Can I Submit This to My Insurance?

The guest’s symptoms suggested a urine infection, one of my favorite diseases. They’re miserable but respond quickly to antibiotics. This looked like a good visit. I quoted my fee.

“Oh… I didn’t realize it would be so much.”

This happens. I remember guests from the Four Seasons where room rates start at $600 who didn’t want to pay half that. In any case, once I mention the fee, I consider it tacky to refuse someone who complains. I quoted a lower fee. That was OK.

It was a good visit. I tested her urine, announced she had an infection, and handed over her medicine. She was grateful. As I left, she indicated my invoice.

“Can I submit this to my insurance?”

“You have travel insurance?”

“I think so. They made us buy something for this trip.”

It was too late to ask why, if she had insurance, she had objected to my fee. But this also happens. In every developed country except Russia and China, if you need a doctor you don’t first decide if you can afford it, so foreign tourists often pay little attention to insurance.

You Don't Need a Better Medicine

“My doctor gave me amoxicillin a week ago, and my sinuses are still blocked. I need a stronger antibiotic,” said a guest.

If a medicine isn’t working the next step is never to find a better medicine but to discover why it isn’t working. Sometimes there’s a problem that medicine won’t help.

Sometimes the patient needs a better exam. Pain on urination usually means a urine infection, and I’ve seen several patients whose urine infection didn’t go away after a course of treatment. They didn’t have a urine infection but herpes. It was obvious when you looked, but the doctor hadn’t looked.

Sometimes the patient needs to wait. After rubbing cream on an insect bite, patients worry when it grows to an itchy patch several inches around. I explain that insect bites generally worsen for two days and then resolve over the following days.

Sometimes the next step is to stop taking medicine. Treating pinkeye with drops usually helps, but patients occasionally return to complain that they’re worse. That’s because the drop has begun to irritate the eye. A few days after stopping, they feel better.

My malpractice lawyer warns me to warn you to read this purely for your own amusement. Only in mathematics can a statement be 100 percent true.

So if a medicine isn’t working, don’t stay away from the doctor on the grounds that I said it was OK.

My Favorite Infections

Number one is urine infections in women, because I quickly make them go away. Handing over a packet of antibiotics, I assure someone who has been running to the bathroom every half hour that she’ll feel better by the next morning. In men, urine infections are usually prostate infections; these resolve slowly.

Eye infections (“pinkeye,” conjunctivitis) go away quickly after we prescribe antibiotic drops because most conjunctivitis goes away quickly whether or not antibiotics help (mostly they don’t). Everyone with a pink eye assumes they need eye drops, and doctors are happy to oblige, so we find these satisfying to treat.

Some intestinal infections respond to antibiotics but almost all occur in poor parts of the world. They’re rare in the US where vomiting and diarrhea is usually a “stomach virus” and short-lived.   

Amazingly, experts debate whether antibiotics help ear infections. Doctors in many nations don’t prescribe them, but Americans do. Patients give us credit when they get better. We like that.

Should I Make a Housecall?

Only half my callers require one.

As I repeat, I’m happy to phone a pharmacy when guests forget legitimate medication: blood pressure pills, heart pills, contraceptives, etc. I don’t do this for guests who tell me “I had the same thing last year, and my doctor prescribed……” 

Exceptions exist. If a caller has had gout I believe him. It’s acceptable to treat a young woman with a typical bladder infection over the phone. If you’re wondering about symptoms of a “typical” bladder infection, I’m not telling. You have to tell me. Most “my doctor prescribes...” calls concern upper respiratory infections where the guest has received the traditional placebo antibiotic and believes he needs another.

Guests with stuffy ears don’t object if told they need a housecall, but I resist the temptation because ordinary congestion causes bilateral ear discomfort without pain. Over the phone, I advise aggressive use of nasal spray before takeoff and before the plane descends.

Injuries can be tricky. A doctor’s exam rarely diagnoses a fracture, but most common injuries are not urgent, even when a fracture is present. If guests are willing to wait until business hours, I can send them to an orthopedist’s office, more civilized than an emergency room. For back pain, a housecall is better. If you go where there’s an x-ray, you’ll get one, and experts agree that back x-rays are almost never helpful.

