Followers

Sunday, December 30, 2012

A Difficult Christmas


A woman began vomiting the morning after Christmas dinner.

People blame upset stomachs on their last meal, but mostly these are viral infections. Although miserable, they rarely last long. Doctors enjoy short-lived illnesses because we get the credit when they go away.

She hadn’t vomited for several hours and was already feeling better. As I was congratulating myself on an easy visit, I heard the unmistakable sound of retching from the bathroom. This was her husband, the woman explained, adding that her mother and two year-old were also ill.

When the husband appeared, I took care of him. Unlike his wife, he welcomed an injection in addition to antivomiting pills which I also gave the mother as well as medication for her cramps and diarrhea. The child had diarrhea and little interest in eating but did not look ill. I limited myself to dietary advice and left my phone number.

When I phoned the following day, the husband informed me that the family was fine although everyone had been vomiting all night.

Tuesday, December 25, 2012

How to Summon a Hotel Doctor

Getting sick far from home is miserable enough; you shouldn’t have to scramble for help. Here’s the best strategy.

1. Ask a hotel employee.

This often succeeds, but you may see him scratch his head. ‘... St. Mary’s is the nearest emergency room. Take Seventh Avenue about a mile, then...’ 

Don’t give up. Relations with the ‘house doctor’ are informal. He or she is never a hotel employee, and many on the staff are unaware of such a person. ‘You’re our doctor?  I didn’t know we had a doctor...’ is a comment I hear at hotels I’ve visited for years.

2. Ask the manager.

All know hotel doctors although you’ll occasionally hear: ‘I’m sorry but we can’t recommend anyone. Here’s a list of local hospitals...’ You are encountering one consequence of today’s malpractice crisis. The hotel’s lawyer has assumed (correctly) that a guest who sues the doctor will also sue the hotel that recommended him, so the lawyer has forbidden the staff to name anyone. When a manager clams up, you have four choices.

A. Demand a doctor.

Occasionally I visit an assertive guest who refuses to take no for an answer. I introduce myself to the manager afterwards, but he or she invariably insists that this was an exception, and the hotel can never, never mention my name.

B. Phone another hotel and ask for its doctor.

All luxury hotels (Four Seasons, Ritz-Carlton, Peninsula) have doctors; popular chains (Hilton, Holiday Inn, Hyatt, Ramada) are unpredictable, but the larger the hotel, the more likely you’ll succeed.

C. Phone a national house call service.

All claim to operate nationwide, but  you're out of luck if no moonlighter happens to be available. Some names to Google are Expressdoc, Housecall USA, AM-PM House calls, Hoteldocs. Their fee not only pays the doctor but the organization, so it can take your breath away. Ask how much and then ask for the extras because the meter may start running as soon as he walks through the door. I’m pretty sure I’m the only hotel doctor who charges a flat fee.

D. Call your family doctor for advice.

The law requires that a doctor be available to patients. You should reach him or someone covering. If not, complain to your state medical board.

What about insurance? Specific travel insurance pays for almost everything, and it’s cheaper than you think. Traditional health insurance may pay a fraction or apply it to your deductible. HMO’s are variable. All claim to cover emergencies, but they look skeptically on house calls…. I hate giving the following advice and never obey it myself: read your policy.


Wednesday, December 19, 2012

Nonsense that Everyone Believes

Here are myths that most laymen take for granted. A more serious problem is that many doctors also believe them. 

1.  If it hurts, it needs an x-ray.
Excellent for detecting fractures, X-rays are surprisingly unhelpful in other painful conditions.  Almost everyone suffering an excruciating headache, backache, bellyache, or hacking cough wants to know what’s going on inside, and they assume that, like Superman’s X-ray vision, a film reveals this, but it doesn’t.

2.  If your sputum turns green you need an antibiotic.
Your respiratory tract produces a quart of mucus every day.  When irritated, it produces more and the sputum may turn yellow, green, or brown. In an otherwise healthy person, this has no significance.

3. If one medicine isn’t working, you need a better medicine.
Understandable in a layperson but doctors should know better. In medical school, students are drilled in the rule:  if a drug isn’t working, switching is almost never the solution. Find out why the patient isn’t improving. It’s more likely that the diagnosis is wrong.

4.  Spicy food irritates your stomach.  Fats are hard to digest.  Tasteless and colorless (i.e. bland) food is soothing.
All proven false by good studies. 

5. High blood pressure causes headaches or dizziness.
Ordinary high blood pressure causes no symptoms.

6. Bronchitis requires an antibiotic.
“Bronchitis” is almost always a viral infection; antibiotics don’t work.

7. Injections work faster than pills.
Sometimes, sometimes, not.  Doctors can charge for an injection. If they write a prescription, the pharmacist gets the money.

***Another warning. It looks like this blog will vanish on January 15 when my Medscape E-mail service goes out of business. Appeals to Google Help have proved fruitless. I plan to start another, and it will probably have the same name The Hotel Doctor. Keep your eyes peeled. ***

Thursday, December 13, 2012

Disappointment

“We have a guest who needs a doctor. Are you available?”

“I am. If you connect me to his room, I’ll try to help.”

My tone was businesslike, but joy filled my heart. The caller was the Renaissance which never called. Acquiring a competitor’s hotel is a rare and delightful event.

A male voice answered after two rings. “There’s something in my eye.”

“Tell me what happened.”

“It’s no big deal. If you give me tweezers, I’ll take it out myself.”

“You mean it’s visible?”

“There’s a sliver stuck in my eyeball… Don’t tell me to go to a hospital. I’ll sign anything. Come to the room. Or get me tweezers.”

He interrupted my response.

“No hospital! No emergency room! Bring legal documentation to protect your liability. I’ll sign. You have to look at my hand. It’s been broken for two weeks. Come alone. Don’t bring any FBI or CIA.”

I called the concierge to report that this was a matter for the police or paramedics. She admitted that the guest was causing a considerable disturbance.

Sadly, I realized that the Renaissance was not changing doctors. Hotels hate dealing with crazy, drunk, or disruptive guests. When the regular doctor refused to come, the staff, in desperation, began calling other doctors in hopes that one would make the problem go away. This happens once or twice a year.

Friday, December 7, 2012

Cash Flow Problems

“Pick up card! Pick up card!” intoned the computer.

Unlike other messages, this never means a typing mistake, but I re-entered the numbers and heard the same announcement.

Wearily, I phoned International Assistance to explain that their credit card had been rejected. The dispatcher put me on hold for several minutes before returning with another card number. In the past, I’ve gone through several before hearing the computer’s approval, but this one worked, and I left for the hotel.

International Assistance insures travelers from Latin America. It’s sent me on nearly 900 housecalls since the 1980s, but over the past decade it began requiring months of pestering before sending a check. Finally I lost patience and demanded a credit card. Credit card companies charge about six percent of my fee, but they’re a big convenience. I punch in data; two days later money appears in my bank account.

Slow payments usually means an organization is struggling. They’re maxing out their credit cards and getting them cancelled but keeping others in reserve. A few have gone out of business, owing money, but International Assistance has been irritating doctors for years; many colleagues refuse its requests. It’s the oldest of half a dozen travel insurers that call me, so this may be a tactic for minimizing cash flow.

Sunday, December 2, 2012

A Dog-Eat-Dog Business, Part 3

November is my slowest month. Calls remain scanty until Christmas, but the last week of December is always the busiest of the year. Don’t ask me why.

Thirty years of records confirm this, so I should keep calm when the phone remains silent, but it’s not easy. Hotel doctoring is viciously competitive.

Waiting at the local carwash, my eye ran over a sheet of ads along one wall. Among notices for personal injury lawyers, pest control, acupuncturists, and pizzas was a photo of a smiling young man in a white coat carrying a doctor’s bag. According to the text, a phone call would bring him to your door at a fee less than an emergency room’s. All ads for housecalls deliver this cheerful boast, never mentioning that the average ER visit, as of 2009, cost $1318.    

My first instinct was to chuckle at the waste of money. Few customers at a carwash will pay the going rate for a housecall. My second instinct was to worry. This fellow was ambitious. His web site features the same photograph plus testimonials from rating sites such as Yelp describing him as a healer of Christ-like compassion.

My third instinct was to recall a visit to Le Petite Hermitage, a small boutique hotel off the Sunset Strip. The guest had spoken to this doctor the day before, decided against a visit, and expressed pleasure at finding me and my lower fee. Since Le Petite Hermitage was a regular, I assumed he’d gotten the name from the internet. Now I’m not so sure because this occurred early in the year, and hotel hasn’t called since.

In large hotels employees know me by sight and take for granted, even without an official announcement, that I’m the house doctor. Since it has only 80 rooms, I may not visit Le Petite Hermitage for months at a time, so I’m not a familiar face. As a result, when an entrepreneurial physician makes an appearance to extol the benefits of his service including, perhaps, an amenity for the employee who refers a guest, he makes an impression.

