I Need a Test

Asked how a doctor makes a diagnosis many would answer: “He does a test.”

This is actually uncommon. Experts agree that ninety percent of our diagnoses come from what you tell us.

Having spoken to the hotel guest over the phone, I’m certain of what’s going on when I drive off ninety percent of the time. Ten percent of the time, I’m not certain. Sometimes more talk or the exam gives me better information. Sometimes, almost always if the illness turns out to be worse than I thought, I send the guest off for a test, usually an X-ray.

I carry dipsticks that detect many substances in the urine. Once or twice in thirty years, I’ve discovered a new case of diabetes. I see guests with symptoms of a urine infection perhaps once a week. I always test their urine.

I then look thoughtfully at the test strip before announcing that the guest has a urine infection. In fact, 10-20 percent of the time the results are normal. No matter. If the guest describes symptoms of a urine infection, I make the diagnosis. Doctors often ignore tests, usually for a good reason.

Something Unforgivable

I sent a colleague to see a hotel guest perhaps thirty years ago. He didn’t carry a bag as well stocked as mine but took some drug samples from the office. He gave one out. Later the guest noticed that its expiration date was past. His anger, when he phoned me, remains a vivid memory.

Commercial prescription drugs are probably OK for years after they expire, but we don’t give them out. My bottle of nasal spray has an expiration date, and it’s pure salt water. When my aspirin expired, I kept it around.

My lawyer has tapped me on the shoulder and warned me to add that this is my personal opinion, that I have no special pharmaceutical expertise, and that you must never take an expired drug.

Keeping the Government Out of Our Hair

I was in Lexington, Kentucky, when a national agency asked me to make a housecall in Columbus, Ohio.

That’s a three hour drive, but I had free time; the guest’s problem was not urgent, and the agency pays generously. A day in Columbus with my wife might have been a treat (it has a terrific zoo). But I couldn’t go because I don’t have an Ohio license.     

I’m licensed in Kentucky ($150 a year) and California ($410 a year), but it’s illegal for me to practice in any other state. The same applies for dentists, lawyers, beauticians, accountants, athletic trainers, and teachers. Some states license interior decorators.

As the recent election demonstrated, keeping the federal government out of our personal business is critical, so we can expect that local officials will take on more responsibility.

Many Americans are disturbed that not only Washington but FOREIGN COUNTRIES determine safety standards for airlines and pilots. Dozens of huge planes fly over our heads every day, yet local officials are helpless to determine if their pilots are qualified. The new administration may return this responsibility to where it belongs. In the future, woe to the pilot who flies his plane over a state where he is not licensed.

A Doctor Who Serves the Poor

People ask if I worry when I make a housecall in a bad neighborhood.

I may worry about my car, but an elderly white man in a suit carrying a doctor’s bag is such a bizarre sight that the average ruffian can only stare in amazement. In any case, everyone assumes that I’m on a mission of mercy, so they’re helpful. Access to apartment buildings is easier than usual because the door locks are broken.

Why don’t people ask if I worry when I make a housecall at the beach? That’s the real nightmare!! Especially during the summer, parking is impossible. Beach apartments are often not on an actual street, so it’s hard to pin down their location on foot. GPS is often vague. Patients are usually not permanent residents, so they can’t help.

I’ll take the ghetto any time.

The Great Credit Card Gamble

AXA insures foreign tourists but has grown fond of American insurer tactics which means it has a number of reasons for not paying me.

It took months, many phone calls, and repeat faxes to collect for previous visits, so I lost patience. After accepting a recent call and copying all the information, I told the dispatcher I’d arrive at the guest’s hotel in an hour. Then I threw the dice. I asked for AXA’s credit card.

 “We don’t have a credit card,” he said.

“Yes you do,” I said. All carriers have credit card, but they vary in willingness to give out the number.

“Let me talk to my supervisor.”  There followed a wait of several minutes before he returned.

“We’ll e-mail a guarantee of payment.”

That’s a legalistic statement describing what the carrier covers and how much it will pay. It doesn’t guarantee anything.

“Go ahead,” I said. “But I still need the card number.”

There followed another long wait.

“I’m afraid we’re unable to supply a credit card.”

I wished him good luck in finding a doctor. Since that 2009 dialogue, AXA calls once or twice a year and we have the same exchange.

I should add that I send bills to many agencies that pay reliably. When they don’t, I ask for a credit card. Some carriers agree, but it’s risky. 

Miracle Cures

As a hotel doctor, I save lives – almost always by calling paramedics or sending guests to an emergency room.

Now and then I cure someone by removing a sliver, ear wax, or a foreign body from an eye. Patients are grateful; it’s a thrill for me, too.

When laymen think of saving lives, they may picture a doctor handing out a prescription, but this is rare. Antibiotics are genuine miracle cures for infections such meningitis, endocarditis, severe cellulitis and other infections that require hospitalization.

When doctors prescribe an antibiotic in the office, it’s mostly as a placebo but even when used properly for infections we encounter (urine, skin, throat) these would usually resolve without treatment.

Cures are a surgeon’s specialty. If a part of your body is diseased, and the surgeon cuts it out, you’re cured.

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.