Saturday, December 10, 2011

Looking for Help

“Your blog is funny, and you’ve got a great thing going with hotels. I wonder if we can work together.”

Flattery is always welcome. The caller was a young doctor who explained that he was starting a concierge practice and needed someone to cover when he was away. Naturally, he was available to cover for me.

I’m always looking for help. Hotel doctors keep each other at arm’s length because, while it’s considered rude to solicit another doctor’s patients, soliciting a hotel is just business, and I don’t want them setting foot in mine. Luckily, I have a friendly relationship with one competitor, but it’s awkward if he leaves town or has an important engagement. Doctors in practice can’t help me because they’re stuck in the office. Residents or retired doctors can’t help because they’d have to buy malpractice insurance whose premium would dwarf any income I’d provide.

We met at a local restaurant. Already familiar with me from my blog, he did most of the talking, describing the superb service he provided his concierge patients. As you may know, concierge doctors accept no insurance. In exchange for a large annual retainer or other cash arrangement, they provide enhanced care: immediate availability, leisurely office visits with no waiting, 24 hour phone service, and house calls. Visits and house calls often cost extra, and none of this money covers tests, x-rays, specialists, and hospitalization, so it’s a service aimed at wealthy patients.

I learned that he worked several shifts a week at an urgent care clinic, so concierge medicine wasn’t paying all his bills yet. He denied any interest in hotel doctoring, but he would have been foolish to admit otherwise. We parted, promising to keep in touch.

I planned to see a Dodger game on July 4, a few weeks later. One of my brothers has season tickets; these are among the few times we get together, and I look forward to them. My hotel doctor colleague was attending a wedding at the same time. He was agreeable to covering but warned that he might have trouble getting away. I decided it was time to give the concierge doctor a chance.

I usually call-forward my number to my colleague, but he knows how to deal with hotel guests. For this new doctor, I decided to answer the phone myself. It rang as we were driving to the stadium. A woman’s child was suffering a severe cough and fever. She wanted a visit as soon as possible. I called the concierge doctor.

“They’re in Hawthorne,” I explained. “It’s far, so I quoted three hundred dollars.”

He sounded shocked “Three hundred dollars!! Doctor Oppenheim! It’s a holiday!”

“Right,” I said. “No freeway traffic.”

“Doctors don’t work on holidays. Patients understand that. They know they have to pay extra.”

“And that would be…?”

“My patients pay six hundred dollars.”

“That’s not in the cards. Do you want to make the visit or not?”

“Of course, I do. But I’m celebrating the holiday with my family like everyone else. I have to earn a reasonable fee if I get called away. Patients don’t object.”

“I’ll take care of this another way.” I hung up, furious. Before ordering my brother to drive me home, I phoned the patient’s mother. The child didn’t seem dangerously ill, so I persuaded her to wait a few hours. That solved the immediate problem but ruined the evening because I spent the time worrying about a catastrophe occurring while I indulged my frivolous love of baseball. When I phoned after the game, the child was sleeping, and the mother wanted to wait until morning. It turned out he had a routine cold.

I’m still looking for help.

Thursday, December 1, 2011

Stressful and Nonstressful Visits

I usually feel good when I finish caring for a patient, but driving to a hotel before a visit can be stressful. I talk to guests by phone beforehand, eliminating obvious emergencies and unreasonable requests, but plenty of worrisome possibilities remain.

Sick infants make some hotel doctors nervous. I see them but some don’t. If, over the phone, the doctor tells you to take your baby to an emergency room, ask politely if he prefers not to see infants. If he admits this is so, you might try to find another hotel doctor before going off (see the appendix).

Elderly patients can be challenging. They seem fragile, so a doctor may lean over backwards to treat illnesses that don’t require treatment or refer to a hospital more quickly than he would a younger person. I consider age eighty the beginning of fragility; other doctors begin at seventy, but this is clearly wrong because I am over seventy and not fragile at all.

