Tuesday, December 31, 2013

How a Hotel Doctor Is Like A Prostitute

2013 was my busiest year. Calls were up twelve percent. It's also the year when calls directly from hotels dropped below fifty percent.

I now make most visits at the request of national housecall agencies, international travel insurers, airlines, and a sprinkling of miscellaneous sources including other hotel doctors. That's fine with me.

About fifteen Los Angeles hotels call me exclusively. That leaves over a hundred, all of whom have my number but who call another doctor or no doctor and sometimes me. Competition for these hotels has become so cutthroat that I'm happy to leave it to others.

If you follow this blog you've learned about my excellent skills and low fees. Why would a hotel bother with anyone else? The answer is that service and price are useless marketing tools in medicine where the law of supply and demand doesn't work.

Providing a doctor produces no revenue for the hotel, and guests don't demand one, so most general managers pay no attention. Asked for help by a guest, employees are on their own.

They may simply give out a number, but many prefer the traditional arrangement once used to summon a prostitute. A bellman made a phone call. As the lady left, she stopped at the bell desk to drop off a portion of her fee.

It's illegal for a doctor to pay for a referral, but what are the options for someone yearning to break in to the glamorous world of hotel doctoring? Claiming to deliver superior medical care sounds weird. Advertising a low fee is vulgar.

Thursday, December 26, 2013

A Hotel Doctor's Christmas

I’m the only hotel doctor who loves to work on Christmas. Freeway traffic is light, always a bonus but more so on Christmas because my competitors, including those in Orange County, prefer their holidays undisturbed, so I make some distant visits.

Guests who fall ill are especially grateful to find a doctor. Employees, apologetic when they phone, are impressed when I make an appearance. Visiting a hotel that doesn’t call provides an irresistible opportunity to point out the superior service I deliver.

The only person not delighted by all this is my wife. Long ago, receiving a second call while engaged in the first, I missed the family Christmas dinner. I won’t do that again, but that’s only a matter of juggling a few hours.

Sunday, December 22, 2013

Good Doctors Do It

“I’m coughing my head off. My head is plugged. I have a fever. I’m on vacation, and I need something.”

I’ve seen over 4,000 guests with respiratory infections. To the average hotel doctor, this is an easy visit. He arrives, performs the traditional exam, prescribes the traditional antibiotic, and accepts his fee and the guest’s thanks. What’s not to like?

That the antibiotic is unnecessary doesn’t bother him. It would bother me, so I prescribe only when it will help. Despite my colleagues’ insistence that patients demand antibiotics, most of mine accept this. A minority appear disappointed, and a few make it painfully clear that I’ve missed the boat.

For decades, solemn editorials in medical journals have urged us to stop prescribing useless antibiotics, warning that they’re poisoning the environment, producing nasty, drug-resistant germs that are already killing thousands. 

Despite this, giving antibiotics for viral respiratory infections remains almost universal. Every doctor whose prescribing habits I know – admittedly a limited sample of about ten – does it. None believe they help. All tell me that patients expect them.

“I don’t want an antibiotic if I don’t need it,” intelligent patients tell me. “But how do I know?”

“You don’t, but bacterial respiratory infections are rare in healthy people.”

“What if it’s bronchitis? I get that a lot.”

“Antibiotics don’t help bronchitis.”

“That’s what my doctor gives me. Are implying he’s incompetent?”

“No.  Prescribing unnecessary antibiotics is so common that one could call it the standard of practice – meaning good doctors do it.”

If you’re coughing and in reasonably good health, the only common disease that antibiotics cure is pneumonia (229 diagnoses on my database). Everything else is a virus.

Wednesday, December 18, 2013

Easy Visits, Mostly

Every day a thousand airline flight crew spend the night in a Los Angeles hotel. Sometimes they get sick and call their supervisor. If they’re American, he tells them to take their American medical insurance and find a clinic. If they’re foreign, he tells them to stay put and wait for the doctor.

That will probably be me. I average half a dozen of these visits per month. I enjoy them because airline crew are young and healthy. Three-quarters suffer respiratory infections and upset stomachs. Since a doctor must certify if they’re fit to fly, I see plenty of ordinary colds.

A minor drawback is two pages of forms to fill out in addition to my medical record. A more serious problem is vomiting: the symptom in nearly half my airline calls. I hate driving during the rush hour, but vomiters don’t like to wait, so I often find myself creeping on the freeway.