Thursday, November 29, 2012

Addicted to Gratitude

“You saw me at the Marriott yesterday. I still don’t feel good.”

“I’m sorry,” I said. “I did mention that you’d be under the weather a few days.”

“I still have a temperature. The Tylenol only works a few hours. The cough medicine isn’t doing much. I need something stronger.”

“I would love to make you better, but, as I explained, there’s no cure for these respiratory viruses.”

“What if it’s bronchitis? My doctor tells me I have a lot of bronchitis.”

“‘Bronchitis’ is just another word for coughing. It’s a virus that runs its course.”

“I guess I just have to be sick. Thank you, Doctor Oppenheim,” she said before hanging up. She remained polite but did not conceal her disappointment. I felt bad.

I also felt a surge of anger at my fellow doctors, most of whom prescribe antibiotics for viral infections. No doctor believes they work, but prescribing them guarantees a patient’s gratitude; doctors are addicted to your gratitude. 

My practice is to prescribe antibiotics when they’ll help and not to prescribe them when they won’t. After I do this, about three quarters of patients seem genuinely grateful. Most of the remainder are dissatisfied but remember their manners. Perhaps one percent make it vividly clear that I have failed them. I must admit that, if I see an explosion in the works, I whip out my prescription pad, but sometimes I’m too late.

Sunday, November 25, 2012

The Superiority of American Medicine

Patriots boast that American medicine is the best in the world. My view is more nuanced, but let me take their point of view. You’ll be amazed at the dumb things foreign doctors do!

They don’t give antibiotics for ear infections!
If your child suffers a miserable, painful ear infection, your doctor prescribes an antibiotic. In many European countries, doctors give medicines for pain and fever but no antibiotic. If you’re wondering what happens to these poor children with earaches, the answer is: they get better. Even in America, experts are debating whether or not antibiotics work for ear infections. Maybe they don’t. Until experts make up their minds, American doctors will prescribe antibiotics.

They don’t care for hysterectomies!
Many women develop lumpy growths on the uterus called fibroids. Although harmless, fibroids may cause pain and irregular menstrual bleeding. A gynecologist can cure this by removing the uterus. Called a hysterectomy, it’s the second most common operation American women undergo (after caesarians; America leads the world in both). Naturally, a woman without a uterus can’t have children.

The French have the odd idea the world would be a better place if there were more Frenchmen, so French doctors don’t sterilize women if they can avoid it. Mostly, they perform an operation that cuts off the fibroids but leaves the uterus intact. The surgery is more complicated and takes longer than a simple hysterectomy. American gynecologists could do the same, but they don’t, and they rarely discuss it with patients because they know American women aren’t interested.

They don’t try to cure every patient.
American doctors order more tests and prescribe more antibiotics, chemotherapy, and other powerful drugs than foreign doctors. They also perform far more surgery. All these extras don’t necessarily cure. Sometimes they make patients sicker, but the important thing is that we’re doing something. American like aggressive doctors.

Foreign doctors spend a great deal of time making patients feel better – for example by ordering physical therapy (massage, exercise, heat, baths). American doctors prescribe physical therapy to help recovery after surgery or injuries. European doctors prescribe it after childbirth and for migraines, irritable bowels, arthritis, fatigue, depression – dozens of problems. European doctors actually send patients to health spas for baths, massage, etc., and health insurance pays for it! If you believe this is a waste of money, American doctors agree. Patients may feel better after a spa treatment, they explain, but it’s psychosomatic (in other words, if someone feels better -- but it’s only psychosomatic -- that’s bad).

They give free medicine to children!
No discounts, no deductible, no co-pay – just free. In a dozen countries including Canada, the government also pays for hospital care, doctor visits, nursing homes, and it even pays women to take off work to care for newborn babies. These foreign countries claim their citizens live longer, have lower infant and maternal mortality, and enjoy better health. This sounds wonderful, and it’s also true, but American advocates of the free market point out the soul-destroying price those nations pay: higher taxes. Americans must never follow that path, they warn.

We haven’t. President Obama took for granted that the most efficient, lowest cost universal program, the single-payer (i.e. everyone pays a tax; the government pays for health care) would never pass, and he was probably right. The result is Obamacare, a tortuously complex Rube-Goldberg program that avoids direct taxes and relies on individuals and businesses buying insurance.

Liberals point out (with complete lack of success) that single payer systems benefit the free market. Employee insurance premiums have always burdened American business. We’ve all read that $1,500 of the cost of a Chevrolet is what General Motors pays for medical benefits of those who built it. The companies that build Hondas and Volkswagens don’t pay employee health insurance.

Sunday, November 18, 2012

The Evils of Common Sense



“I can walk on it, so I know it’s not broken.”

It turns out that the fibula, one of two bones in the lower leg, doesn’t bear weight. You walk on your tibia.

“I can move it, so I know it’s not broken.” You may know, but I’m not so sure.

Patients yearn to understand their problem. In the absence of evidence, they use common sense which turns out to be a terrible way to get at the truth. In fact, it’s a good rule that any common sense explanation of a medical problem is wrong. Here are others that I hear all the time.

“I have to let this run its course…”

Seeing smoke pour out of your car’s exhaust, no one explains that the engine is repairing itself by expelling bad things. Yet plenty of patients believe their vomiting or diarrhea is the body’s attempt to cleanse itself. In fact, it’s a simple malfunction. It’s OK to treat it although exceptions exist for a few serious diseases.

“Fever is your body’s way of fighting an infection.”

This may not be wrong (scientists still debate this), but it leads to many sensible beliefs that, being sensible, are wrong.

Google “does fever treatment help” for an avalanche of praise for fever's healing properties from doctors and medical sites as well as laymen. Don’t believe it.

Here’s the truth. Your body generates fever in response to viral and bacterial infections. It’s an immune response. Enthusiasts regularly quote studies showing certain germs that grow at 98.6 don’t grow as rapidly at 102. Common sense teaches that you shouldn’t interfere. But you already know my opinion of common sense.

Here are questions that you might ask.

1. In what specific infections is lowering the fever harmful? I can’t think of any.

2. What infections do doctors treat by giving patients a fever?  The answer is none (a note to nitpickers: I know medical history – I’m talking about doctors today).

3. Every day, across the world, a hundred million people take medicine for fever. How many end up at the doctor who explains that this made the problem worse?

Wednesday, November 14, 2012

Warning: This Blog May Vanish



I suspect this blog will disappear on January 15, 2013. That’s when Medscape shuts down its E-mail which I’ve been using since the 1990s. At first, I assumed this would be no problem. I would log on using my other E-mail addresses, but they don’t work.

Innocently, I went to a Google forum to ask how to transfer the blog to another E-mail. Almost immediately a responder explained that I must use the permissions wizard – “carefully.” My heart sank as I read an entire page of instructions, links, and warnings plus the suggestion that it works best using two computers and two browsers. I didn’t understand.

My current plan is to recreate the blog which will probably require a different name, so keep your eyes peeled.

Saturday, November 10, 2012

Election Results



Now that the election is over, Obamacare will go forward.

As a member of the entitled class, I have collected Medicare since 2005. Being on Medicare doesn’t mean everything is free; that requires signing up for Medicare Part B and D and for supplementary insurance. I pay about $350 a month. In exchange, I get almost no medical bills. I love it. Even though Medicare is a government program, I receive less paperwork than when I belonged to Blue Cross (even writing “Blue Cross” produces a surge of anger; I hated it). 

My brother, a physician, detests Obamacare. He is liberal, and he dislikes Obamacare because it will deliver a bonanza for the insurance companies with no controls on cost. His criticisms are correct, but I tell him that when premiums skyrocket – as they will, especially if younger people are allowed to opt out of buying insurance – the outcry will force Washington to take action.

Conservatives tell us that in Europe's national health plans the downtrodden physician takes his orders and pitiful salary from the government. In fact, all these countries have some private insurance. In many, such as Switzerland and the Netherlands, everyone buys medical insurance from private carriers just as they will do in the US. The difference is that laws closely regulate them. The carriers aren’t losing money.

Things will work out.

Wednesday, November 7, 2012

Historical Diseases


Standby MD asked me to see a guest at the Doubletree – in Santa Ana. That’s fifty miles away, but it was Sunday morning; freeway traffic was light, a perfect time to go to Orange County. I quoted the fee which was larger because of the distance. The dispatcher promised to call back after consulting his supervisor.

Some travel insurers won’t pay extra. When the phone remained silent throughout breakfast, I suspected that was the case, but approval finally came through.

The guest was an elderly Canadian man suffering diarrhea and vomiting. He mentioned that a dozen members of his tour were affected; several had gone to the emergency room.