If a patient has a bellyache, I’m never relaxed as I drive. Without tests or x-rays I have to decide whether or not it’s safe to wait. When I decide it’s safe, I’m almost always right, but I send guests to emergency rooms if some uncertainty remains. Many endure a long, tedious expensive experience only to learn that nothing abnormal has turned up. Some consider this good news, but others wonder why, having summoned me and paid my fee, I didn’t save them the trouble.

I’m always uneasy before seeing guests suffering a cold or other ordinary respiratory infection because a large percentage – perhaps a quarter – are obviously disappointed if I don’t prescribe an antibiotic. You don’t realize how bad we feel when a patient believes we haven’t helped. To avoid this, most doctors (yes, most) prescribe a useless antibiotic, but I don’t, so I approach these visits knowing I might leave feeling depressed.

On the bright side, I often drive off knowing the diagnosis, knowing I'll help, and certain the guest will deliver a satisfying dose of gratitude. Relaxing drives include those for simple urine infections, eye infections, ear infections, and rashes. I’m rarely concerned if a guest suffers vomiting or diarrhea, even in the presence of abdominal pain, because this usually indicates a short-lived stomach virus. Guests who want their blood pressure checked rarely worry me. High blood pressure doesn’t cause symptoms, so those who make this request have other problems, generally anxiety-related. This usually becomes clear during the phone call, but it’s risky to assume a complaint is purely emotional without an exam, and I do well reassuring anxious patients.

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.

Sunday, October 30, 2011

It's Still a Good Job

“How quickly can you get here?”

That may be the most common phrase I hear after a concierge identifies herself.

“Pretty quick, but I like to talk to the guest first. Would you connect me?”

I didn’t assume this was an emergency; guests who make urgent request are more often impatient than sick.

“When can you get here?” asked the guest impatiently.

“Pretty quick. What’s going on?”

“It’s my assistant. He’s got the flu.”

“Could you tell me what’s bothering him?”

“I’m not a doctor. That’s why I called you.”

I suppressed a surge of annoyance. “People mean different things when they say ‘the flu.’ Is he vomiting?”


“Is he feverish?”

“Yes. Listen! I have a dinner reservation at 6:15. Can you make it?”

It was 5:30. Unless guests feel truly miserable (vomiting, pain) they are usually willing to wait a few hours, so I often delay dinnertime calls until rush hour traffic dwindles. But hotel doctoring is a service as well as a dog-eat-dog business, and if I disappointed this demanding caller, he might ask the concierge to suggest someone else.

Creeping 1½ miles to the freeway onramp took fifteen minutes, but then traffic moved slowly but steadily, and I arrived on time. As is often true in my business, delivering medical care is the easiest part. The patient suffered a bad cold and didn’t consider it a serious problem. In person, his boss seemed congenial.

On my drive back, the freeway stopped cold. I took an exit three miles from home. Despite this, traffic crawled so slowly I was expecting a blocked lane ahead, but it was just the rush hour. It took an hour. On the bright side, I had finished half my dinner when the call arrived,, so I wasn’t hungry. And in hotel doctoring, when you finish seeing one patient, you go home.

Wednesday, October 26, 2011

Too Many Cooks

As I was preparing for bed, a call arrived from one of my favorite hotels, the Palomar. I like it because it’s large and upscale but mostly because it’s only a short drive. The caller explained that his nine year-old son had been coughing for three days.

“I started him on phenoxymethy penicillin,” he added.

“Does he have a bad sore throat?” I asked. Penicillin treats strep throat and no other common childhood illness, but the presence of coughing makes strep unlikely.

“No. I thought it might help… My brother is a pediatric consultant in London. He gave me a Ventolin inhaler.”

“Did that help?”

“A little.” That means “no,” but it was a good idea. Asthma inhalers often relieve a cough even in patients without asthma.

“I’m a doctor who comes to hotels. Would you like me to see him?” I asked.

“My wife wonders if I should take him to a clinic for a chest x-ray and blood tests.”

“Unless he’s very sick, that’s not necessary.”

“He’s doing better today. Maybe you should come. Can you give him cortisone?”

“I carry cortisone….”

