I Resist Temptation

A businessman at the Hilton-Garden Inn asked a pharmacist to recommend a cream for his insect bites. To his alarm, the pharmacist informed him that what looked like insect bites might be Lyme disease and that he should consult a physician.

This provided another delicious temptation in the life of a hotel doctor. I could make a housecall, assure the man he did not have Lyme disease, and collect my fee. He would feel vastly relieved and grateful. Everyone would be happy.

The businessman described half a dozen itchy pimples around his ankles. Even over the phone, it was obvious that they were insect bites. I reassured him, and he was relieved and grateful, but no money changed hands.

We Yearn to Help

If a prescription gave you diarrhea or made you vomit, you might complain. But until well into the twentieth century, the average American looked on a good “purge” as a way to expel disease. Physicians took pride in their cathartics, and when patients discussed a doctor’s skill, they gave high marks for the violence of his purges.

Nowadays Americans frown upon purging, but we seem to expect a medicine. It should be one only a doctor can prescribe; over-the-counter drugs don’t count. Pills are good, but an injection is better. Of course, modern drugs often work, but this is a minor matter compared to the deep human desire that a doctor do something.

I apologize if this sounds mildly insulting; I suspect most of you will deny expecting a drug. You want whatever will help. If nothing will help, you want to know.

Such sensible patients do appear, but no day passes when I don’t see disappointment in a patient’s eyes when he or she realizes I don’t plan to “give them something.” 

Doctors genuinely want to help you, and we feel bad when we can’t. We also feel bad when we do our best, and it’s obvious a patient doesn’t feel “helped.” So many of us add a prescription to convince you that we’re doing what a proper doctor should do.

Three More Great Sins of the Medical Profession

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

Correct. We love tests, but so you. Most patients with a painful injury assume they need an X-ray, but they don’t.  Those with a high fever (“flu”), sore throat (“tonsillitis”), cough (“bronchitis”), or stuffiness (“sinus infection”) 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.

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

We can’t win.  Some clinic directors and insurance plans restrict the tests and drugs we can order. This infuriates doctors as well as patients, but the sad fact is that experts set up guidelines to discourage useless tests and wrong or unnecessarily expensive drugs. They sometimes work.

6.  Doctors ignore alternative and folk medical practices.

I notice enthusiasts treat folk medicine with respect, but no one advocates folk dentistry...  It turns out that 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 for anesthesia. Chiropractic manipulation relieves some backaches for a limited time.

Laying Over

In the old days, airlines called me directly to care for crew laying over in Los Angeles. I enjoyed those visits because patients are mostly young and rarely seriously ill.

Since then they have given responsibility to an independent agency which contracts with a national housecall service. The housecall service calls me. I collect the same fee, but it costs the airlines triple what they once paid. I am too old to question their logic.

Hotels compete to put up crew, offering discounts. Always searching for a better deal, airlines often change places. Long ago they stuck to lodgings near Los Angeles Airport eight miles away. In another mysterious deterioration from former times, crew now mostly stay in wildly distant hotels. 

During a recent visit, I traveled to the Long Beach Hilton, thirty-five miles away, to care for a Virgin-Australia flight attendant with an earache. As usual, delivering care was the easiest part. Afterward I filled out a form required by the housecall service plus another form from the airline containing many identical questions followed by another airline form to determine when the flight attendant could work or return home as a passenger. 

A Near Miss

No one came to the door after several knocks.

I had spoken to the guest an hour before and announced my arrival time. Taking for granted that doctors are never early, some guests wander off, but I wasn’t early. This was serious. Unlike the case when a travel insurer sends me, when guests call and vanish, I don’t get paid.

Some guest sleep soundly. I phoned the room; no one answered. I called the concierge to ask her help; before I could interrupt she cheerfully offered to phone the room and hung up. She came back on the line a minute later to announce that, sadly, the guest hadn’t answered, but she would be happy to take a message.

Sticking my business card in the door frame, I returned to the lobby and wandered about. Occasionally, for mysterious reasons, guests decide they must meet me downstairs. I look like a doctor in an old movie with a white beard, suit, and doctor’s bag, but no one took the bait.

I struck gold in the hotel restaurant where a man leapt up from a crowded table and hurried over. He began reciting his symptoms until I suggested we wait for some privacy.