That brought back memories of a guest in 1991 with the same symptoms. Stomach viruses are among the most common ailments a hotel doctor encounters. They’re miserable but short-lived; I had delivered the usual advice and remedies, but when I called to check the next day, he was in the hospital with cholera. That’s when I remembered he had flown in from Peru.

Cholera also causes diarrhea and vomiting. It’s extremely rare in the US. In fact, if an American patient turns up with any of the major historical diseases (cholera, malaria, rabies, leprosy, typhoid, typhus, plague, even tuberculosis) there’s a good chance the American doctor will get it wrong on the first visit.

The Canadian gentleman was already recovering, but my phone rang before I left with a request to see another tour member. She was sick enough to send to an ER where she stayed until the evening. There is little cholera in Canada, so this was a stomach virus or run-of-the-mill food poisoning.

Monday, October 29, 2012

Colic

I saw a young Australian couple traveling with an infant. A placid sleeper in Australia, the infant had been screaming through the night since arriving six days earlier, attracting complaints from other guests, driving the poor parents to desperation. They wanted to go home.

This was colic, a surprisingly common affliction of healthy infants. In theory, they are suffering abdominal pain, but all tests are negative, and none of the innumerable treatments work well. It disappears after a few months. I wrote them a note. 

Friday, October 26, 2012

Another Death


When I arrived at the hotel, a father explained that his daughter was under treatment for leukemia. They were visiting relatives when, a few hours before, she had refused to speak.

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. They obeyed, and the daughter died soon after being admitted.     

Sunday, October 21, 2012

A Death

A guest at the Park Sunset complained of the flu. His temperature was 101; my examination was normal, but patients with influenza have a normal exam.

He looked miserable, but he was forty-one and in good health, and everyone with the flu looks miserable. There was no reason not to give the usual remedies and check back later. This happened long ago, but I still remember the inexplicable feeling that something was not right. I couldn’t bring myself to leave him in the room.

Leaving after extracting a guest’s promise to go to an emergency room is a bad idea. If the guest decides not to go and something dreadful happens, I’m the last doctor he’s seen. Calling paramedics was another option, but they might not share my vague unease.  

Explaining that he required further attention, I took him to my car and drove to the nearest hospital. The next day I phoned. He had been admitted and died a few hours later. The doctor who cared for him was as mystified as I. We theorized he was suffering an overwhelming infection from an unknown source. Perhaps he took drugs. This was early in the AIDS epidemic, and victims sometimes died abruptly when their immunity vanished. We never found out.

Monday, October 15, 2012

Not Hitting the Jackpot

“Our client had a heart attack,” explained the dispatcher from Universal Assistance last week. “He wants to go home to Portugal, but the specialist says he must have a doctor. We have hired a medical flight, and we want to know if you can go to New York. You come back the same day.”

Experts advise waiting a week or two after being discharged for a heart attack, but no one knows the risks of flying earlier because almost no one does. An expert who suggests that a physician go along is covering his ass, not delivering advice based on evidence.

Still, the insurer had agreed, no minor matter when an air ambulance coast to coast costs about $40,000. I had no idea what I would earn; nor did the dispatcher, but it would be breathtaking. Hiring a doctor for a day to testify in a malpractice trial runs to $7000.

I still remember with pleasure the single occasion I flew first class. Flying in a private jet while earning the price of a European vacation might leave an even better memory.

But would the patient require my skills? It was unlikely, but, not being young and stupid, I could not dismiss the possibility. Like most doctors, I can perform basic CPR, but I and most doctors have long since forgotten advanced CPR: complex drugs and techniques required for various cardiac malfunctions. Emergency room doctors, paramedics, and ICU nurses deal with these routinely.

Wistfully, I informed the dispatcher that those were the appropriate escorts. 

Monday, October 1, 2012

Perks of Getting Old

Getting old is a nuisance although there are benefits. Police in passing patrol cars no longer eye me suspiciously late at night. Lone women in hotel elevators have stopped looking uneasy when I join them.

As a college student in 1965, I wrote a one-act play that won a national award. It was never produced professionally, but a few years ago, a theater group in New York chose it for a staged reading. This was not a big deal, but I wanted to attend.

As soon as I entered the small theater, everyone perked up. I became the center of attention; people introduced themselves; they sat me in the place of honor. For reasons I still puzzle over, the group boasted that its public readings were cold (i.e. unrehearsed). The performance made this only too clear.

Later I realized why everyone treated me so well. No one in that theater appeared older than forty. Since I was past middle-age they assumed I was an agent or producer – an important person. They did not forget their manners on learning I was merely the writer.

Wednesday, September 26, 2012

A Dog-Eat-Dog Business - Part 2

“Doctor Dolman is out of town. Could you speak to a guest at the Fairmont?”

That was a jolt. Dolman was an ambitious young doctor aiming to start a concierge practice. He had phoned months earlier to introduce himself and offer to cover my hotels when I wanted to get away. I declined but suspected he was poaching. For Dolman to instruct his answering service to send me to one of my regulars showed immense gall or perhaps immense confidence.

In private practice it’s unethical to solicit another physician’s patients, but hotels are a grey area. Established hotel doctors who want to remain on friendly terms do not step on each other’s toes, but newcomers have no inhibitions.

I had made hundreds of visits to the Fairmont. The staff knew me, and I took for granted that providing good medical care was enough to keep their loyalty.

After the visit, I stopped by the concierge desk to mention that a guest seemed to have called another doctor.

The concierge’s eyes widened. “Gosh, I don’t know what happened, Doctor Oppenheim. The guest never talked to me.”

I felt better. Maybe it was an innocent mistake. This feeling lasted until I passed the front desk, and a bellman called to me.

“Doctor! My name is Andre. I’m glad to meet you.” He hurried over, holding out his hand; we shook. “It was me that called you for the guest. Is he doing OK? This is the first time I called, but you’re the doctor I’m going to use.” I knew what this meant.
   
“Who do you think I am?”

The bellman cocked his head. “Aren’t you Doctor Dolman? People say I should call Doctor Dolman.”

“I’m Doctor Oppenheim, the hotel’s doctor.”

He looked confused. “Where’s Doctor Dolman?”

“He’s not available. You should call me in the future.” I walked away, pleased at frustrating the bellman who clearly expected a payoff. Bellmen were hopeless, I told myself. Concierges were the key to a hotel’s loyalty, and it looked liked they were still in my corner.

But this happened some time ago, and I haven’t heard from the Fairmont since. 

Thursday, September 20, 2012

Impressing the General Manager

Years ago Prentice-Hall published The Man’s Health Book, and UPS delivered my ten free copies. Usually I gave those to family and friends. Except for my mother, no one read them, so I wondered if I could put them to better use. 

I decided to visit general managers of my ten biggest hotels, introduce myself, and impress them by handing over my new book. This qualified as aggressive marketing because I had never before approached a hotel employee.

I began my rounds up the street at the Century Plaza and JW Marriott. Then I drove to the San Fernando Valley to visit the Sheraton Universal and nearby Universal Hilton followed by the Hollywood Holiday Inn and Roosevelt, and then downtown.

At each, I approached the secretary in the executive office, identified myself as the hotel doctor, and asked for a minute of her boss’s time. I delivered my spiel, surrendered the book, and accepted their thanks. Some GMs expressed pleasure at finally meeting me, adding flattering words about the quality of my service. Others listened politely and thanked me for the book, but it was obvious they had no idea who I was.

I encountered a third reaction at the Los Angeles Downtown Hilton. The secretary had barely replaced her phone when the GM shot out of his office and hurried over. I began my spiel but he interrupted.

“What do you mean you’re our hotel doctor?” he shouted. “This hotel doesn’t have a doctor!”

“I’ve been coming for years….,” I said. When I checked later, I found I had made 119 visits which implied over 200 phone calls. The staff knew me; the valets never refused to hold my car (essential downtown).

“This hotel doesn’t have a doctor!” he repeated. “What do you mean calling yourself our doctor?”

“I’m not really your doctor,” I admitted. “But when a hotel calls so often…”

“You’re damned right you’re not our doctor. We don’t have a doctor. You’re not to call yourself our doctor!”

Flustered, I did something I still regret. I held out my book. He snatched it and disappeared back into his office. I could have made better use of that copy. A few days later the mail brought a certified letter from an attorney informing me that the Los Angeles Hilton did not require a physician and that I was hereafter forbidden to refer to myself as the Los Angeles Hilton’s doctor.

I stopped passing out books. I take for granted that no Los Angeles hotel familiar with my service can tolerate being without it for long. Although there’s some truth in this, seven years passed before the hotel, now the Wilshire-Grand, resumed calling.