“So you could give him an injection?”

“I would have to examine him first.”

After consulting with his wife, he said “We will wait for you.”

I exchanged my pajamas for a suit, filled out my encounter form, and was about to leave when the phone rang. It was the Palomar again, and I knew what that meant. Guests don’t like to cancel in person, so a hotel employee delivered the message.

“The gentleman says he’s decided to take the child to an urgent care clinic.”

“There’s no urgent care clinic in this area open so late. He’ll have to go to the UCLA emergency room.”

“Thanks for the information. I’ll tell him.”

I reverted to my pajamas and went to bed where I passed an uneventful night. The Palomar guest probably passed it in the emergency room.

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, October 8, 2011

Clever I-Phone features

My wife wanted to visit the Riverside photography museum, seventy miles away. On these trips, she drives, and I read aloud to her (on this occasion, Freedom by Jonathan Franzen… terrific!).

During any four hour period, there’s an even chance of a call, but only half require a visit. Our luck didn’t hold, and my phone rang after forty miles; someone was vomiting, not a visit I can stall. When we looked up the address on her I-phone GPS, it claimed no such location existed. Since this was an insurance call, the patient was foreign. She had phoned the insurance office whose dispatcher (also foreign) phoned me, so addresses often become garbled. I called the patient’s number and heard a busy signal, always a bad sign on today’s phones. I was forced to call the insurance number, spending a few minutes on hold before reaching a different dispatcher who spent several minutes researching before turning up the correct address.

Then the I-phone GPS worked its magic, laying out a detailed route to an obscure area near Long Beach thirty miles away. While I took care of the patient, she looked up a nearby restaurant on an I-phone Ap (Urban Spoon). We ate lunch and returned home.

Two days later we repeated the drive, this time successfully. Most photography museums are simply art galleries, but Riverside’s is part of the University of California, so it delivers large dose of interesting history with quantities of old cameras and old photographs. Afterward, she looked up a restaurant near the museum. Driving home with the rush hour approaching, I kept an eye on her I-phone GPS, marveling at its accuracy at predicting freeway jams.

My wife urges me to buy an I-phone. She loves it except when she hates it, and I observe her cursing, poking in vain at the touch-screen. So far my three year-old unsmart phone sends and receives calls without fail; no clever feature can match that.

Sunday, October 2, 2011

Why I Discourage Appointments

“The guest will be in the room at six o’clock and would like to see you then,” announced the concierge at two o’clock.

Tactfully, I suggested that she not make appointments without consulting me. The Torrance Marriott is eighteen miles away, and I didn't want to drive across town during the rush hour to see someone who wasn’t sick enough to leave work. I phoned to tell the guest that I could come immediately or around nine p.m. She chose nine.

Arriving ten minutes early, I knocked, and no one responded. Reached by cell phone, the guest reminded me that the visit was scheduled for nine. She was dining nearby, she added, and would hurry back. Twenty minutes passed before she arrived, but during that time another hotel phoned with a visit on my way home, so it looked like a good evening.

The guest arrived, apologized, and described her problem, a minor eye irritation. After I’d finished she mentioned that her husband felt under the weather. This is usually pleasant news because this couple had travel insurance. My routine is to ask the patient to phone the insurance to obtain its approval, so I could care for him and be paid. But obtaining authorization takes time. It was late, and I was anxious to see the next patient who seemed genuinely ill, so I treated the husband’s cold gratis and hurried off.

Wednesday, September 28, 2011


“I’m Doctor Oppenheim….”

“Welcome to the Intercontinental, Doctor Oppenheim. Are you checking in?”

Damn. Another employee who doesn’t recognize me. This happens in hotels that have called for decades. Who knows what she’ll tell a guest who asks for help?

No American hotel employs a “house doctor.” Some general managers designate a local practitioner. Some (under the impression that it protects them from liability) make up a list of physicians, but many pay no attention, leaving it up to guest service personnel. This gives the advantage to entrepreneurial doctors who tour hotels and extol their services to the staff, perhaps with the hint of material gain for a referral.

