Sunday, November 20, 2011

Returning from ten days out of town, I took my phone off call-forwarding, unpacked, and prepared to drive to Trader Joe’s for groceries. Before I left, the phone rang with a housecall at the Torrance Marriott, twenty miles distant. The good news was that it was Saturday evening, so freeway traffic was light, and the patient was seventeen, an age when illnesses are rarely complicated. The bad news was that he was Japanese, a people admirable in every respect except for their reluctance to learn English.

As I stepped out of the elevator, a middle-aged Japanese man rose from a chair. “Are you the doctor for the hotel?” he said.

I was delighted. “Yes. Are you going to interpret for me?”

He stepped back in alarm and waved his English-Japanese phrase book. Hiding my disappointment, I followed him to the room. When he began flipping through the booklet, I shook my head and pointed to the phone before dialing the guest’s Japanese insurance service for an interpreter. There followed a lengthy encounter as the phone passed back and forth between me, the parents, and the patient. The young man had suddenly complained of fatigue the previous day. He was otherwise in good health; he had no other symptoms, and I found nothing abnormal on examination. Sudden fatigue is an ominous sign in the elderly but rarely in an adolescent. I suspected an emotional problem, perhaps from the stress of travel. This is hard to explain across both language and culture, made even harder because I didn’t give a medicine. Giving medicine is a universal language; that’s why doctors prescribe even when it isn’t necessary.

Luckily these were Japanese, so they listened to my advice (get a good night’s sleep, continue with their itinerary, call if the problem persisted) with unfailing courtesy, nodding approval, and thanking me effusively as I left.

Wednesday, November 9, 2011

Can I Submit This to My Insurance?

The phone rang at 9:30 a.m., the perfect time. I was finishing breakfast. My routine is to work an hour on the computer and then go to the gym, but I’m happy to do a housecall instead. If two housecalls arrive, I skip the gym, an even greater pleasure.

The hotel was the Holiday Inn at the airport. The patient, a young Australian woman, had arrived after a tiresome flight during which she was forced to run back and forth to the bathroom. Urine infections are among my favorite diseases. They’re miserable but respond quickly to the antibiotics I carry. Patients are always grateful. This looked like a good visit. I quoted my fee.

“Oh… I didn’t realize it would be so much.”

This happens now and then. I remember guests at the Beverly Hills Hotel where room rates start at $300 who didn’t want to pay half that. In any case, once I mention the fee, I try not to refuse someone who thinks it’s too high. So I asked if $100 was OK. It was.

It was a satisfying visit. I tested her urine, announced she had an infection, and handed over a packet of pills. She was grateful. As I left, she indicated my receipt.

“Can I submit this to my insurance?”

“You have travel insurance?”

“I think so. They made us buy something for this trip.”

It was too late to ask why, if she had insurance, she had objected to my fee. But this happens regularly. In every advanced country outside the US, except Russia, China, and South Africa, if you need a doctor, you don’t first decide if you can afford it, so foreign tourists often pay little attention to their insurance.

Friday, October 21, 2011

Hitting the Jackpot

Two miles from the airport, the Adventure resembles a youth hostel: a mixture of single rooms and dormitories with an outdoor restaurant on the premises. Guests are mostly colorful, raffish, college-age, and from around the world. Many are traveling so cheaply they have no insurance, so I spend a great deal of time giving phone advice and making visits at a discount.

Conventional tourists also stay, and one called at 8:30 as I was preparing breakfast. I told her I’d arrive between 9:30 and 10. During breakfast, the phone rang again. The caller was the Miami office of Coris USA, a travel insurance agency that mostly serves Latin Americans. Half my calls from hotels require only phone advice, but insurance calls are almost all paying visits, so I answered in a happy frame of mind, certain that I could skip my daily workout. I like to exercise before the noon rush, and two morning housecalls make that impossible. This doesn’t happen often, so I reward myself without guilt. Keeping fit is healthy, but an hour of exercise is as exciting as an hour brushing your teeth, and I’m deeply suspicious of anyone who claims to enjoy it.

It’s not rare to drive thirty miles between hotels, so I awaited the location of my second visit with anticipation. It was the Adventure. Two visits at the same hotel, a rare treat!

A downside was that both patients seemed to be suffering my least favorite illness: a respiratory infection. Almost all are viral, but prescribing antibiotics is so common that even good doctors do it, so patients are often puzzled and disappointed when I don’t. Doctors love their patients’ gratitude, but prescribing Tylenol and cough medicine get them very little.

Having gotten this off my chest, I’ll admit that neither of those patients had a virus. The first had a severe cough and high fever, probably pneumonia because listening to her left lung revealed abnormal noises. In an otherwise healthy person, pneumonia is the only common chest infection that medical science can cure. So I cured her.

