Love to Hear, Part 2

4.  “Staying in bed won’t make this go away any faster.”

Many laymen believe illness requires rest. They skip work or school. Mothers go to great (and futile) length to keep children immobile. Travelers waste days in a boring hotel room. This myth is so universal that when I reassure non-English speaking guests, I ask them to repeat what I’ve just said. Almost always, they miss the negative.

5.  “The fever (or vomiting or diarrhea) won’t harm you.”

Temperature by itself - even to 104 - won’t damage a healthy person.  Patients should pay attention, but they needn’t worry that death is near. When patients ask for a genuinely dangerous temperature, I answer “over 105,” but this is less helpful than it sounds because at this level, patients feel very bad. Similarly, healthy laymen fear that a few episodes of vomiting or diarrhea will produce serious malnutrition.

6.  “You’ll feel under the weather for a few days; then you’ll feel better.”

Patients may suffer for a week, but once they see a doctor, they want things to move quickly, so I warn guests that this might not happen. In my experience, if I neglect this, patients become concerned if they’re not feeling better the next day and take advantage of #3.

7.  “It’s not your fault.”

All our efforts at patient education plus the popularity of alternative medical theories have convinced Americans that they are responsible for getting sick. This is occasionally true but mostly not.