I can’t stomach delivering a sales pitch, but years ago I decided to hand a copy of my latest book to each general manager and explain modestly that writing allowed me free time to serve their guests. The managers listened politely, made flattering comments, and went back to work. It was clear many had no idea who I was. My tenth visit, to the downtown Hilton, was my last. “What do you mean ‘serve our guests?’” snapped the GM. “We don’t have a hotel doctor. We don’t want a hotel doctor. You’re going to get a letter from our lawyer!” He snatched my book and marched off. I was a familiar figure to Hilton staff, having made over 100 visits, but I never made another.

That was my first encounter with the epidemic of suitophobia that rages among hotel managers, compelling them to forbid staff from helping sick guests except by getting them off the premises. At any given time, about ten percent are affected. Most recover after a few years. I made over 600 visits to the J.W. Marriott in Century City before calls abruptly stopped. I learned the reason from concierges who swore me to secrecy when they snuck me in to see a particularly demanding guest.

Here’s a scenario that should give these managers pause. A guest asks for a doctor. The employee explains that, for liability reasons, he cannot comply but will happily provide directions to the nearest hospital. The guest declines to go. The employee offers to call paramedics. The guest refuses, returns to his room, and dies. Lawyers will fall over themselves to take this case: the guest asked for help and didn’t get it. I’ve dealt with similar cases, often over the phone. Most sick guests don’t need an emergency room or the paramedics, but when they do I don’t take no for an answer. I’ve delivered this argument to half a dozen general managers and persuaded none. The disease must run its course.

Sunday, September 11, 2011

Popular requests

Long ago a man phoned to inform me that he was on his honeymoon and would like a shot of testosterone. I explained that this was unlikely to solve his problem. Then I gave advice.

He did not want to leave any stone unturned, and I’m happy to make a housecall to deliver a harmless injection, but I couldn’t in this case because I didn’t carry testosterone. I bought some on my next drug order. Sadly, I never received another request. I discarded the vial after it expired and never replaced it.

Also long ago, a woman whose hot flashes were acting up asked for an estrogen injection. I explained that pills work as well, but she was willing to pay for an injection which I couldn’t provide. I ordered estrogen, but no one has asked for it since.

I carry two sorts of medication: those guests need and those they ask for. The second category is tricky as these examples illustrate. Another: bereaved guests or those in great emotional distress often beg for a shot to “put them out.” Unfortunately, although movie doctors use it regularly, there is no injection that makes you go to sleep. Given intravenously, a general anesthetic works, but it’s a bad idea to do this outside of a medical facility. Michael Jackson’s doctor disagreed, and it turned out badly.

B12 remains a hotel doctor’s only reliable moneymaking placebo. I’ve never encountered an illness that required it, but requests arrive several times a year. Celebrities often ask for an injection before a performance, always a thrill.

Friday, September 9, 2011

Sorry for the Mess

This is the most common phrase a hotel doctor hears. Sometimes I hear it as I step into the room, more often when I look for a place to set down my paperwork because all surfaces are piled with discarded clothes, toilet articles, food wrappers, luggage.

A messy room does not greatly embarrass guests. This is not the case when, after putting a thermometer in a guest’s mouth,I announce that I will wash my hands. That produces a minor panic as someone hurries into the bathroom to clear away another mess and search, sometimes in vain, for a clean towel.

A final ritual is collecting my fee. Technology makes accepting credit cards easy although the company takes about five percent for the convenience. Using a phone, I dial a computer whose automated voice instructs me to enter half a dozen codes (my bank number, my merchant number, the credit card number…). In the past I used the room phone until I noticed guests looking uneasy and remembered that hotels charge for calls. Now I use my cell phone, an awkward alternative because the small keypad encourages mistakes. At the end, the computer announces its approval and recites an authorization code which I dutifully copy. Occasionally, in an ominous tone, it denies approval, and I laboriously re-enter everything. If this doesn’t work, there is a scramble as guests search for another card or their wallets.