Saturday, September 15, 2012

Bad Credit Cards

A member of an Argentine soccer team fell while roller staking, wrenching his ankle.  A doctor from their travel insurer in Buenos Aires determined that he needed an orthopedist but that this could wait until office hours the following day. However, the doctor wanted someone to examine him that evening, so my phone rang.

The team was staying in Long Beach, 35 miles away, but the rush-hour had passed, and the agency did not object to the extra fee. This was International Assistance. I’ve made 896 of its visits, but after an ownership change, it became extremely slow to pay. Losing patience, I insisted it give me a credit card number, so I could pay myself. This is always a critical request, because some agencies refuse and disappear from my radar. But International Assistance agreed.

As soon as I hung up, I remembered that IA’s current credit card had expired in August. When I called back, the dispatcher put me on hold to consult her superior. After a few minutes, she returned with a new number.

I phoned the credit card company and entered my identification and the credit card number only to hear the computer declare: “Do not honor! Do not honor!” I phoned IA again, awaited the consultation, and received another card. “Do not honor!” intoned the computer a second time.

“Invalid credit card number” I heard on my third attempt. This turned out to be my mistake; in my increasing frustration, I made an error entering her third number. After correcting it, I heard the satisfying: “Approved” following by a confirmation number. Insurance agencies often give me bad credit cards. I suspect their business is as competitive as mine, so many are in perilous financial condition.

My patient was reclining on a couch, an ice pack on his ankle, his teammates gathered around. The ankle was massively swollen, and he was in pain. Waiting would not have caused permanent harm, but people with painful injuries deserve quick attention.

Fortunately, IA is an agency that takes my advice even when it costs money, so his companions took him to an emergency room to deal with fractures of both leg bones. 


Tuesday, September 11, 2012

A Dog-Eat-Dog Business

Years ago I opened a letter from the California Medical Board announcing a complaint against me.

The days when state boards went easy on doctors are long past. In response to persistent criticism, California has joined others in raising license fees, hiring investigators, and issuing press releases boasting of doctors it has disciplined. Every month I receive a bulletin announcing license revocation, suspension, or some humiliating probation. These doctors seemed sad cases: incompetent, alcoholic, dishonest without being clever. Was I about to join them?

Although Los Angeles is the largest city in California, my hearing took place in Diamond Bar, thirty miles east, and it was a gloomy drive. The investigator ushered me into a room where I sat opposite him at a long table, bare except for the evidence. He told me the name of my accuser who turned out to be a competing hotel doctor. We had never met.

The investigator held up a pill box labeled with my handwriting. Later, when I looked up the name on the box, I discovered it was a guest I’d seen a few months earlier. My rival had visited her, noticed the box, and realized it offered an irresistible opportunity.

I carry dozens of medications in little boxes. Handing them out, I once wrote the name of the patient and instructions for taking the pills. This violated California State Pharmacy laws, the investigator informed me. Whenever anyone (not only a pharmacist) gives out a prescription drug, its container must include the patient’s name, the date, the drug’s name, dose, quantity, expiration date, and instructions plus the doctor’s name and contact information. For violating these laws, he added, the board would levy a fine and issue a written reprimand. This was not, however, an offense that endangered my license.

The reprimand announcing my three hundred dollar fine duly arrived. For months I scanned the bulletin, dreading to read my name, but my offense apparently didn’t qualify. It also never appeared on the California Medical Board’s web site when I checked for transgressions.

You can check any California doctor at http://www.medbd.ca.gov/Lookup.htm. Other states have a similar arrangement.

Obeying the pharmacy law required a great deal of writing on that tiny box, but I went along. As for repaying that doctor for the dirty trick, my only recourse was to continue setting foot in his hotels. If this gnawed at him as much as learning of trespassers bothers me, it was vengeance enough.

Tuesday, September 4, 2012

A Doctor for Cheap Lodging

The Banana Bungalows consists of cabins strung out along narrow alleys off the Hollywood Freeway. I parked near the largest.

A desk clerk directed me to a cabin a hundred yards up a hill. Its Spartan interior contained accommodations for eight in four bunk beds, all unmade. Papers, food cartons, luggage, and clothes littered the floor, and there was no furniture, not even a table where I could write. The air smelled of French fries and unwashed bodies:  a typical youth hostel.

Sitting on a vacant bed, I introduced myself. One glance under the man’s shirt confirmed the diagnosis. Chicken pox can be serious in an adult, but this was a mild case.

Walking down the hill, I puzzled over the appeal of youth hostels. They charge thirty-five dollars a night, a bargain, but cheap motels begin at fifty dollars and offer privacy as well as an unshared bathroom. Perhaps young travelers like to clump together.

Back at the front desk, I stood on tiptoes to examine the reverse side that revealed stickers advertising two long-defunct housecall agencies. I caught the eye of the desk clerk, a youth with a shaved head, tank top, and jeans. The quality of front desk personnel varies directly with the quality of the hotel. Since hostels are a nonprofit enterprise, their employees fall below the bottom of the scale.
   
“Could I speak to the front desk manager?”

“I guess that’s me.”

“I’m Doctor Oppenheim. I took care of the man in bungalow ten. Did you call me?”

The clerk shook his head no.

“Maybe one of your colleagues?”

“I’m the only one on duty.” It’s a mystery how often I find no one willing to admit referring a guest. I began my sales pitch.

“Who do you call when a guest wants a doctor?”

“Nobody gets sick. We send them to an ER.”

“You must call someone. Someone called me. And look at those stickers.” The clerk looked down, but his expression remained blank. I pressed on. “I’m a fulltime hotel doctor. All the hotels use me. Your guests can call any time….”

At chain hotels, staff maintain eye contact and a smile as I speak. I often sense their lack of interest, but at least they remember their manners. The Banana Bungalow’s clerk kept nodding to encourage me to get to the point. He flicked an impatient glance at a guest standing nearby.

“I’m always available.”

“We don’t really need a doctor.”

“I notice others have their phone numbers on your desk. Would you mind adding mine?”

“No problem.” The clerk snatched my card and then turned to the waiting guest. I decided not to hang around to make sure he posted it.

Saturday, September 1, 2012

Adventures in Parking


In parts of Los Angeles, especially downtown and the Sunset Strip, street parking is impossible. I dislike turning my car over to an attendant because it can take fifteen minutes to retrieve it from the parking garage. Also, although it’s irrational, I’m willing to pay $15 for a movie or book but not for twenty minutes of parking. I try to leave my car near the entrance, a small area where only VIPs are permitted. When the attendant doesn’t recognize me (“Welcome to the Biltmore; are you checking in?...”), I do not accept the voucher he holds out, explaining “I’m the hotel doctor visiting a sick guest. They let me park.” This sometimes works, but if he insists, I take it. Sometimes the hotel will validate, but it’s unpredictable.

Searching for a spot on the street, I follow the position of the sun as closely as a sailor because I must park in shade. I keep extra supplies in the car, and an hour in blazing sun will melt my pills and ruin batteries. I don’t mind walking a few blocks if I find free street parking (and I know all the secret places), but since I wear a suit and tie, hot weather discourages this. Rain does the same because carrying an umbrella is awkward in addition to my doctor bag and clipboard.

One advantage of wee-hour calls is that parking restrictions vanish and valets grow somnolent or disappear entirely. I’ve never felt in danger, but downtown parking remains problematic because homeless men invariably rush up and offer to watch my car.

My most upsetting parking experience occurred during a visit to the Ramada in Culver City at 4 a.m. I left my car at the deserted entrance, cared for the guest, and returned to find a parking ticket on my windshield. The hotel’s driveway was private property, so ticketing a car requires phoning the police. Looking around the lobby I noticed a security officer looking innocently away. There was nothing to be done.

Thursday, August 30, 2012

Phrases I hear again and again


“Can you come up right away?”

It’s surprising how many guests believe I am sitting in an office downstairs. In fact, I’m at home or going about my daily business when the phone rings. I keep a suit jacket, tie, black bag, and paperwork in the car. Inevitably, calls arrive at awkward times such as during a meal or movie. Meals don’t take long, and I can’t enjoy a movie knowing a patient is waiting, so I leave. Most of the time, I’m happy to go, and when people express sympathy I point out that, unlike other doctors, after I see one patient, I go home.    

“I’ll call you back.”


Before making a housecall, I speak to the guest, ask about his or her problem, and deliver my impression. I may simply give advice because only half my callers require a doctor’s presence. If a housecall is appropriate and the guest agrees, I announce my time of arrival and the fee.

Middle-class Americans are mostly insured. Talking to a doctor willing to make a housecall is already disorienting; hearing they’ll have to hand over money comes as an additional jolt, so they often reconsider (“I’ll talk to my husband and call you back…..”). This is my signal to switch gears and find an alternative means of care: office visit, urgent care clinic, or sometimes even a reduced fee.

