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Diagnosis And Care: Just A Phone Call Away

In my medical practice, I have a simple yet revolutionary idea: I get paid to answer the phone. Every one of my 3,000+ patients has my cell phone and email address so that they can reach me the instant they need help, which is no different than any of my friends or family who may be trying to reach me. Our practice motto: “Talk to your doctor anytime, anyway, anywhere.”

It’s not that I’m trying to not see you, or want to be impersonal or to practice risky healthcare. In fact, each of these common assumptions is pointedly wrong. By answering my phone, I can know my diagnosis and treatment worked (or not), or I can help someone avoid an ER visit or unnecessary office visit. My patients call me when they’re traveling, or at work, or from their car, at night and on weekends. There’ve been occasions that I need to see a patient NOW and I’ve come to the office a 2AM to keep someone out of an ER. No matter what, by picking up the phone to talk to my patients, I’m the first person in the healthcare system to know something is wrong, not the last.

Although good examples supporting the power of a doctor answering a phone occur daily, I have one I want to share with you.

It began about six weeks ago during one of Northern Virginia’s biggest snowstorms in recorded history. Already 20+ inches were on the ground and I was huddled next to my wood stove in the basement, having lost electricity 18 hours ago. Fortunately my cell phone worked. I got a call from Mr. AA, who was referred to me by a mutual acquaintance.

AA, a 30-year-old who traveled a lot, had been in many several countries including East Africa and Indonesia in the last 6 months. Five days before calling me, he developed a high fever associated with headaches and body aches. These symptoms resolved within six hours. He visited an urgent care center where labs and exam were normal. For the next four days, he’d been fine. But then, trapped at home in the middle of the snow storm, he found himself racked with a temperature of 104.2 degrees with a headache and body aches. When we first spoke, he felt he was through the worst and was recovering, after six hours of fever and a dose of ibuprofen.

During our phone conversation, he explained that he’d not been to East Africa in over 3 months, where he’d taken malaria prophylaxis.  However, he’d returned Bali and Indonesia several weeks before, and he’d not taken malaria medicine while there, having been told by a reliable source that he didn’t need malaria meds where he was traveling.

Suspecting malaria, I asked if he still had any malaria medicine at home. As luck would have it, he did.  I advised a treatment immediately.  Falcipaurm malaria (usually acquired in Africa) has a 30% mortality rate if left untreated, while  Plasmodium vivax (most frequently acquired in Indonesia) also would respond to the treatment. I did tell AA that recurrence rates later are common with vivax malaria due to a chronic liver stage and we could easily cross that bridge if that happened.

We spoke 24 hours later and his symptoms had not recurred. But 30 days later, my cell phone rang. AA’s fever had returned.  He had been perfect for three weeks, but within the last week he’d had two fever attacks, each lasting six hours.  The second had recurred three days after the first.

We then met at our practice offices, even though his fever was gone. A recurrent high fever is a good reason to see your doctor in person, and one of our practice tenets is you must meet the doctor face to face at least once.

During our visit, he’d told me that his friends in Indonesia had pooh-poohed the idea of malaria. He produced a list of possible causes of his fever that he’d researched on the Internet.  Being a causality of the American health care system with no health insurance, he was all ears when I explained that rushing pell-mell through thousands of dollars of tests, ER visits, and specialists encouraged under the insurance model was unnecessary.  Instead he would pay our office less than $100 for the tests he needed, which he could access via a local lab at a discounted rate.  At the next episode of a fever he would take the lab order to the hospital no matter the time of day to get the five tests I requested.

Three days later AA’s mother called me at 8 PM. She was taking her son to the hospital lab since his temperature had started going up an hour before. To avoid any possible glitches, I called the lab to clarify the orders and account.  At midnight , as I headed for the ice arena to play my weekly hockey game, I received a message from the lab:  “He has a positive malaria parasite smear,” reported the lab tech. “Specific typing between vivax and falciparum malaria will be done by the pathologist in the morning. “

I immediately pulled my car over and called AA. He was feeling better and the fever was gone. I told him that everything pointed to vivax malaria, but we’d wait until the morning for the pathologist’s findings. If it was vivax, I’d research the best drug to use, considering the resistance patterns out of Indonesia. I’d want him to return to the lab in the afternoon for a G6PD blood test,  which would see if he could take the drug safely that would eliminate the recurrent liver stages of the malaria.

Our predictions were correct: vivax malaria.  His G6PD lab test was normal.  I called AA four weeks after he’d started the two medications to treat vivax malaria. I was relieved that he was well and not bankrupt from medical costs. He, like me, is a convert to having the doctor answer the phone to solve a problem. In the future, I’ll be the first one he calls for a medical need, whether a fever or anything else.

And, the total cost of service from first call until cure including costs of labs and tests
(excluding meds): $401.00.

Until next week I remain yours in primary care,

Alan Dappen, M.D.

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