Cash-paying foreign guests take time counting out my fee because all American bills look alike. Around the world, denominations vary by color, so a quick glance tells a native its value. I think America is the only nation with monochromatic money.

When guests mention their difficulty, I joke that Americans find colored bills frivolous, like Monopoly money. Real money is green.

Friday, September 2, 2011

Mid-level chains (Hilton, Hyatt, Holiday Inn, Sheraton) provide most of my business. I love luxury hotels, but these have traditionally been the bread-and-butter of hotel doctoring, so my competitors, all more entrepreneurial than I, love them more. The result is that when one of them notices an iconic Los Angeles hotel (Bel Air, Beverly Hills Hotel, Sofitel, Four Seasons) calling me too often, he steps in and points out the error of their ways.

My colleagues don’t care to travel, so I’m the doctor for the most opulent hotel in the county: the Langham (formerly Ritz-Carlton) in Pasadena 25 miles away. It sits on twenty acres that includes a beautiful Italianate-style main building, luxurious Spanish Revival-style cottages, and a historic garden.

Last week the Langham concierge asked me to speak to a guest. As soon as she came on the line, I knew she felt terrible. She sounded weary and hoarse after vomiting for several hours. She was in good health, so odds favored the usual stomach virus, miserable but rarely life-threatening. Most vomiters want quick relief, but she preferred to wait it out. I gave the usual advice (don’t eat, don’t drink, suck on a piece of ice) and left my number. Fifteen minutes later the concierge connected me to another vomiting guest who also declined a visit.

This would have been a rare treat Рtwo patients at the same hotel. Sadly, both were American. Since Pasadena lacks the tourist cach̩ of Los Angeles, Langham guests include more Americans who are less inclined to pay for a housecall than foreigners who accept their helplessness in the hands of a rapacious medical system.

When I phoned later that day, both had recovered. They were grateful for my concern, but they would have been more grateful if I’d cared for them. Although you might not think so, I consider vomiting a good visit. It usually doesn’t last long, and the doctor gets the credit when it stops.

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.

Saturday, August 13, 2011

Years ago, I noticed that International Travel Assist was taking six months to pay and then only after repeated phone calls. When it refused to give me a credit card number, I began declining its visits. With the stock market diving along with my retirement nest egg, I’m less inclined to turn away business. So I accepted an ITA visit to a middle-aged man with a bellyache.

“He has terrible pain,” his wife announced as she ushered me into his room. I dismiss many worried complaints (“His fever isn’t going away….” “His mucus is green…”), but this one often means bad news.

Sure enough, the man looked sick. He was feverish. His abdomen felt exquisitely tender and rigid, a sign of peritonitis. He needed to go to an emergency room, I informed them. I dialed ITA’s number to let them know.

Uneasily, I recalled that International Travel Assist had other ways to economize besides stiffing doctors. Sure enough, after hearing the news the dispatcher informed me that the patient must first go to the Airport Medical Center, an urgent care clinic. I often do the same when guests from nearby hotels need something I can’t provide such as an x-ray. It’s not part of a hospital, and the doctor on duty has the same training as I.

I gave the patient and his wife directions to the clinic. Since many doctors lean over backward to send patients to emergency rooms, a second opinion probably saves ITA money, but it wouldn’t in this case because my patient needed an ER. There was always a chance the doctor on duty would decide to send him home, so I phoned the clinic to make sure he thought twice.

Telling a doctor what to do is counter-productive, so I chose my words carefully. I was sending a man with bad abdominal pain and peritoneal signs, I explained. If it were an office patient, I would have sent him to the hospital for scans and a surgical consult, but his insurance insisted he go to an urgent care clinic.

He thanked me for the information. “We don’t have too many facilities here,” he added. “But we’ll do what we can.”

“Don’t do anything. Send him to the hospital,” would have been tactless, so I didn’t say it. Once a doctor decides a patient needs emergency care, allowing a test to change his mind is a bad idea. Thus, I thought the man had an abdominal infection. Had I ordered a blood count, an elevated white cell count would point to an infection. Good... But sometimes the test comes back normal. What then? The answer: send him to the ER anyway. It’s another rule of medicine that a doctor shouldn’t order a test that doesn’t change the treatment, but we disobey that all the time.