Walking upstairs, I examined the Coris patient, a middle-aged man from Brazil who explained that he had bronchiectasis. This is an uncommon condition in which a small area of the lung becomes obstructed with frequent infections. He was suffering an exacerbation, so I gave him antibiotics in good conscience.

These were satisfying encounters. That both patients were staying at the same hotel was a delightful bonus, but there was a downside. With no travel between visits, I finished at 11 o’clock, too early to skip the gym without guilt.

Friday, October 14, 2011

“Can you make a housecall in Larkspur?”

I’d never heard of it. Google Maps revealed that it’s four hundred miles away, north of San Francisco. The dispatcher seemed disappointed at the news.

Half a dozen travel insurance agencies serving clients from Latin America have US offices in Miami, and it’s natural that they’re unfamiliar with California geography. Looking up cities is easy, but it’s even easier to call me. I'm sure you've phoned your family doctor, wading through voicemail, answering services, receptionists, and leaving messages. Hours may pass, but eventually the doctor calls except when he doesn’t.

Pity these poor dispatchers. Once a sick client phones, the dispatcher retrieves a list of doctors from that city and begins calling. Even after she finds one willing to make a housecall, her task is not finished because everyone knows doctors are terribly busy. I can confirm from my own experience that a colleague who agrees to help might not give this a high priority. Early in my career my requests were invariably followed, a few hours later, by a call from the hotel informing me that the guest was still waiting. Now I extract a promise that he will go quickly and then phone later to make sure he does.

I’ve never had an office. My number reaches my cell phone; I always answer in person, and I try not to decline visits within reasonable driving distance. Without being asked, I always tell the caller when I’ll arrive.

This turns out to be good for business. Tracking down a doctor remains a tedious process in other cities but requires a single call in Los Angeles, so dispatchers find it easiest to call me. Some phone whenever a California client calls, so I often deliver the bad news that they must begin working down the list for San Francisco, Sacramento, or San Diego.

Saturday, August 27, 2011

Various Way in Which I Didn't Get Paid -- Part 4

I didn’t charge eight guests because theirs was the first call from that hotel, and I wanted to make sure they had a good experience. I stopped when I realized that most hotels that call for the first time never call again. The important call is the second.

Assistcard, which insures travelers from Latin America, owes me for six visits from the 1980s. Other doctors had warned me of its reputation as a slow payer, but I was eager and young. After several years, innumerable calls to its billing department, and with my business prospering, I began refusing its requests. A few checks owed to me drifted in over the following year but not all.

After ten years, an Assistcard employee called to announce that the company was under new management and to promise to pay more reliably. Since then I’ve collected on every visit but often after months of reminders. I finally decided to cut back on pestering but add $100 to my fee. Assistcard knows this, but nothing has changed. Most of its bills are vastly higher than mine because they come from hospitals and emergency rooms, so delaying payment helps their bottom line so much that making an exception for me is probably too much trouble.

Thursday, August 25, 2011

Various Way in Which I Didn't Get Paid -- Part 3

Four times I arrived to discover another doctor in the room. The hotel had summoned another doctor. After waiting a few hours, the guest complained, so the hotel summoned me without mentioning the other call.

Eighteen guests gave me a bad check. Almost all were single males, and these occurred before I accepted credit cards. While everyone I managed to contact expressed surprise and promised to correct matters, this was not always a lie. In six other cases, guests sent a second, good check.

I mailed a refund to three guests on Medicare. Early in my career, I simply informed elderly American guests that I was not a Medicare doctor. Most assured me that was no problem, but it turned out many believed I meant only that I didn’t bill Medicare myself. When Medicare rejected their bill, they were outraged. Since then I explain in more detail that they can collect nothing from Medicare or any Medicare supplement insurance. Some agree to a visit; others accept my directions to an urgent care clinic.

I also reimbursed a guest who was unhappy to hear that an antibiotic would not help his flu. He went to an urgent care clinic later that day, received the traditional antibiotic, and felt better as soon as he swallowed the first pill. The hotel manager who passed on his complaint expressed sympathy, but I felt it best to make a refund.

Wednesday, August 24, 2011

Various Way in Which I Didn't Get Paid -- Part 2

Over the past thirty years, twenty-four guests cancelled. I don’t count those that arrive before I leave the house, so all occurred while I was on my way. To this I must add eighteen no-shows: guests who weren’t in the room when I knocked. This always annoys me because I tell guests when I’ll arrive. In my younger, passive-aggressive days, I would phone later. Guests would swear they had told the hotel and express outrage that the employee had failed to pass on the message. After hearing the same excuse every time, I stopped calling.

Fifty database files appeared under “No Pay,” meaning I wanted to collect but couldn’t. A minority were blunt refusals from guests who never intended to pay; a dozen were clearly mentally ill. Four guests had called the paramedics before I arrived, and they were already on the scene.

