Addicted to Gratitude

“You saw me at the Marriott yesterday. I still don’t feel good.”

“I’m sorry,” I said. “I did mention that you’d be under the weather a few days.”

“I still have a temperature. The Tylenol only works a few hours. The cough medicine isn’t doing much. I need something stronger.”

“I would love to make you better, but, as I explained, there’s no cure for these respiratory viruses.”

“What if it’s bronchitis? My doctor tells me I have a lot of bronchitis.”

“‘Bronchitis’ is just another word for coughing. It’s a virus that runs its course.”

“I guess I just have to be sick. Thank you, Doctor Oppenheim,” she said before hanging up. There was sarcasm in her tone. I felt bad.

I also felt a surge of anger at my fellow doctors, most of whom prescribe antibiotics for viral infections. No doctor believes they work, but prescribing them guarantees a patient’s gratitude; doctors are addicted to your gratitude. 

My practice is to prescribe antibiotics when they’ll help and to not prescribe them when they won’t except when it’s clear that the patient will blow his top if I don’t. This turns out to work pretty well. About ninety percent of patients seem genuinely grateful. Most of the remainder are dissatisfied, but they remember their manners. Perhaps one percent make it clear that I have failed them.

The Superiority of American Medicine

Patriots boast that American medicine is the best in the world. My view is more nuanced, but let me take their point of view. You’ll be amazed at the dumb things foreign doctors do!

They don’t give antibiotics for ear infections! 

If a child suffers a painful ear infection, the doctor prescribes an antibiotic. In many European countries, doctors give medicines for pain and fever but no antibiotic. If you’re wondering what happens to these poor European children, the answer is: they get better. Even in America, many experts believe that antibiotics don’t work for ear infections. It will take a lot more than expert opinion to persuade American doctors to avoid antibiotics in ear infections. American doctors love antibiotics as much as American patients.

They don’t care for hysterectomies!

Many women develop lumpy growths on the uterus called fibroids which may cause pain and irregular menstrual bleeding. A gynecologist can cure this by removing the uterus. It’s the second most common operation American women undergo (after caesarians; America leads the world in both).

The French have the odd idea the world would be a better place if there were more Frenchmen, so French doctors don’t sterilize women if they can avoid it. Mostly, they perform an operation that cuts off the fibroids but leaves the uterus intact. The surgery is more complicated and takes longer than a simple hysterectomy. American gynecologists could do the same, but they don’t, and they rarely discuss it with patients because they know American women aren’t interested.

They don’t try to cure every patient.

American doctors order more tests and prescribe more antibiotics, chemotherapy, and other powerful drugs than foreign doctors. They also perform far more surgery. These extras don’t necessarily cure. Sometimes they make patients sicker, but the important thing is that we’re doing something. American like aggressive doctors.

Foreign doctors spend a great deal of time making patients feel better – for example by ordering physical therapy (massage, exercise, heat, baths). American doctors prescribe physical therapy to speed recovery after surgery or injuries. European doctors prescribe it after childbirth and for migraines, irritable bowels, arthritis, fatigue, depression – dozens of problems.

European doctors actually send patients to health spas for baths, massage, etc., and health insurance pays for it! If you believe this is a waste of money, American doctors agree. Patients may feel better after a spa treatment, they explain, but it’s psychosomatic (in other words, if someone feels better -- but it’s only psychosomatic -- that’s not good).

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?

I Love Medicare

I have collected Medicare since 2005. There’s a belief that this means I get free medical care, but that’s definitely not true. Both Medicare Part A and B have deductibles, and sensible retirees buy a policy that pays most of what Medicare doesn’t pay (and it doesn’t pay quite a lot). There is also Medicare Part D which requires a premium that pays for drugs. Believe it or not, Part D was passed by Republicans.

Being Republicans they made sure the plan met the approval of pharmaceutical companies, and it does. They love it. Part D specifically forbids Medicare from negotiating for lower prices. Other government departments such as the V.A. can negotiate. Hospitals and private health insurers can negotiate. Medicare can’t. As a result, Part D premiums, no less than drug prices, have been shooting up each year.

The result is that I pay about $550 a month for medical insurance. In exchange, I get almost no medical bills. I love it. Even though Medicare is a government program, I receive less paperwork than when I belonged to Blue Cross (even writing “Blue Cross” produces a surge of anger; I hated it). 

My brother, a physician, detests Obamacare. He is liberal and an activist, and he dislikes Obamacare because it delivers a bonanza to insurance companies with no controls on cost. His criticisms are correct, but I tell him that as premiums skyrocket the outcry will force Washington to take action.

Conservatives tell us that in European national health plans the downtrodden physician takes his orders and pitiful salary from the government. In fact, all these countries have some private insurance. In many, such as Switzerland and the Netherlands, everyone buys medical insurance from private carriers just as they do in the US. The difference is that laws closely regulate them. The carriers aren’t losing money.

Things will work out.

Historical Diseases

Standby MD asked me to see a guest at the Doubletree – in Santa Ana. That’s fifty miles away, but it was Sunday morning; freeway traffic was light, a perfect time to go to Orange County.

The guest was an elderly Canadian man suffering diarrhea and vomiting. He mentioned that half a dozen members of his tour were affected; several had gone to the emergency room.

That brought back memories of a guest in 1991 with the same symptoms. Stomach viruses are the second most common ailments a hotel doctor encounters. They’re miserable but short-lived; I had delivered the usual advice and remedies, but when I called to check the next day, I learned that he was in the hospital with cholera. I remembered that he had flown in from Peru.

Cholera also causes diarrhea and vomiting. It’s extremely rare in the US. In fact, if an American patient turns up with any of the major historical diseases (cholera, malaria, rabies, leprosy, typhoid, typhus, plague, even tuberculosis) it’s almost certain that the American doctor will get it wrong on the first visit.

The Canadian gentleman was already recovering, but my phone rang before I left with a request to see another tour member. She was sick enough to send to an ER where she stayed until the evening. There is little cholera in Canada, so this was a stomach virus.

Colic

I saw a young Australian couple traveling with an infant. A placid sleeper in Australia, the infant had been screaming off and on since arriving six days earlier, attracting complaints from other guests, driving the poor parents to desperation. They wanted to go home.

It was colic, a surprisingly common affliction of healthy infants. In theory, they are suffering abdominal pain, but all tests are negative, and none of the innumerable treatments work well. It disappears after a few months. I wrote them a note. 

Another Death

When I arrived at the hotel, a father explained that his daughter was under treatment for leukemia. They were visiting relatives when, a few hours before, she had refused to speak.

Except that she was bald from chemotherapy, the daughter looked fine. She was sitting up in bed, arms folded, looking glum. When her parents appealed to her to talk to me, she obviously heard but merely shook her head and remained silent. She did not resist when I examined her, and nothing abnormal turned up. I was faced with a sullen teenager who didn’t appear sick.

This was another occasion when, for no obvious reason, things didn’t seem right. I told the parents she needed to go to an emergency room. They obeyed, and the daughter died soon after being admitted.