So the man passed a few miserable hours while the doctor ordered tests that doctors order when a patient has a fever and bellyache: a blood count and an abdominal x-ray. I have no idea of the results, but I checked to make sure he’d gone to the hospital, and he had.

Monday, August 8, 2011

A guest from Argentina reported his child had a fever. He spoke no English but, through the bellman, asked if I took his insurance: Universal Assistance. I did, adding that he must call Universal Assistance first and receive a go-ahead. Then Universal Assistance calls me. After giving its 800 number to the bellman who passed it on to the guest, I hung up and immediately regretted it.

I should have asked the guest’s name and insurance I.D. number and then sent the guest to his room. Then I should have phoned Universal Assistance to tell them a client wanted a housecall. When I’m lazy and trust the guest to take care of things, I often never hear back.

I called an hour later, but the bellman didn’t remember the guest’s name.

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, July 20, 2011

I Get Letters

Mostly from workers in the hotel business. In my dreams, agents write, suggesting a book, perhaps entitled “Hotel Doctor to the Stars.” So far these haven’t arrived, but physicians occasionally E-mail me. They want to know how to become a hotel doctor.

I suggest reading the earliest entries to this blog where I describe my own beginnings, but here's a short version.

To become a hotel doctor I advise them to (1) let local hotels know they’re available and (2) wait. It helps if (3) there’s no competition. That worked for me although it took over ten years from the time I began until 1992 when my yearly visits passed 1,000, and I quit other jobs to become a fulltime hotel doctor. By then others were entering the field, so newer doctors will wait longer. No one likes to read that.

My only advertising is a letter to general managers three or four times a year, but I'm aware that there are better techniques. Aggressive competitors who extol their services to desk clerks and concierges often take over my regular hotels, at least temporarily, but it didn’t work when I tried it. At better hotels, employees are nice to everyone, so they listened intently, eagerly accepted my business card, and promised to keep me in mind. The first few times, I left feeling pleased with myself, but calls never followed. At cheaper hotels and motels, staff seemed mystified at the concept of calling a hotel doctor. No one ever got sick, they insisted.

It’s possible I was missing the key inducement: money. Paying a bellman, desk clerk, or concierge “referral fee” has a long tradition in hotel doctoring. It’s illegal for a doctor to pay for a referral. All my competitors denounce the practice, but it’s not rare for a bellman to rush up and announce, “I’m the one who told Mrs. Jones to call you. I always tell guests to call Dr. Oppenheim…” They invariably look puzzled when I explain that I’m happy to provide free consultations to employees, but tips are against the law. They never argue, but I suspect they’re mentally crossing me off their list.

Thursday, June 30, 2011

In rudimentary English, a guest from Checkers, an upscale downtown hotel, explained that his rash needed attention.

“I’ll be there within the hour,” I said, and quoted the fee. He replied with a phrase that makes a hotel doctor’s heart sink.

“I have insurance.”

From an American, this means the visit is no-go. I work alone, and collecting from American carriers requires either a trained billing clerk or far more patience and self-control than I possess. Mostly I refer these guests to a local walk-in clinic.

Foreign travel insurers are better. I send a bill, and (unlike American insurers) they always send a check for the identical amount. I asked the name of his insurer. It was Assistcard, an agency that’s called since the 90s.

The proper step was to ask the guest to phone Assistcard who would check his eligibility, approve the visit, and phone me. This never happens quickly, but it’s rarely a problem because 95 percent of travelers call their insurance first, so I don’t hear about the visit until it’s approved. This guest had mistakenly called me. To speed up matters, I told him I would call.

After listening to my explanation, the Assistcard dispatcher said she would call the guest, confirm his coverage, and call back. To pass time, I booted up my copy of Sim City. This worked too well; after 45 minutes of wrestling with urban problems I realized the phone had remained silent. Calling, I discovered that my dispatcher had vanished, perhaps to lunch. After putting me on hold, another dispatcher assured me that the wheels were turning. I phoned the guest to make sure he hadn’t wandered off only to learn that no one had called and that his tour was leaving in two hours. I called the dispatcher who explained that the guest was Indonesian, and he was in Argentina, so approval might take a while.

