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.

Things I Don't Say to Patients

1. Get plenty of rest. 

Rest treats fatigue, but that’s all. I tell patients with minor illnesses to stay in bed only if that’s where they want to be.

2. Watch your diet. 

For minor illnesses, proper nutrition isn’t very helpful. If you have no appetite, forcing food down makes you feel worse without accomplishing anything useful.

3. Drink plenty of liquids. 

There are two problems here.

A.  More water evaporates during a fever, so replacing it is a good idea, but a healthy adult can safely ignore this for a day or two. If the fever lasts longer, a doctor’s first step is not to replace liquids but to find out what’s happening.

B.  Since the dawn of history, people have believed that a sick body is full of toxins. This is common sense (almost always wrong when applied to your health). Nineteenth century doctors prescribed drugs to produce vomiting or diarrhea, and patients knew this worked because they could see the smelly stuff pouring out. We no longer believe in “purges”, but enthusiasts (doctors among them) still believe that urinating expels toxins, so they advise you to drink 6 or 8 or 10 glasses of waters a day.

4. Be sure to take aspirin or Tylenol. 

“But then the fever came back,” patients tell me as if this were bad. In fact, these drugs wear off after a few hours. The fever of common infections won’t harm a healthy person, and aspirin or Tylenol won’t shorten the course of any ailment.  It’s all right to take them to feel better but not essential.

5. Keep warm.  Keep cool. 

We shiver when our tem­perature rises and sweat when it falls. That’s how the body warms up and cools down. Shivering or sweating are not necessarily ominous signs; nor is it good “when the fever breaks.”

Things I Say All the Time

Long experience has taught me that patients love to hear the following.

1.  “This isn’t a serious problem, and it never turns into a serious problem.”

Doctors know that many tiresome ailments such as hemorrhoids, bladder infections, migraine, or herpes don’t turn into something worse, but patients don’t know this. A doctor must tell them. 

2.  “I want you to call me any time.”

Doctors say this all the time, but you know what happens when you try. I show guests my cell phone and promise to answer in person. Naturally, I do this because I’m a compassionate physician, but there’s an element of self-interest. If guests aren’t getting better, I want them to tell me – not the hotel.

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

Travelers waste valuable days in a boring hotel room, so I try to take the pressure off. This myth is so universal that when I reassure non-English speaking guests, I ask them what I’ve just said. Almost always, they repeat it back minus the negative.

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

Guests may suffer for weeks, but once they see a doctor, they want things to move quickly. If I don’t explain that this might not happen, I may hear from them the next day.

5. “It’s not your fault.”

A baleful consequence of the popularity of alternative medical theories is that patients believe they’re responsible for getting sick. Mostly, they’re not.  

Neither Rain Nor Snow

My phone rang as I was driving to the Langham in Pasadena. Coris USA, a travel insurer, had another housecall. Since I was on the freeway, I couldn’t write, so I asked for the address, planning to collect the remaining information from the patient. I hate to be late, so I told the dispatcher I might not arrive for several hours. 

The Langham guest had a sore throat, an uncomplicated visit. I reached the Coris destination, a private house in Hollywood, an hour after the call. The gate in the surrounding fence was locked. The buzzer felt loose in its housing, giving the impression that it was broken. This seemed the case because no one appeared.

What to do… Usually I phone the patient, but I didn’t have a number. I considered phoning Coris, but whoever answered would ask for the patient’s name which I also didn’t have. She might or might not succeed in tracking down the original dispatcher, but it was guaranteed I’d spend a long time on hold in a chilly drizzle.

The railing was my height, and there were footholds. Passerbys certainly wondered at an elderly man in a suit struggling over a fence, but I succeeded without tearing my clothes.

The woman who answered the door denied that anyone wanted me. It turned out this was not a private house but a youth hostel. The woman consulted other residents; one remembered someone who wanted a doctor, but she had left. 

The resident didn’t have her phone number but offered to leave a message on Facebook. I called Coris to warn them that matters were not looking well.

Then the door burst open, revealing the patient, gasping for breath after running several blocks. The visit itself was uncomplicated. 

Three More Great Sins of the Medical Profession

4.  Doctors spend too little time explaining how to relieve stress.

     Probably… Stress makes everything worse but doesn’t cause anything. Seeing a doctor for stress results from what I call the “medicalization of society” - the notion that life’s difficulties (a hateful job, unsatisfying sex life, shyness) represent a medical problem. There’s no harm in this; a good doctor can listen sympathetically and make sensible suggestions which require no medical training.

5.  Doctors don’t pay much attention to diet, rest, exercise, and other natural methods of treating illnesses.

     True and proper. Diet, rest, etc. play an essential part in preventing disease but drop to minor roles once you get sick... A perfect example were tuberculosis sanitariums, the oldest government supported medical program. They began appearing in the nineteenth century. Patients received nutritious food and plenty of rest in a healthy, rural environment.  They were discharged (sometime after years) when their TB became inactive. No one was cured, and many relapsed. When drugs appeared after 1945 sanitariums vanished. Nowadays doctors encourage TB patients to eat a nutritious diet, but they’ll get better even if they don’t – provided they take their drugs.

6.  Doctors ignore alternative and folk medical practices.

     I notice enthusiasts treat folk medicine with respect, but no one advocates folk dentistry...

     In fact, 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 in place of anesthesia... Chiropractic manipulation relieves some backaches for a limited time.

     The better doctors handle a problem, the less you’ll read about “alternative” treatments. Your local health food store doesn’t sell an herbal remedy for appendicitis. Don’t laugh. Appendicitis is fatal; until a century ago victims died after weeks of agony. Then we discovered that snipping off the appendix (something any bright high school student can do) cured it. Today no one searches for an alternative treatment of appendicitis. 

     On the other hand, doctors don’t do so well treating obesity, arthritis, aging, or senility. So if you want to find an alternative remedy that doctors have stupidly ignored, you’ll find plenty.  Good luck with them.

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.