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.


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.