“No way!... Take it up with the manager” caused trouble until I saw the light. Hotels often pay if guests are injured on the premises, find bugs in the room, or believe they’re poisoned by hotel food. Unfortunately, sometimes the hotel refuses, and it’s a bad idea to argue. After leaving unpaid several times, I learned to stay alert during the initial phone call for situations when guests blame the hotel. If so, I tell them to discuss matters with management before I leave the house.

Saturday, August 20, 2011

Various Way in Which I Didn't Get Paid -- Part 1

In my database of over 16,000 visits, entering zero for my fee and searching turns up 789 files, but this includes 529 when colleagues covered. That leaves over 200 where I collected nothing.

On nearly 100 occasions, this was my decision. 50 patients were hotel employees whom I don’t charge even if they’re willing to pay. Most can’t afford the fee, and I’m happy at the thought that they’ll tell their co-workers about the experience.

In 19 cases, I arrived and realized immediately that the guest needed a referral, either to a specialist or an emergency room. I try to detect these during the phone call before the visit, because I feel guilty accepting a fee and then sending the guest off to pay a second fee. In four additional cases, I had decided to call the paramedics, and I remained in the room until they arrived. Naturally, these were distressing events. Everyone was preoccupied, and I felt inhibited about mentioning my fee. In other cases, the guest or his companions remembered, but these were the times they didn’t.

Poor people rarely stay in hotels, but a few cheap motels and youth hostels have my number, and college-age travelers often arrive in the US without health insurance. As a result, I sometime trim my fee and occasionally charge nothing if they come to my home. I’ve done that a few dozen times.

One guest was dead when I arrived. I didn't collect from his wife.

Sunday, July 31, 2011

Why I Love Arabs

Examining a Danish hotel guest last month, I became uncomfortably aware of sweat dripping down my back. I hadn’t experienced this since the previous autumn.

Summer doesn’t arrive in Los Angeles until mid-June, and it was an average day with temperatures in the 80s. The hotel lobby and corridors felt comfortable, but a wave of hot air greeted me as the guest opened his door.

Entering, I recalled why I like Arabs so much. They appreciate air conditioning as much as Americans. Citizens of all other nations believe it spreads disease. They tolerate it as one of the perils of foreign travel, but when someone falls ill, the air conditioning stays off. Hip young hotel doctors dress in shirtsleeves, but hipness is a distant memory for me, so I wear a suit and tie. During a long summer visit, it’s debatable if I or the patient is suffering more.

I always explain that the machine that cools air in an air conditioner is identical to that in your refrigerator, and no one worries about disease from refrigerator air. This convinces no one, college graduates included.

Wednesday, June 22, 2011

Sunday, April 10, 2011

The room stood at the end of the hall, the largest suite on the floor. Through the half-open door I smelled alcohol and cigarette smoke, never a good sign. At my knock a voice urged me to enter. The room was empty, but this was the sitting room. A doorway led to the bedroom containing a small figure in a huge bed, covers drawn up to his chin. Balding and past forty, his disheveled hair was the single unkempt feature, and a goatee the only evidence of his foreignness. He was Prince Abdul-Aziz from Saudi Arabia. Arabian princes are more common than you’d think.

“I have pain,” he announced.

“Where is the pain, Mr. Aziz?”

“Kidney. I have kidney stones in my kidney.” He threw the covers to one side and pointed to his right flank. “My doctor prescribes Dihydrolex.”

“That’s not a drug I’m familiar with.”

“It is from London. I live in London.”

“Do you need a prescription?”

“Yes, but also a shot.”

I examined the prince’s abdomen and tested his urine for blood. Both exams were normal but this can happen with a stone. I thumped his back in the kidney area, and he groaned.

“I’ll give you a Toradol injection, but if the pain comes back, you’ll have to go where they can do some tests.”

“Many thanks.”

Any doubt about the prince’s drug consumption vanished when my needle jerked to a halt half an inch beneath the skin. Fibrosis from hundreds of injections had given his gluteus the consistency of a block of wood. I forced the syringe down a further inch and delivered the injection. Anticipating the pleasures ahead, the prince whirled to thank me, clasping my hand in gratitude.

“Remember what I said if the pain returns…” I repeated. “Should I ask the hotel to pay and put it on your bill?”

“No, no no. I pay!” Keeping a grip on my hand, he yanked open the drawer of the bedside table which turned out to be stuffed with hundred dollar bills. He snatched a handful and held them out.

Grateful the prince had forgotten his request for a prescription, I thanked him and hurried off. Later I counted fourteen bills. I gave them to my wife who bought a small Chinese rug for our living room.