When asked why he wasn’t in his room, he answered that he was hungry but that he had “told the hotel” where I could find him. He pointed to a desk clerk who was busy checking in a family.

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. 

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).

I Like Vomiting

A businessman at the Standard had been throwing up since the wee hours. I assured him I’d arrive within the hour. It was nine a.m., so the usual half-hour drive downtown might last longer.

Before leaving, from my medication closet I extracted a syringe, a packet of antinausea pills, and an antivomiting suppository and dropped them into my pocket. This enabled me to avoid restocking my bag after returning home. Sometimes I forget.

The drive was tolerable. The guest was miserable, but he hadn’t vomited in two hours, so I suspected he was over the worst. I left feeling good. I like vomiting.

People chuckle to hear this, but in an otherwise healthy person, most episodes don’t last long, rarely more than a day. My medicines help symptoms but don’t speed recovery. When guests feel better, often by the time the medicine wears off, they believe I've cured them. He felt better by evening.

A Stressful Life

I’m running low on ondansetron, the best antinausea pill.

Unfortunately, I’m not low on many other supplies. I buy through an internet pharmaceutical company that charges a fat handling fee for orders under $200. Eight bottles of ondansetron, 240 pills, will cost $25. I could use more tongue depressors, but 500 at $5.24 is not much help. I dispense large quantities of  cough medicine and lidocaine gargle for sore throats, but those cost only a few dollars a piece. My bottle of 500 Amoxicillin capsules ($28) is half empty; stocking up would help but medicines have expiration dates, so one must be careful.

A few years ago, after thirty years of use, my blood pressure cuff broke, but I had a spare. Should I buy another? Will I be practicing when I’m 108?....

One of my boasts is that, unlike other hotel doctors, the fee I announce is the fee I collect. I don’t charge extra for anything. It turns out that pills, injectables, and supplies for common ailments are so cheap that I struggle to assemble an order exceeding $200. Life is tough.

Dealing With Buenos Aires

“Can you make a visit to Palo Alto?”

“That’s four hundred miles away!”

“How much would you charge?”

“I’m in Los Angeles. Do you understand?”

“Yes. How much would you charge?”

In fact, she didn’t understand. To save money, many travel insurers have closed their US offices, so this call originated from the patient’s home country. Inevitably, dispatchers in Buenos Aires don’t speak English as well as their former colleagues in Miami. I carefully explained that the distance made a visit impossible.

Unlike American travel insurers who require clients to pay up front and submit a claim, South American insurers send a doctor and pay me directly. I’ve made over two thousand visits for them. They’re among my favorites because patients who don’t pay directly are less demanding. Also, these insurers send me to hotels that don’t call or, even better, to my competitor’s hotels. A downside is that, if I don’t listen carefully, they send me to the wrong address. In Spanish “v” and “b” have identical sounds; so do “y” and “ll.”  

Then there was the time an insurer called at midnight.

“Can you make a visit to Culver City tomorrow?”

“Yes… But why did you call so late?”

“Because it says on your profile that you are available 24 hours.”

Traffic

Bending over, a guest at the Georgian felt stabbing pain in his back. He could barely move.

Acute back pain usually doesn’t last long, so, over the phone, I assured him that he would be disabled for a day and then gradually improve. I was not anxious to make this visit because it was 4 p.m. I would be driving to Santa Monica and back during the rush hour, a tedious experience. But he wanted a visit.

It was a tedious drive, not improved by the sight of immobile traffic on the opposite side of the freeway. The guest answered the door himself, always a good sign in someone with back pain. I examined him, repeated what I had said over the phone, and handed over pain medication; it was an easy visit.

Returning, I settled into the rear of a nearly motionless stream of cars. I was in no hurry; it was suppertime, but I wasn’t hungry. After ten minutes, my phone rang. A guest at the Crowne Plaza in Beverly Hills asked for a doctor. His wife was vomiting.

I often delay visits, but people who are vomiting hate to wait. This would normally be a quick drive because the Crowne Plaza was only five miles away, and I was headed in that direction. But it was the rush hour. I left the freeway and crept for thirty minutes along Pico Boulevard to the hotel. The visit went well, and the drive home was tolerable.