“Sorry about the mess”


Entering a room, I look for a place to set down my writing material, so I hear this as someone hastily removes the pile of articles covering the desk. After learning about the illness and perhaps putting a thermometer in the guest’s mouth, I announce that I will wash my hands, so I hear it again as someone rushes ahead to clear a space around the sink. 

“Do you accept insurance?”

My answer is yes – if the guest is foreign and has purchased travel insurance from an agency with an office in the US or that is willing to give a credit card number so I can pay myself. I work with a dozen. It’s no for Americans. US insurers look with suspicion on housecalls, and billing them is a complex process; doctors' offices employ trained billing clerks. I work alone.
                                            -0-



 



Thursday, August 23, 2012

Why Don't They Call?

A buzzer sounded, and the Airport International’s security office door opened. Two officers behind a counter heard me explain that I had cared for a guest. One of them had called earlier.

The International has over 1,200 rooms. In my experience, a hotel generates about one request for a doctor per month for every hundred rooms. My record is 208 calls in 1995 from the old Century Plaza at 1076 rooms. I received eleven calls from the International during 2011 and five so far in 2012.

When I asked the security officer why the hotel called so infrequently he gave the usual incorrect response (“no one’s been sick”). When I asked who they called besides me, he peered down at his desk where, under a sheet of glass lay business cards advertising taxis, ambulance services, hospitals, clinics, pharmacies, et al. I saw my card and none from three rival hotel doctors.

They prefer central Los Angeles from Hollywood through Beverly Hills to the beach cities where the luxury hotels concentrate. Less often, they drive long distances, including the extra ten miles to the airport, but I doubt they’re responsible for my shortfall.

My eyes fell on a card advertising a national housecall service based in New York. Several exist; all boast that they can send a doctor at a moment’s notice. This is not easy, so all quickly learn about me. I made half a dozen visits for this agency but stopped because guests blamed me for the bill.

“Do you know how much these people charge?” I asked.  “Six hundred dollars!” They expressed polite dismay. They didn’t care.

That’s the problem. Luxury hotels always provide a doctor, but many mid-level managers give it a low priority, so employees make their own choices when a guest asks for help.

Now and then, mysteriously, the light dawns, and a hotel suddenly begins to call regularly. Decades may pass before this happens, but I’m doing fine. 


Thursday, August 16, 2012

Drugs are Cheap

A least they’re cheap for common problems your doctor encounters in the office which are the same as I see in hotels. Here are examples from my favorite internet supplier as of 2012.

Some drugs cost almost nothing, less than a penny a pill. I can buy a thousand Benadryl, an antihistamine, for $4.02. A thousand hydrochlorothiazide (the most popular diuretic and blood pressure pill) costs $7.46

Tranquilizer: Valium 5mg is about two cents apiece; $2.04 for a hundred.

An excellent non-narcotic prescription pain remedy, Tramadol, costs $7.00 for a hundred; $50.00 for a thousand.

States require doctors to file a report each time they hand out narcotic pain pills, so I gave it up. Despite the impressive street price of the most popular drug of abuse, Oxycontin, a bottle of a hundred costs less than $10.00.

Cortisone cream: $1.44 per tube.

Antibiotic eye drops for conjunctivitis: $2.93
Antibiotic ear drops for swimmer’s ear: $2.66

A three day Bactrim antibiotic treatment for urinary infection (six tablets) is 40 cents. A hundred costs $6.27.

Ten day treatment for strep throat, twenty amoxicillin 500mg: less than two dollars. A hundred amoxicillin costs $9.29.

Ten day treatment for pneumonia, twenty doxycycline, is about $1.30. Five hundred capsules costs $32.60.

A big attraction of injections is that a doctor can charge for them. If he writes a prescription, the pharmacy gets the money. Don’t assume common injectables are expensive. To begin, a syringe costs a dime (100 are $10.07).

For allergies and itching, a vial containing thirty doses of injectable cortisone (Decadron 4mg) costs $18.88. That’s about sixty cents a shot.

For pain, a shot of morphine costs less than a dollar. It’s $15.49 for a twenty-dose vial.

Within the past few years, ondansetron has replaced Compazine and Phenergan as the leading treatment of vomiting. One shot costs a quarter. The vial of ten doses is $2.52.

Plain old Valium has skyrocketed. This happens when some companies stop making a drug and the others realize they have little competition. Less than a year ago, I paid $5.04 for a vial of ten shots; it’s now $23.02.

Sunday, August 12, 2012

Why I Am a Patriot

Hot summer days remind me of why I love America. We appreciate air conditioning. Citizens of most other nations consider it unhealthy. They tolerate it as an exotic American quirk, but as soon as someone in the party falls ill, the air conditioning goes off.

Wearing a suit and tie, I conduct my business in suffocatingly hot hotel rooms. When I extol the benefits of machine-cooled air to foreigners, they listen politely with an expression identical to that of Americans hearing me explain that antibiotics will not cure their bronchitis.

Saturday, August 4, 2012

Something to Knock It Out - Part 3

Her vacation had been a disaster so far. Since arriving, she had suffered a terrible cold and cough. Worse, when she went tried to buy amoxicillin to knock it out, the pharmacist told her she needed a prescription. This was obviously a scam to line the pockets of American doctors, the guest added. She didn’t need my services except to provide the amoxicillin, so I should not take up her time.

This monologue occurred in Spanish. I don’t speak Spanish, but as the doctor for Latin American travel insurers, I get the drift of most conversations.

This lady appeared upset as soon as she answered the door. Accustomed to this behavior, her husband and child sat in a corner, trying to look inconspicuous. I had no plans to refuse the amoxicillin, but first I had to deliver good medical care. I phoned the insurance office, and the dispatcher agreed to interpret.

I asked the usual questions; she answered at great length.

The dispatcher translated but summarized her frequent interruptions with: “she’s mad about something.”

The guest rolled her eyes when I put a thermometer into her mouth and seemed impatient during my exam.

“She’s really mad,” said the dispatcher as he translated my findings. When I concluded that she would recover in a few days with or without an antibiotic but that I would give her amoxicillin, she slammed down the phone and waved off the prescription I offered.

“If you don’t think I need an antibiotic then I don’t want an antibiotic. According to you I should continue to suffer. Thank you very much!….”  I’m not certain those were her exact words, but they were close.

I laid the prescription on the bed and expressed sympathy. The door closed behind me with a deafening slam.


Friday, August 3, 2012

Something to Knock It Out - Part 2

Influenza had kept a guest in bed five days with fever, body aches, and general misery. He had meetings, he said, and needed something to knock it out.

While antibiotics don’t affect influenza, antiviral drugs such as Tamiflu shorten the illness by a day or two. Sadly, they only work if taken within the first 48 hours; afterwards they are useless although doctors continue to prescribe them. This encounter occurred long ago, before I had learned some facts of life.

After I left, the patient dragged himself to a local clinic and received the traditional antibiotic which solidified his conviction that I did not know my business. Returning to the hotel, he demanded his money back. Guests often believe that the hotel doctor works for the hotel.

The general manager phoned to pass on this information. He was sympathetic, but hearing a complaint from a general manager is the low point in any hotel doctor’s day.

Thursday, August 2, 2012

Something to Knock It Out - Part 1

An FBI agent was suffering a bad cough. He informed me that this happened every year, and his doctor knocked it out with an antibiotic.

My philosophy on prescribing a useless antibiotic (pneumonia excepted, coughs in healthy adults are viruses) is that I don’t unless the patient threatens to make a scene.

This FBI man seemed out of an old movie: dressed in suit and tie, composed and unemotional. He made eye contact, listened intently, answered succinctly, submitted to my exam, and did not interrupt as I spoke.

Afterward, I explained that he had a virus that was incurable but would go away in a few days. As I delivered advice and handed over cough medicine and tablets for his fever, I could see him absorbing the news that I wasn’t prescribing the antibiotic.

He was not a person to quarrel with a figure of authority, but, in his mind, I was clearly incompetent. He said nothing, but I could sense his turmoil….

Deciding the ice was getting very thin, I added: “You said your doctor gives you an antibiotic. This illness doesn’t require one, but I’ll write a prescription in case you want to call him and discuss it.”

He accepted it without comment. He also handed back the medical form I had asked him to sign. In the hall, glancing at the paper, I saw that he had covered it with obscenities.

Friday, July 27, 2012

24 Hour Call

As a hotel doctor, I’m on duty 24 hours a day. This sounds oppressive until you realize that even a busy week – say twenty visits – requires about thirty hours of actual work. A downside is that calls can arrive at precisely the wrong time.