Sunday, December 15, 2013

Recovering From Cocaine

He had turned bright red an hour earlier, a frightened guest informed me. Searching the internet revealed that this indicated dangerously high blood pressure. Could I come…?

This was as accurate as most internet medical advice, so I was not alarmed. In response to my questions, he admitted using cocaine earlier but emphasized that this had never happened before. His heart was pounding, his skin tingling, and his head pulsating but he denied having a headache or chest pain. Could I come?

What to do…. Allergic reactions turn patients red, but this is accompanied by itching which he didn’t have. Otherwise, his symptoms were typical of cocaine. They didn’t sound life-threatening, but it’s a bad idea to dismiss the possibility.

I do not like to make housecalls to frightened hotel guests. Waiting often becomes intolerable, so they dash off to an emergency room or call the paramedics before I arrive. When I suggested these possibilities, he refused, urging me to come quickly. I asked him to count his pulse. It was 100:  not terribly fast. I kept him talking, and he grew more calm.

A hotel doctor’s nightmare is a guest dying after he leaves the room, but dying before he arrives may be worse. It was a stressful drive.

When he opened the door, he wasn’t bright red, perhaps very faintly pink. When I took him to a mirror, he agreed that he had improved. His blood pressure was high, but not too high. His heart sounded normal. He was recovering from the cocaine.

Wednesday, December 11, 2013

A Sad Story

The caller was Chinese, and he wanted a medicine. That could mean anything. He gave the name which, through his thick accent, sounded like “desitin,” an over-the-counter treatment for diaper rash.

That didn’t seem right, so I coaxed him through the spelling (“S as in Shanghai….? “T as in Taiwan…?). The result was “dasatinib.” This turns out to be treatment for a common leukemia, FDA approved a few years ago, and superior to other treatments. A friend in China had asked the guest to obtain some.

I fulfill these requests if they sound legitimate, and this qualified. I made sure he understood that he must find a pharmacy and explain exactly what his friend needed including the dose, number of pills, and instructions. This sometimes involves phoning back to the home country. The pharmacist would then call me, and I would approve. A trip to the hotel wasn’t necessary.

The guest had phoned in the evening and mentioned that he was returning to China the following morning. When the day passed with no call, I had the sinking feeling that, by delaying till his departure day, the guest had waited too long. The average CVS or Walgreens might not stock these high-tech, chemotherapeutic drugs, so the pharmacist might refer him to a large medical center such as UCLA. This would take hours. With a plane to catch, the guest probably realized that there wasn’t time.  

Sunday, December 8, 2013

Sticking With the Errant Doctor

A guest had a flight in a few hours, explained the front desk manager of the Marina Marriott. His wife was ill and needed a doctor’s note to reschedule. How fast could I get there?

“Very fast,” I said. It was Saturday evening, and I was at the computer.

The Marriott had called regularly throughout the 1980s and 1990s before falling silent. Hotels occasionally do that, and this call gave me hope.

My competitors enjoy an active social life. It was the weekend, and hotels often turn to me when the regular doctor is hard to reach.

After caring for the guest, I returned to the lobby where the manager shook my hand.

“Thank you so much for coming,” he said. “We have your card, and we’ll be calling in the future.”

I drove off in a happy mood. These urgent requests arrive several times a year, and my prompt response has won me new clients.

But not often. Few hotels give a high priority to providing medical services. Ninety percent of the time the staff continues to call the errant doctor.

Still, I have fond memories. Twenty years ago, Loews phoned when its regular doctor hadn’t appeared after several hours. I hurried, but when I knocked on the guest’s door, it was the regular doctor who answered. The embarassed manager promised to make it up to me, and he kept his word.

Wednesday, December 4, 2013

You Must See "The Dallas Buyer's Club"

Everyone agrees it’s one 2013’s outstanding films. On Rotten Tomato’s site, a spectacular 42 of 42 reviewers approve. Matthew McConaughey delivers an Oscar-winning performance as a homophobic Texas good-old-boy who learns that he has AIDS in 1985.

Defying his doctor, who announces that he has thirty days to live and that no treatment exists, he pulls himself together, searches for treatments in places beyond the influence of the medical establishment (Mexico, for instance), smuggles them into the USA, and distributes them to AIDS victims despite government persecution.

Although I recommend The Dallas Buyer’s Club, I left halfway through. I couldn’t bear it because it contains every dumb Hollywood cliché about physicians and science.

Every doctor is a jerk except (a) the beautiful young woman doctor who finds Matthew McConaughey cool and (b) the seedy, unshaven doctor whom McConaughey stumbles upon running a Mexican clinic. After announcing that he has lost his US license (undoubtedly for being too compassionate), this doctor explains that his regimen of vitamins and immune boosters will help.