The following day a rival hotel doctor phoned. “The Nikko wants me to see a guest,” he said. “Apparently you saw him yesterday, but you don’t want to see him again. Naturally I’m curious to know why.”

“I’m pretty sure he’s a drug abuser.”

“They said he was difficult. Is there any reason for me to see him?”

“He’s a big tipper.”

Wednesday, January 26, 2011

A guest at a Beverly Hills hotel was sitting in the hotel restaurant when her chair collapsed. Unfortunately, her hand was resting underneath. The desk clerk asked if I could come immediately.

During my early years, I often hurried over, took care of the problem, and presented my bill only to have the guest insist that the hotel was responsible. Management sometimes disagreed, leaving me unpaid, so I quickly learned to settle matters over the phone.

“Who’s responsible for the bill?” I asked. “If it’s the guest, I have to talk to her.”

The clerk hadn’t thought of this, so she put me on hold, returning to announce that the hotel would take care of it. This would be my 139th medicolegal visit, my name for a housecall when the hotel pays. The majority involve minor injuries that occur on the premises. There were also thirteen upset stomachs, purportedly from hotel food, and nine insect bites, always bedbugs according to the guest.

I arrived at the restaurant to greet a pleasant young Englishwoman, her hand in a bowl of ice. My examination revealed a torn and bloody middle fingernail but no laceration that required suturing. I explained that her nail might fall off but that another would grow. Unfortunately her ring finger, while not bloody, was exquisitely painful. She needed an x-ray.

If there were a fracture, an emergency room or perhaps even a family doctor would refer her to an orthopedist, so I decided to send her directly. If someone needs a referral, I want to make sure that they go, so I make the appointment myself. I didn’t know anyone locally, so I found an orthopedic group on the internet and phoned. When the receptionist asked about insurance, I said she would be a cash patient, a rare phenomenon even in Beverly Hills.

“An initial visit is $500,” the receptionist said. “She should have it when she comes in.”

“Wow!” said the patient when I passed this on. This was probably not a comment on the size of the fee (which the hotel would pay) but the traditional European amazement-cum-horror at American doctors’ preoccupation with money.

Both fingertips were fractured, she announced over the phone the next day before asking how long the pain would last. I sympathized; fingers are sensitive. She should apply ice and take ibuprofen and see her doctor in a few days. She planned to fly home.

Tuesday, January 11, 2011

Universal Assistance, a travel insurer asked me to visit an Argentinean teenager who was behaving oddly. When I arrived, her father explained that his daughter was under treatment for leukemia but was doing well. They were visiting relatives when, a few hours before, she had stopped speaking to them.

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 and then phoned Universal Assistance who would handle matters. The family obeyed. The daughter died soon after being admitted.

Sunday, January 2, 2011

The Christmas Rush

The last week of the year is my busiest. Competitors with whom I’m on speaking terms deny this, and I’ve long stopped theorizing why this is so. But calls begin pouring in at Christmas.

His teenage son had a terrible cough and sore throat, explained a caller from the Shangri-La, an upscale beach hotel. Maybe he needed an antibiotic.

The son had the usual virus. The father and mother were unfailingly polite as I delivered my explanation, handed over a bottle of cough medicine, and took my leave, but it was clear they would have been preferred an antibiotic. I urge patients to resist suggesting a treatment to a new doctor. If it’s unnecessary, the doctor may prescribe it anyway to make you happy. If he doesn’t prescribe it, and your thank-you at the end isn’t heartfelt (we are supersensitive to gratitude) he will feel he disappointed you.

Two hours later I drove to another Santa Monica hotel to see another teenager, this one with a sore throat. The father had seen white spots on her tonsils. Laymen believe “white spots on tonsils” is a sign of “strep,” but ordinary viral infections can make tonsils look bad. Some day I’ll write an article on ominous-signs-that-usually-aren’t (white spots on tonsils, cough with green mucus, yellow mucus, thick mucus, no mucus, fever more than … degrees, fever more than … days, green diarrhea, yellow diarrhea, funny smelling diarrhea, funny smelling urine….). Hearing this, patients invariably ask “then how do I know I’m sick?” My answer is: “because you’re sick.” Sickness makes you sick. If you don’t feel very sick, you’re probably not sick. Decide to see a doctor because you feel bad, not because a symptom.

It turned out that I treated her for strep. Good studies reveal that exudates on tonsils plus three other symptoms (fever, swollen neck glands, absence of cough) make the chance for strep fairly likely, and she had all four, so I handed over ten days of penicillin and received everyone’s heartfelt gratitude. Another pearl: if you’re not allergic to penicillin, and a doctor prescribes a different antibiotic for your sore throat (amoxicillin is acceptable), that’s excellent evidence you’re getting a placebo. After 70 years, penicillin is still the treatment of choice for strep; newer antibiotics work as well, but none work better, and all cost far more.