Much of my decision on making a housecall depends on the law of averages. Chest pain in a fifty year-old is usually not serious, but it’s unwise to assume this. It’s less unwise in a twenty year-old. A sore throat in a child or adolescent might be strep which medical science can cure. After age fifty it’s almost unheard of. I’ve never seen a case.

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.

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.

Breaking My Rule

I was awake at 7 a.m. writing this blog when a guest called with symptoms of a bladder infection.

Being American, her first question was: do I accept her insurance. I explained that I didn’t, adding that there was an urgent care clinic a mile away that would.

“I’d probably have to wait forever,” she said. “I have meetings.”

“I’m definitely convenient,” I said.

“Do you bring the medicine?”

“I do.”

I wanted to finish writing and eat breakfast, so I told her I’d arrive at 9 a.m., thereby demonstrating that, despite my wisdom and vast experience, I do stupid things.

It’s a rule of hotel doctoring to go as soon as possible. Guests who wait often reconsider, so I knew what to expect when the hotel’s number popped up on my caller ID at 8:00.

“I’m feeling better,” she lied. “I won’t need to see a doctor after all.”

“You won’t save much at the clinic,” I pointed out. “They’ll charge extra for the urine test and extra for the culture, and you’ll have to find a pharmacy and pay for the prescription.”

“Oh, no! I’m feeling fine,” she insisted. “Thank you for your help.” She hung up.

When patients cancel, I console myself if the illness seems likely to produce an unsatisfying encounter. For example, guests are often disappointed when I can’t cure their respiratory infection. But urine infections are easy to treat and treatment produces dramatic improvement. I hate to miss one.  

Ignoring the Lab

A young woman complained that urinating was painful, and she was running frequently to the bathroom.

That sounded like the common bladder infection, my favorite disease. It’s one of the infections that antibiotics treat, and patients usually feel better within a day. Everyone is pleased.

After arriving in the room, I asked for a urine sample and took a dipstick from a bottle I carry. It can detect sugar and blood and protein and half a dozen other substances in urine, but in this case I was looking for white blood cells (a sign of infection) and leukocyte esterase, a chemical that bacteria produce. Both tests were negative. What was going on? Her story and all the evidence pointed to a bladder infection.

Every medical student learns to treat the patient, not the test. The test showed that she didn’t have a bladder infection, but I disagreed, and I turned out to be right.

A Better Medicine

“My doctor gives me Bactrim to take whenever I get another infection, and I need more.”

Antibiotic requests are good news to some hotel doctors who know that, provided they go along, the guest will happily hand over the fee. An easy visit.

When I see these patients and do my best and don’t prescribe an antibiotic if they don’t need one (usually the case), most are grateful, but a minority aren’t. It’s not a small minority, and I hate driving off to what might be an unpleasant encounter.

Hearing this request I go into “no-housecall” mode, perhaps mentioning that the illness is self-limited and doesn’t require medical attention or directing the guest to an urgent-care clinic. I don’t want to see them.

But I gave this lady her Bactrim.

There is a single exception to the rule that healthy patients are wrong when they decide that they need an antibiotic: the common, uncomplicated urinary tract infection. In fact, it’s OK to prescribe over the phone. Scientific studies show that this works as well as an office visit.

When an Antibiotic Helps

If you receive an antibiotic for a respiratory infection, it’s probably a placebo because almost all respiratory infections are viruses.

If you receive an antibiotic for a skin infection, there’s a chance you have a bacterial infection that an antibiotic won’t help. A boil or other collection of pus will heal if the pus is drained. If the doctor gives an antibiotic but doesn’t drain the pus, it will also heal. That’s because most infections, boils included, eventually heal.

You’ll get an antibiotic if your doctor diagnoses an ear or sinus infection. It’s a bad idea to ask if this will help because (if he’s honest), he’ll admit that no one knows. In experiment after experiment, when researchers compare patients given and not given antibiotics for ear or sinus infections, the results are never dramatic. Often there’s no difference. Sometimes they help a little. Doctors in some nations don’t treat these with antibiotics.

That’s why urine infections are my favorites. It’s not controversial that antibiotics help. For infections in young women, help comes quickly, usually within a day. These are satisfying encounters for everyone concerned.