Once the guest left for his tour, the visit would evaporate, so, after waiting another half hour, I decided to drive down and take my chances. My phone rang while I was on the freeway. The dispatcher informed me that no one could find the guest’s proof of insurance, but that didn’t mean it wouldn’t turn up. Learning I was on the road, he offered to call the guest and suggest he pay me directly and try to claim reimbursement. That rarely works, but it worked this time.

Wednesday, June 22, 2011

Tuesday, June 14, 2011

“Woody Allen needs a doctor. How quickly can you get here?” The caller was the concierge from the J.W. Marriott. This happened almost twenty years ago.

“Ten minutes,” I replied. The J.W. Marriott was in Century City, near Beverly Hills, a five minute drive. I had only to change into my suit and grab my bag.

“I don’t know….” She seemed doubtful. “I guess you should come.”

That was strange. How many doctors appear at your door ten minutes after you call…? I threw on my suit and raced to my car. Nearing the hotel revealed a sight that always makes my heart sink: a paramedic ambulance. The odds that a second guest had fallen ill were tiny, so the arrival of paramedics meant my visit was in vain.

“He couldn’t wait,” the concierge called out as I hurried past. There was still a chance. Most 911 calls are not emergencies, and paramedics sometimes declined to transport those. Sadly, they were burned in several well-publicized cases when someone died after they left. Thereafter, their refusal rate plummeted, but I never lost hope.

Leaving the elevator, I had no trouble finding the room because paramedics attract a crowd. It parted as I approached, and I caught a fleeting glimpse of Woody Allen as paramedics rolled him past on a gurney. I returned home. According to the news, he was back in circulation the next day.

My experience with actors is that their day-to-day personality carries over to the screen, so I theorized that Woody Allen had suffered a panic attack. Agitated guests frighten hotel employees, so they’re quick to call paramedics, but if they have the sense to think of me, their problem vanishes. I have a soothing manner, a white beard and white hair (they weren’t so white back in 1993). Once I arrive and settle into a chair, I rarely fail to calm a panicky guest. Phoned in the middle of the night, I do the same without getting out of bed. Woody Allen should have waited for me.

I can name Woody Allen because I was never his doctor, but, sadly, celebrity patients are off limits. Most were nice, but over thirty years, I’ve cared for a number of misbehaving luminaries including several who died under dramatic circumstances. The curious assure me that “you can’t libel the dead,” but the dead’s loved ones have been known to sue after unflattering remarks.

Wednesday, June 8, 2011

I broke my distance record last week, driving 94 miles to care for a man with a sore throat.

I’ve found it good business not to refuse distant visits. It’s hard arrange a housecall on short notice, so housecall agencies and travel insurers keep a list of doctors for every area. But humans are creatures of habit, and once a dispatcher learns that calling me always gets the housecall, they continue to call. Ignored, other doctors drift away, and I become the only one available. As long as I don’t refuse too often, they don’t bestir themselves to refresh the list.

I quoted a fee that took into account the long drive, pointing out that it would be cheaper to send the patient to a local clinic. This sometimes gets me off the hook, but it didn’t in this case, so I drove to Santa Barbara. That’s where I served my internship long ago in 1972-73, and the hotel turned out to be three blocks from my former apartment. It was not there forty years ago, and the area has become unrecognizable, so I felt no nostalgia. I saw the patient, stretched my legs, and drove home.