This one came one hour and twenty minutes before a dinner reservation with friends. I calculated furiously and decided I could make it. As always, time constraints were driving and parking. My destination, the Mondrian, was on the Sunset Strip, six miles away. It was Sunday, so traffic was tolerable, but street parking on the Strip is difficult. The Mondrian is not one of my regulars, so parking attendants would probably not accommodate me. The hotel possesses only a skimpy open space around the entrance, so the valets might drive my car deep into the garage where it might take ten minutes to retrieve. Worse, there was a chance they would charge for parking.

Making a snap decision, I drove past, but no street parking materialized. I turned down a side street but no luck, so I returned to the hotel, handed over my keys, and announced (incorrectly) that I was the hotel’s doctor.

I arrived at the room and introduced myself only to hear the discouraging question: “Spik Spanish?”

I shook my head regretfully and began asking questions in English. This usually works because most Latin American male guests speak enough English to get along (women don’t do so well). Sadly, he proceeded to perform the Zero-English pantomime: pointing to his throat, pointing to his head, making coughing noises.

No problem. American hotels could not survive without Hispanic employees, and I doubt if naturalized citizens make up a majority. Peering outside the door, I appealed to a group of maids on their cleaning rounds, but they were recent arrivals and spoke no English. Luckily, a bellman pushing a food cart was bilingual.

Delivering medical care was, as always, the easiest part. To my delight, the valets had held my car, and I arrived at the restaurant not excessively late.

Monday, July 23, 2012

No Income Today

A lady at the Westin wanted a housecall for her cough and fever. This seemed reasonable until I learned she was under treatment for multiple myeloma, a serious blood disease. It affects the immune system, so any sign of infection is a red flag.

I explained that she needed more than I could provide in a hotel room and gave directions to the nearest emergency room.
                                                 *          *          *
Two hours later I spoke to a guest at the Airport Holiday Inn who was experiencing sharp chest pains. Chest pain is worrisome, but significant chest pain lingers. Fleeting pain in an otherwise healthy person is almost never a serious sign. I looked forward to the visit when, after my exam, I would deliver the gratifying news that I had found nothing wrong. That anticipation disappeared when the guest mentioned that he had suffered blood clots in his lung and was taking blood thinners. He hastily added that these chest pains were nothing like those when he was having blood clots.

Different or not, it was a bad idea to assume that these were trivial. I sent him to a facility that could perform tests.
                                                *          *          *
Coris-USA asked me to see a hotel guest in Encinitas.

“That’s near San Diego,” I pointed out. “It’s a hundred miles.”

The dispatcher explained that no one in San Diego was willing to make the visit.

I’ve traveled that far in the past and charged accordingly, but I didn’t want to quote a fee and risk having it accepted because I wasn’t in a mood for the grueling drive. I referred her to the internet for local urgent care clinics. 
                                                *          *          *
“I’m a physician in the U.K., and my wife has conjunctivitis in both eyes. I went to the chemist for antibiotic drops, but apparently I have to see an American doctor.”

“It’s unusual to have bacterial conjunctivitis in both eyes at the same time,” I pointed out. “But if you’re certain, you can ask the pharmacist to phone, and I’ll approve the prescription.”

He thanked me and hung up. Later the pharmacist phoned. When it comes to their own illness or that of their family, doctors are no more accurate than laymen, but they have no interest in my opinion. 

Saturday, July 14, 2012

Unexpected Symptoms

Universal Assistance asked me to see a young woman with abdominal pain at the Airport Marriott. According to the dispatcher, she had no other symptoms.

As I’ve mentioned, I prefer abdominal pain accompanied by vomiting or diarrhea. This is usually a stomach virus and easy to treat. Abdominal pain alone is trickier. Talking to the guest beforehand, I often conclude that he or she requires more than I can provide in a hotel room.

I never talk to guests when travel insurers call, so I sometimes encounter an urgent problem. A big advantage of dealing with an urgent problem through travel insurers is that I send them a bill and get paid. When guests call directly, I always discuss my fee, but in the distress of hearing upsetting news during the visit, dealing with paramedics, or hurrying off to an emergency room, they sometimes forget to pay, and I’m reluctant to remind them.

Arriving in the room, I learned things the insurance dispatcher hadn’t mentioned. The woman was three months pregnant and had noticed vaginal bleeding. That meant she had to go to an emergency room. It’s surprising how often doctors know the diagnosis as soon they set foot in the room, but it looks bad to blurt it out, so I asked questions, performed an exam, delivered my conclusions, and then phoned the insurance office with the news.

The following afternoon, the lady’s husband called. They were back in the hotel. The emergency room doctor had diagnosed a miscarriage, he explained. That was also my diagnosis.

The doctor had discharged his wife, he added. But she was still bleeding. Was that normal?...

Bleeding stops when a miscarriage is complete; if it continues, a doctor performs a D&C to remove remaining tissue. I have no explanation of why she was sent out still bleeding. I told the husband that, sadly, he would have to take her back. The second time she received her D&C.   

Monday, July 2, 2012

A Quick Look

“My other son is coming down with something. Do you mind taking a quick look?”

If you wonder if it annoys doctors to see an extra patient at the last minute, it does. They grumble regularly on physician internet forums which, like forums in general, are full of petty complaints.

In an office, that second patient generates a second bill, but I rarely charge double in a hotel. Driving takes up 80 percent of my housecall time, so an extra consultation doesn’t add much. I’m also aware of one rule of medicine that may come as a surprise.

Rule:  If one member of a family is ill, it might be serious. When two members are ill, it’s never serious.

A guest with chest pain, vertigo, or difficulty breathing is probably the only one in the room suffering. When two people are sick, it’s a respiratory infection: cough, congestion, fever, sore throat… These are not serious.

No medical rule is one hundred percent accurate, but I’d rate this near 99. In an otherwise healthy person, the only common, serious, and curable respiratory infection is bacterial pneumonia. Since pneumonia is not generally contagious, I’ve never seen two cases in the same room.

Tuesday, June 26, 2012

Special Treatment

“Our general manager’s husband has an eye problem. Could you see him this morning?”

“I could.”

“She’s wondering how much you’d charge?”

“There will be no charge.”

The concierge sounded delighted. I was also pleased. She worked at a large West Hollywood hotel that doesn’t call often. The list of doctors at the concierge desk contains several names, but mine is not at the top. Given a list, most people call the first name first.

I don’t charge hotel staff, but caring for them delivers priceless public relations. A lower level employee will certainly talk about the experience. This is important because, even at hotels that call regularly, many employees don't know that I exist, and guests who ask for help usually ask only once.

Hotel managers, of course, have the power to make important decisions.

I’ve never been asked to see a general manager’s spouse, but it seemed wise to give him special treatment. He was staying in the penthouse. The eye problem presented no difficulty; I informed him that no treatment was necessary and symptoms should vanish once he began wearing goggles when riding his motorcycle.

On my way out, the general manager expressed gratitude. I nodded modestly and kept my hopes to myself.

Thursday, June 21, 2012

Waiting for the Second Call

“This is the Shore hotel.”

This sounds routine, but it brought joy to my heart. It was a first call!... I almost never acquire new hotels, and the Shore, an upscale, boutique on the Santa Monica beach, opened last October.

I and my rivals keep an eye on new construction. As the opening nears, more aggressive hotel doctors approach the general manager or visit the lobby to extol their virtues to the staff. I send a dignified letter of introduction to the GM. This rarely works, but after more letters and the passage of time – years or perhaps a decade or two – calls materialize.

Before leaving the Shore, I stopped at the front desk to introduce myself, give thanks for the referral, and pass out business cards. The clerks responded with enthusiasm, accepted my cards, and promised to keep me in mind, but it was clear they had no idea who I was. When asked who had contacted me, they scratched their heads, consulted colleagues, and admitted they had no idea.

This reminded me that, over thirty years, every Los Angeles hotel has called for the first time. These always excite me, but it’s surprising how often they never call again. A hotel’s first call means little; if I get a second, more follow.  

After two weeks, it’s too early to give up on the Shore, but the tension is rising.

Friday, June 15, 2012

Fatal Diarrhea

Coris USA, a travel insurer, sent me to see a 35 year-old Argentinean lady with diarrhea at the Beverly Hills Hotel.

When a hotel calls, I always speak to the guest. This allows me to take care of trivia without a visit and intercept problems which a housecall can’t help.

When a travel insurer calls, I never speak to the guest. This has the advantage of earning me money for tasks like replacing forgotten prescriptions, but there’s a downside. I insist on more information if the insurance dispatcher mentions symptoms such as chest pain or paralysis, but diarrhea seemed a no-brainer.

Arriving, I learned that her illness was entering its sixth day: too long to be the ordinary stomach virus. The diarrhea was profuse, and she felt weak and feverish. She had recently taken antibiotics, so I wondered this was Clostridium difficile colitis, a rare consequence of the avalanche of unnecessary antibiotics consumed by humans everywhere including readers of this blog.

