Dear Dr. Gott: My doctor recently refused me a referral for a second opinion. The problem required a nephrologist, and no one in that speciality will see me without a referral from my primary-care doctor. Compounding the problem, one or two doctors my son tried to get me to change to said they were not taking new Medicare patients. What is medicine coming to?

Reply> Rather than focusing on how medical care is changing, I’d rather comment on your family doctor’s unwillingness to refer you for a second opinion. I don’t have to know the situation, analyse the insurance components or shake hands with the primary-care physician.Put simply, he did wrong. Is this a common occurrence? Unfortunately, yes. Speaking personally, I welcome requests for medical referrals. Because I want my patients to be as healthy as possible, I sometimes need help or my patients need diagnostic confirmation. This is part and parcel of good medical care.

To back up a moment, doctors have the right to refuse medical or other insurance. My concern lies with the original doctor who refuses to authorise a second opinion.

Do I have any recourse to investigate?

No, but I recommend that you show your doctor my response to your valid frustration and ask for his response to it.Dear Dr. Gott: First, thank you for your column and all of your thoughtful, informative responses to your readers’ questions.Please address haemorrhoids. What are they? How do they form or come about? What can be done besides ointment creams? Are there any permanent cureB>Reply: Haemorrhoids are swollen veins at the anal opening and/or the lower rectum. They can be caused by straining, constipation or external irritation. (I got haemorrhoids while riding a motorcycle around Europe the summer after I finished college. What a nuisance — the haemorrhoids, not the biking.)Ordinarily, the swelling takes care of itself in a matter of days with minimal discomfort. The swollen vein is usually easily palpable unless it is inside the anus.

Problems develop if the blood travelling through the vein moves so slowly that it clots, leading to a painful condition called thrombosis.

This usually responds to stool softeners, meticulous attention to hygiene, warm baths and over-the-counter remedies, such as Preparation H.

However, surgery to tie off the vein may be indicated in some cases.

Sometimes, thrombosed anal haemorrhoids bleed. Although this may be simple, harmless spotting that clears up in days, persisting or significant rectal bleeding will require the services of a surgeon, who may be able to cauterise the offending veins.

For large, recurrent “piles”, surgical removal may be necessary. Patients with chronic constipation may eventually develop haemorrhoids. Attention must be paid to softening the stool through a variety of means, starting with fibre in your diet (such as bran) and other preparations.

Check with your family doctor for additional information; he or she is your best resource.

To give you related information, I am sending you a copy of my Health Report “Constipation & Diarrhoea”.

Other readers who would like a copy should send a long, self-addressed, stamped envelope and $2 to Newsletter, PO Box 167, Wickliffe, Ohio 44092-0167. Be sure to mention the title.Dr. Gott is a retired physician and the author of ‘Dr. Gott’s No Flour, No Sugar Diet’. Contact him c/o United Media, 200 Madison Avenue, fourth floor, New York, New York 10016.