Monday, May 30, 2011

Tokio Marine, a Japanese insurance service, phoned about a patient at the Kyoto Grand. Insurance services make up a quarter of my business, and I love them. All serve foreign travelers who often speak no English and stay in distant locations, but they also stay in every local hotel including those of my competitors. I enjoy good relations with one competitor, so I wouldn’t step on his toes. Others regularly poach, and while I don’t visit their hotels to solicit, if I happen to be there on other business…

The Kyoto Grand is a large hotel in downtown Los Angeles. Insurers send me every few months, but the hotel never calls. I was pleased when the Tokio Marine dispatcher told me to stop at the front desk where an employee would accompany me to interpret. Of all foreign patients, Japanese have the largest percentage of zero-English speakers, and interpreting over the phone with the insurance company is tedious.

Leaving after caring for the patient, I told the employee of my services. She responded that the hotel had a doctor who practiced in nearby Little Tokyo, but she accepted my business card, promising to keep me in mind.

Minutes after returning home, my phone rang. It was the employee informing me that another guest needed my services. Naturally, I was delighted, and I drove back downtown to care for an Australian with an upset stomach.

You might think I am now the doctor for the Kyoto Grand, but this incident happened months ago, and no calls have arrived since. While the lady may have lost my card, it’s more likely she simply neglected to tell anyone else about me. A dozen Los Angeles hotels call rarely because only a single employee knows me. Now and then the news gets around, and the hotel becomes a regular, but I have never figured out how to persuade someone to pass the word.

Sunday, May 22, 2011

Several hundred Norwegians arrived in the city last week, and I cared for four who fell ill. Not all Norwegians are good-looking or blonde, but I didn’t see any who were overweight, and they spoke English.

They were guests at the Hollywood Heights hotel in my least favorite part of Los Angeles. Hollywood's tourist glitz is a minor matter; I dislike the drive. Despite our legendary freeways, none reach from my part of Los Angeles to Hollywood, so I travel nine miles through the city. Planned in the 1960s, the Beverly Hills freeway would have solved my problem, but it vanished from maps when the city insisted it be built underground, a good idea.

The first Norwegian suffered a urine infection, common and easy to treat. The second had a hacking cough, present several days, which tormented three roommates almost as much as the patient. I handed over a bottle of cough medicine. The third had been vomiting. Everyone with an upset stomach blames their last meal, so I listened to a recital of everything he’d eaten.

The last had been to Universal Studios and thought she had sunstroke. Sunstroke is life-threatening, but there are lesser sun-related conditions, none of which she had. She did not even have the painful sunburn that northern Europeans acquire almost as soon as they get off the plane. Universal City is beyond the Hollywood Hills, an area hotter than Los Angeles proper, but it hadn’t been abnormally hot.

Hearing my reassurance, she admitted that her nausea and anxiety may have represented a mild panic attack. She suffered them regularly. This one was receding.

At midnight two days later she phoned, begging me to come immediately. Something terrible was happening, and she needed me to take her blood pressure and examine her and tell her she was OK. This was a full-blown panic attack, she informed me. She believed she was dying. When I assured her that she would not die, she did not deny it but pleaded tearfully for me to come. Victims of panic attacks are not psychotic. They know their fears are irrational, but they can’t resist them.

These calls are not rare, and I try to handle them without a visit. Ten minutes of soothing reassurance and the knowledge that I’m immediately available over the phone usually works. It also works when I visit a guest whose complaint unexpectedly turns out to be a panic attack. Unfortunately, these successes are guests who don’t know they’re having an attack or suffer them only rarely. This lady was a hard-core, locked-in panic attack regular. Her attacks followed a strict pattern, and no reassurance would change matters.

If I came, examined, and found everything normal, she would express gratitude, but even before I finished counting my money, she would be pleading for another exam. Yes (I know you’re asking) there are shots, and I give them, but they never work. I hate walking out on a guest who’s begging me to stay, and these attacks may last hours.

This guest was young and healthy. Her conviction that she was dying was clearly wrong. Yet… Every doctor has heard stories of patients who announce that they’re dying and then proceed to die. No doctor wants to be the source of such an anecdote, so this lady needed at least one exam. As I was agonizing, she broke in to say she would ask the hotel to call an ambulance. Then she hung up. I phoned the front desk ten minutes later to make sure they had done so. The paramedics would examine her and, if the results were normal, leave despite any pleas.

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.