Every antibiotic you swallow kills trillions of germs living in your bowel, most of whom are doing no harm. They are immediately replaced by other germs that can grow in the presence of that antibiotic (why would you want that?....). Most bowels don’t harbor C. difficile, but if yours does, antibiotics may convert a small population into a large one, and it produces an irritating toxin that causes diarrhea that can be fatal in debilitated hospital patients. 

Diagnosing Clostridium requires more than suspicion, and there were other obscure possibilities. She needed a thorough evaluation.

Fortunately, Coris USA is a good travel insurer: meaning that it (a) pays me promptly and (b) takes my advice. These sound like unrelated qualities, but I’ve found that good travel insurers do both, bad ones do neither.

I phoned Coris’s Miami office with the news and the name of the doctor I recommended. The dispatcher contacted the main office in Buenos Aires for authorization; it appeared within the hour, and the patient went off. If I were dealing with a bad insurer, authorization would be denied or simply vanish into the void. I might phone back several times to hear that authorization was still pending, and I often sent patients off, warning that they would have to pay up front and try for reimbursement later.

Tests turned up Clostridium difficile, and she began improving after a few days of treatment.

Monday, June 11, 2012

Free Enterprise in Action

Visiting Disneyland last week, a couple’s two year-old twins fell ill. The parents consulted the concierge, and a doctor who wasn’t me duly arrived.

The family then traveled to Hollywood to spend a few days before flying home to Australia.

A delightful perk of hotel doctoring is the “clearance to travel” visit. Few conditions make flying dangerous for otherwise healthy people. I usually tell guests to travel if they feel up to it, but some insurers demand an exam and written permission. That’s where I came on the scene.

The children had recovered, and I dutifully wrote my consent. From the parents’ description, they had suffered viral upper respiratory infections with cough, fever, congestion, and general miseries. The hotel doctor had diagnosed: “otitis, tonsillitis, bronchitis, and mild pneumonia.” He had given injections, handed over medication, and written prescriptions for antibiotics, cough medicine, and eardrops.

The parents showed me his invoices. The fee for one child totaled $495, for the other $390. The prescriptions came to over $100, so they paid nearly a thousand dollars for a single visit.

I occasionally see guests after they’ve seen another hotel doctor, and the resulting bills often contain a string of itemized charges and a spectacular total.

Nothing I do in a hotel room costs much. That doctor billed $30 apiece for his injections; those I carry for common problems (vomiting, pain, allergy) cost less than a dollar a dose. A syringe costs a dime. He handed over several small packets of pills, charging $20 apiece. I carry about twenty similar packets containing from three to eight pills. Each pill costs between a nickel and a quarter. A bottle of cough medicine costs $1.50. A week’s supply of antibiotics is usually less than $5.00. I pay about $3.00 for a bottle of antibiotic eye drops. Perhaps my most expensive drug is antibiotic ear drops at $8.00. Doctors charge $30 for a urinalysis, but the dipsticks they dunk in your urine come in bottles of 100 at $40.00. That’s 40 cents a dipstick.

Medicine is a noble profession, and while I’m in favor of doctors earning a large income, it’s beneath their dignity to pay obsessive attention to it. This might not be a majority opinion. Doctors with an office practice often insist that they are businessmen operating in a free market. As such, it’s reasonable to charge for every service they provide; sensible patients will understand. Many of these doctors yearn to charge for phone calls.

You can read more about how doctors and money interact on my blog for February 12, 2010. It’s a depressing story.

Wednesday, June 6, 2012

A Second Opinion

“I need a second opinion about something personal,” said an elderly man at a West Hollywood hotel.

It’s always pleasure to visit a patient who isn’t sick, although this seemed an odd situation. But first, since he was American and over 65, I explained that I wasn’t a Medicare doctor, so Medicare wouldn’t pay for this visit.

“That’s OK. I need to see you.”

I drove to the hotel and listened as he explained that his scrotum hung too low. His family doctor hadn’t taken it seriously, so he wanted my advice.

On examination, his scrotum appeared normal although perhaps a bit long. I asked how this caused a problem.

“When I sit on the toilet, it dips into the water,” he said.

I scratched my head.

“A urologist could probably do surgery to shorten it, but I’m not sure Medicare would pay.... Why don’t you lower the water in the toilet bowl?”

Tuesday, June 5, 2012

You Win Some....

I was awake at 7 a.m. writing this blog when a woman from an airport hotel called with symptoms of a bladder infection.

Being American, her first question before agreeing to a visit was: do I accept her insurance. I explained that I didn’t, adding that there was an urgent care clinic a mile away that would.

“I’d probably have to wait forever,” she said. “I have meetings this morning.”

“I’m definitely convenient,” I said.

“Do you bring the medicine?”

“I do.”

I wanted to finish writing and eat breakfast, so I told her I’d arrive at 9 a.m., thereby demonstrating that, despite my age, wisdom, and vast experience, I do stupid things.

It’s a rule of hotel doctoring to go as soon as possible. After waiting a few hours, guests often reconsider, so I knew what to expect when the hotel’s number popped up on my caller ID at 8:30.

“I’m feeling better,” she lied. “I won’t need to see a doctor after all.”

“You won’t save much at the clinic,” I suggested. “They’ll charge extra for the urine test and extra for the culture, and you’ll have to find a pharmacy and pay for the prescription.”

“Oh, no! I’m feeling fine,” she insisted. “Thank you for your help.” She hung up.

When patients cancel, I often console myself if the illness seems likely to produce an unsatisfying encounter; for example guests are often disappointed when I can’t cure their respiratory infection. But urine infections are easy to treat and produce dramatic improvement, so I hate to miss one.  

Thursday, May 31, 2012

A Hotel Doctor's Database: Part 2

Now and then I consult my database for business purposes: for example, to check on a guest who claims to have seen me before. Mostly, I use it satisfy my curiosity.

Men travel more than women but are less likely to ask for a doctor so women outnumber them 8834 to 7800. I’ve cared for 110 patients under age one and thirteen over 90, the oldest 97. The smallest of the small hours are not silent. I’ve made 634 housecalls between midnight and 5 a.m.

My leading diagnosis is the same as that of any family doctor: respiratory infections, 4219 visits. In second place are upset stomachs with vomiting and diarrhea: 2346.

I’ve been around long enough to see 76 patients with chicken pox, another 76 with gout, 12 with mumps, 53 with herpes, 29 with poison ivy, and 149 suffering a kidney stone. Victims of kidney stones rarely delay calling a doctor, and since they are rarely emergencies I visit a fair number.  I’ve seen 79 guests with chest pain and sent ten to the hospital. Far more of my 30,000 callers complained of chest pain, but I work hard weed out emergencies over the phone. Those ten were mistakes.

My most numerous foreign patients are, as you’d expect, the British:  1,711. You won’t guess number two: Argentineans with 1,686. That’s the home base of Latin American travel insurers, but they have prospered and spread; since 2000 I receive more calls from the largest country in the hemisphere, Brazil which will eventually overtake Argentina. 

I’ve cared for guests from Tonga, Malta, New Caledonia, and Curacao but not from Latvia, Estonia, Yemen, and half a dozen African nations. Russians didn’t travel until the fall of the Soviet Union. I saw my first in 1991. The Chinese don’t appear until 1998. So far Cuba has sent one.

Six guests died – fortunately none in the room after my visit. One was dead when I arrived. Four died soon after I sent them to the hospital, and another died after the ER doctor (mistakenly) sent her back. I called the paramedics after examining sixteen guests. Many more needed attention but weren’t urgent. To leave after accepting their promise to go to an emergency room guarantees intense worry on my part. If the guest decides to wait, and something dreadful happens, I’m the last doctor he or she saw, a situation that brings joy to the heart of malpractice lawyers. When a guest needs an emergency room, I stay until they head off. I’ve done this 51 times.

37 guests asked for a visit but weren’t in the room when I arrived. 58 refused to pay. 18 paid with a bad check. I don’t record guests who get a discount but 1331 paid between $5 and $50. 102 guests paid nothing. I will not deny that I have a category for “celebrity.” It has 90 entries although that includes their wives and children. I try to head off drug abusers over the phone but 77 slipped through. The diagnosis on four was “drunk,” but that’s certainly too few.

Friday, May 25, 2012

A Hotel Doctor's Database

At the end of every month I enter my data into the computer. It takes an hour during which the past flashes before my eyes. I re-experience its pleasures: calls from new hotels, dramatic cures, wee-hour or distant visits (extra money with the tedium a distant memory), and gratitude but also the pain: visits that didn’t turn out well, regular hotels that should have called but didn’t. At the end I punch F10 and the screen displays the month’s events: total calls, total visits, and income.

Few things besides wine and cheese improve with time, but a database is among them. Since 1984 I’ve answered the phone over 30,000 times and made 16,634 visits.