Going to Disneyland

A child at the Disneyland Hotel had a fever. Disneyland is forty miles away, but the call arrived Sunday morning. Freeway traffic was light; a perfect time for a long drive.

It was nearly noon when I greeted the parents and three other children. Being stuck in a hotel room with a sick child was not part of their plans, so all looked depressed. The child had a fever and cold symptoms but did not seem ill. I explained that children catch half a dozen viral infections every year; they last from a few days to a week or two; one can treat the symptoms, but there is no cure. Rest does not help.

“You mean we can go to Disneyland?” asked the father.

“Saying in bed doesn’t make it go away quicker.”

The family erupted in cheers and followed me out the door.   

A Delightful Bonus

The patient was a Brazilian two-year old who may or may not have had ear pain. Infants love everyone, and older toddlers are usually frightened enough to hold still, but from one to three years of age, children who don’t like doctors are uncontrollable. Taking a temperature in the armpit required the parents to hold her down. I dreaded the ear exam.

There was a knock on the door, and an elderly gentleman entered. This was the child’s grandfather, I learned as we shook hands, and he was a pediatrician. Immediately I held out my otoscope which he accepted with thanks. 

The entire family piled on; the child screamed and fought as the grandfather looked in her ears and forced open her mouth to examine her throat. He spoke little English but made it clear that nothing abnormal had turned up. He delivered an elaborate explanation to the family in Portuguese. I handed over a bottle of Tylenol, and everyone was happy.  

Why Do I Get So Many?...

Everyone thinks he or she has a weak spot. “My kidneys are weak...” “I have a tendency to strep...” “My resistance is low...” In fact, most recurrent complaints are not your fault.

Colds (or other viral infections such as bronchitis, tonsillitis, flu) are contagious diseases. You catch them from another person. They are not caused by chilly weather, wetness, stress, poor nutrition, or a weak immune system.

Backaches happen because our skeleton is defective. Animals walked on four legs for hundreds of millions of years. Humans stood erect a few million years ago, too soon for evolution to correct matters, so back muscles are too weak for the extra work, and our spine is not built to carry so much weight.

Bladder infections plague young women. Many suspect something is wrong, but this is rarely the case. In young adults, these are caused by germs that normally live around the genitalia. Young men suffer much less often because having a penis gives germs much further to travel to reach the bladder. Men catch up after middle-age when their swelling prostate obstructs urine flow.       

Bruises.  Black-and-blue marks occur after an injury. Rarely, they are the sign of a bleeding disorder, but in young women bruises often appear for no reason at all.

 

Flatulence is usually a sign of good health. Humans digest protein and fat easily, so very little reaches the colon. Carbohydrates are another matter; a person who eats a great deal of grain, vegetables, and fruits delivers plenty of undigested carbohydrate to colonic bacteria that feed on it, producing gas.

Age spots become tiresome if you or your doctor don’t take them seriously. They begin around age forty as small brown spots. A quick freeze with liquid nitrogen makes them vanish with no scarring. If ignored, they never go away. They enlarge; some become thick and wart-like; others appear. Eventually there are too many to treat.

Allergies tend to appear in childhood. Most reactions that adults call allergies are something else. If a medicine makes you ill, that’s probably what doctor’s call “drug intolerance,” not an allergy. This is not splitting hairs. A drug allergy can kill you; drug intolerance is merely annoying. Most stuffy noses are not allergies. Neither are most rashes or upset stomachs.

A Difficult Night

People blame an upset stomach on their last meal, but mostly these are viral infections. Although miserable, they rarely last long. Doctors enjoy short-lived illnesses because we get the credit when they go away.

The guest hadn’t vomited for several hours and was already feeling better. As I was congratulating myself on an easy visit, I heard the unmistakable sound of retching from the bathroom. This was her husband, the woman explained, adding that her mother and two year-old were also ill.

When the husband appeared, I took care of him. Unlike his wife, he welcomed an injection in addition to antivomiting pills which I also gave the mother as well as medication for her cramps and diarrhea. The child had diarrhea and little interest in eating but did not look ill. I limited myself to dietary advice and left my phone number.

When I phoned the following day, the husband informed me that the family was fine although everyone had been vomiting all night.