Sunday, December 18, 2011

Everyone Wants To Go Home

“Our flight leaves at nine. My son was vomiting all afternoon, but he’s sleeping now. Is it OK to go?”

The son was 18 months old. Doctors don’t prescribe antivomiting drugs to young children, so there was nothing I could do over the phone except give advice. Most vomiting in children isn’t serious and doesn’t last long, but……

“There’s six of us going to Australia. We can’t miss the flight.”

Long ago if you faced this problem, you went to the local airline office and exchanged your ticket. Local airline offices are a distant memory, and ticket exchange with its restrictions and expensive penalties strikes fear into the heart of any traveler. No one wants to miss a flight.

If I came to the hotel, examined the child, and found nothing wrong, I couldn’t promise he wouldn’t resume vomiting in a few hours. I’d be more confident after a day, but the family didn’t want to hear that.

I hung up, knowing I’d sentenced them to a bureaucratic nightmare and also knowing I’d probably hear from them again. Some travelers head for the airport and hope for the best; others phone the airline for advice, emphasizing that the child was sick earlier but is perfectly fine now. No airline wants a sick person on board, and every customer service agent knows what to say.

“They want a doctor’s note,” explained the same caller an hour later. “Can you come?”

Most visits to deliver a doctor’s note are a snap because guests have already been sick, missed their flight, and recovered, so I’m simply handing over official permission to board the plane. This is never true while the illness is running its course. Guests yearn for me to clear them for the flight, but I almost never do. Failing that, they hope my note will persuade the airline to reschedule everyone gratis. This sometimes works, but the era when a doctor’s note served as a get-out-of-jail-free card is long past. In this case, they were lucky. The airline insisted that four proceed on to Australia, reticketed the mother and child for the next flight in four days with no penalty but also no reimbursement for the extra days in the hotel.

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.