Of those visits, nearly 12,000 requests came directly from a hotel, but hotels are only the first of five sources of calls.

My second source is agencies that insure travelers visiting America: 2958 visits. Sick guests phone the agency’s US office; the agency phones me; I make the housecall and send my bill to the agency. I like these calls. Foreigners defer to doctors more than Americans, and patients who do not pay directly are less demanding. Sadly, some insurers are adopting the American system of requiring elaborate forms, itemization, and codes for every procedure. Others pay very slowly and only after many reminders. When my patience runs out, I ask for a credit card number so I can pay myself. If they refuse, I stop accepting their calls.

This doesn’t mean I stop seeing their clients because they switch their business to the third source that I call “competitors:” 1213 visits. These are national housecall services with names like Expressdoc, AMPM Housecalls, Hoteldoc, Housecall MD. If you live in a large city, they’re available, but their fees may take your breath away. All claim to provide a prompt housecall, but this is hype. None employ doctors, so when a request arrives, the dispatcher consults a list of local practitioners and begins calling. Finding a doctor willing to make a housecall at a moment’s notice is hard except in Los Angeles. Since I collect my usual fee, I don’t care if a travel insurer calls directly or calls a housecall service.

Category four is foreign airline crew: 655 visits. American airlines have no interest in what happens to crew when laying over. They have medical insurance, but with no transportation or knowledge of facilities in a strange city, they are out of luck. Occasionally I deal with their pitiful calls and treat them as charity cases. As with American insurance carriers, billing an American airline for a housecall is hopeless. 

A minor fifth category is what I call “private-parties:” 55 visits. These are people who learn about me from another source. That includes locals as well as former patients who return to the city and call me directly.

In a few days, I’ll extract some interesting statistics from the database.

Thursday, May 17, 2012

Everything Feels Worse in the Middle of the Night

That’s my mantra during a wee-hour visit.

I’ve made a thousand housecalls that got me out of bed. Patients are often suicidally reluctant to wake a doctor, but I don’t object. Freeway traffic is light, parking is easy, and since I have no office, I can sleep late.

What happens in a hotel room when the lights go out? Mostly, guests stub their toes and bump into furniture. I bring a flashlight when I go on vacation.

Many callers have awakened in the dark certain something terrible is about to happen. Now and then life seems overwhelming, and everything feels worse in the middle of the night. I try to handle anxiety attacks over the phone using sympathy and calm reassurance. Logic is useless; I never point out that nothing terrible will happen because guests know that; it’s one reason they’re upset. I explain that no one is perfect; sometimes our brains go haywire, but it never lasts long. If I can keep the guest on the line, this almost always works. Making a housecall is risky because guests often begin to feel better and cancel before I arrive, or they feel worse and call paramedics.

Unlike many doctors, hotel doctors included, who use the paramedics as a substitute for getting out of bed, I reserve them for emergencies. Mostly, these are obvious. Heart attacks can rouse victims from sleep, but they are not subtle. Niggling chest discomfort doesn’t qualify, and severe pain in a young person is probably something else. 

I see a cross-section of ailments, but guests with an upset stomach seem overrepresented. I consider a wee-hour visit for vomiting a good call (i.e. not life-threatening; I can help; patients are especially grateful). The latest antivomiting drug, ondansetron, is superior to Compazine, the choice for the past fifty years. Ondansetron was once wildly expensive and used only for vomiting after cancer chemotherapy, but its patent expired a few years ago, and the price has plummeted, so I can afford it.

Most violent upset stomachs don’t last long. I assure guests they’ll probably feel better when the sun rises , and (a perk of being a doctor) when that happens, guests are convinced I’ve cured them.

Tuesday, May 8, 2012

You Can't Make a Diagnosis Over the Phone


“Of course, you can’t make a diagnosis over the phone,” guests tell me.

But I can. Doctors do it all the time. I’d estimate my accuracy at ninety percent. It may be one hundred percent for some problems: respiratory infections, urine infections, backaches, many rashes, injuries, anxiety attacks. Driving to the hotel, it’s relaxing to know in advance that the guest has chicken pox, gout, herpes, a bladder infection, an acid stomach, or the flu. I can deliver my diagnosis, advice, and medication, collect my money and thanks, and drive home. What an easy job!

Jumping to conclusions is a major reason doctors get into trouble, but this is less of a problem when I make a housecall. A guest may announce that he’s having an allergic reaction and then describe symptoms that don’t quite fit. An examination will provide better information. 

Phone consultations require caution. If a fifty year-old describes chest pain that doesn’t sound like a heart attack, it’s unlikely I’ll tell him that it’s OK to wait. It’s also unlikely that I’ll make a housecall because an examination rarely helps, and I hate collecting a fee and then telling a guest to go somewhere else and pay another fee. On the other hand, chest pain in a twenty year-old is almost never a serious matter.

Abdominal pain is tricky at any age. Guests suggest gas, indigestion, and constipation. I worry about a dozen conditions that require a surgeon’s urgent attention. Oddly, it’s reassuring when vomiting or diarrhea accompanies the pain. Provided the guest is in good health, it’s usually a short-lived stomach virus, among my most frequent reasons for a housecall. Without vomiting or diarrhea, I’m likely to suggest a clinic visit where a doctor can get more information than a housecall provides.

"I know it's not broken because...." You don't know. Neither do I.

Monday, April 30, 2012

Satisfying and Unsatisfying Problems

A guest interrupted my questioning to dash into the bathroom, and I heard the sounds of gagging as she vomited.

While waiting, I took a vial of ondansetron from my bag and began filling a syringe. After a few minutes I heard the toilet flush.

“Why don’t I give the vomiting injection now?” I said when she reappeared. “You’ll probably want one.” She agreed with enthusiasm.

I finished my exam, made a diagnosis – the common stomach virus – and delivered advice and a packet of pills. I also went to the ice machine down the corridor and filled her ice bucket, so that she could suck on the chips for the next few hours. She was very grateful and equally grateful the following morning when I phoned to learn she had recovered. Most stomach viruses don’t last long, a day or so.

Vomiting and diarrhea are usually satisfying problems for a doctor. Most skin problems are easy. I rarely have a problem with earaches, backaches, minor injuries, common eye inflammations, even most urinary and gynecological complaints. A hotel doctor’s patients are healthier than average, but serious problems occur. It turns out that these are not necessarily “hard.” When I encounter someone with chest pain, eye pain, sudden weakness, difficulty breathing, or an injury that may be serious I know what to do. At the end patients receive the care they should receive, and we both know it. That’s a satisfying feeling.

What is the most unsatisfying problem a doctor faces? Rare diseases? Puzzling symptoms? Neurotics? Drug addiction? None of these. Most doctors would agree that it’s the common viral upper respiratory infection. About twenty percent of everyone who consults a doctor suffers. Hotel guests are no exception. No one tries to educate me about heart attacks, but everyone is an expert on these. Patients tell me how they acquired theirs (“I got caught in the rain”), or why (“I’m not eating right; my resistance is low”), the proper treatment (“my doctor gives me a Z-pak”), and what will happen if I disagree (“It’ll go to my chest”). These explanations are always wrong.

You catch a virus from another person. The illness lasts from a few days to a few weeks. If you see a doctor, he or she will prescribe an antibiotic at least half the time. The antibiotic is useless. Doctors know this but prescribe them anyway.

No patient agrees. “I have a good doctor,” they reply. “He would never do that.”

My response is that prescribing useless antibiotics is not necessarily a sign of incompetence. It’s so common that good doctors do it. One expert calls this avalanche of unnecessary antibiotics one of our greatest environmental pollutants. It’s producing a growing race of “superbugs:” germs resistant to all antibiotics.

Here’s a professional secret. When doctors chat among themselves, we often bring up the subject. Challenged by colleagues like me, prescribers never claim that antibiotics cure these infections. They know they’re a placebo, but they respond with a powerful argument. “When I’m finished, I want patients to be happy, and they are happy. One hundred percent. What’s your experience?”

It’s not as good. When I deliver sympathy, advice, and perhaps a cough remedy to patients with a respiratory infection, most seem genuinely grateful, but a solid minority drop hints (“Isn’t there something to knock this out….?” “My regular doctor gives me…..” “I have a meeting tomorrow, and I can’t be sick…”).

Doctors love helping patients. That’s why we went into medicine. Equally important, we want you to feel “helped,” and we are super-sensitive to your gratitude. Almost everyone is too polite to argue with a doctor, but we can detect the tiniest trace of disappointment as you leave. It hurts us. Every doctor knows that he can eliminate this pain and produce heartfelt gratitude by prescribing an antibiotic. This is terribly tempting, and after a few dozen or few hundred or few thousand disappointed patients, most doctors give in.