I am not one of those tiresome people who insist that movies stick to facts. History is boring and complicated. American movies must tell a coherent story with an upbeat ending and an admirable hero (Matthew McConaughey has flaws, but they are cute flaws: he is oversexed, a spendthrift, rude, and he lies – but only to bad people).

At that time, a hundred Mexican clinics sold AIDS treatments. None worked. Everyone who took them died. No American audience would accept Matthew McConaughey passing out fake drugs, so the screenwriters tweak the historical facts. In the movie, the drugs work.

I’m puzzled why conservatives denounce Hollywood for turning out liberal propaganda. The Dallas Buyer’s Club is a Tea Party dream. The government is a heartless oppressor. That includes the FDA which the writers confuse with the FBI because they create a menacing agent who threatens to arrest Matthew McConaughey. This FBI… I mean FDA agent never says “Your drugs don’t work!” He says “Your drugs are not FDA approved!” which, since he’s a villain, means they do work.  

Let me know how it turns out.

Monday, December 2, 2013

Rashes are Easy, Part 2

His client had developed redness over her eyelids. Could I come?

As I repeat, rashes are easy, and eyelid rashes mostly turn out to be one of two or three diagnoses. I asked for the room number.

The guest was in a meeting, the caller responded. When I arrived, I should ask the concierge to fetch her.

So I did. The concierge returned to say the meeting would end shortly. I waited fifteen minutes.

As expected, the eyelid rash was no problem. After accepting a tube of cream, she mentioned that her knee had hurt since her run the previous day. I examined the knee and reassured her. She added that her ankle had been bothering her for some time. I examined the ankle and gave my opinion. Then we talked about her husband who had a sore shoulder but refused to see a doctor.

Friday, November 29, 2013

Rashes Are Easy

Some hotels visits are hard; some are easy. I love the easy ones.

A lady at a Sunset Strip hotel had seen a doctor for an allergic rash, and now she wasn’t feeling right. Rashes are easy, and her symptoms were probably medication side-effects, so I expected no problem. That seemed to be the case. Her rash was improving, and she agreed to stop the medicine.

She handed me her Visa card. I took out my cell phone, dialed the credit card company’s computer, and entered a series of numbers at its request. It denied approval. This often means a typing error, so I entered the numbers again. Another denial.

In the distant past, guests would apologize profusely and promise to send a check once they returned home. Some kept the promise, but I quickly decided this was not the way to go.

This guest seemed genuinely puzzled. She wondered if the hotel was responsible. At check-in, a hotel often places a hold on a large sum from the guest’s credit card to ensure it gets paid. She wondered if this exceeded her limit. She phoned the front desk and confirmed this. There followed a long series of calls, referrals, consultations, and arguments before the hotel agreed to remove the hold. It worked. The computer reversed itself and approved.

Saturday, November 23, 2013

Searching for a Doctor on the Internet

If you get sick in a local hotel, you might google “Los Angeles hotel doctor.” My name turns up but only with links to this blog. I don’t have a web site. Nor do my long-established competitors.

You haven't searched in vain because several young doctors turn up. All promise to arrive promptly and deliver superior care. Don’t take their word for it. Testimonials from rating services such as Yelp are unanimously enthusiastic. Five out of five stars.

In fact, sick guests are more likely to appeal to the hotel than the internet, but these doctors have been working their charms on bellmen, concierges, and desk clerks.

All this takes money and work, but it’s not going to waste. Old hotel doctors possess an exquisite ability to detect an interloper, and these doctors are definitely setting foot in my territory. Listening to my colleagues grumbling, I know they are not immune.

As I complain regularly, only a minority of general managers have the good sense to designate an individual, usually me, as the house doctor. I have never solicited hotel employees. It wasn’t necessary when I began because there was no competition. I’m too shy or perhaps too lazy to begin. The result is that I am losing business. In a way.  

Friday, November 15, 2013

Searching for a Doctor on Craigslist

A caller from the Airport Hilton asked how much I charged.

Guests often ask this question. If I answer immediately, the guest is likely to thank me and hang up. So I always respond that phone calls are free and might be all he or she needs. What’s the problem?....

He wasn’t a guest, the caller replied. Hilton management was checking on what hotel doctors charge. There had been an incident…. 

With over 1,000 rooms, the Hilton is one of the largest hotels in Los Angeles. It should generate 100 requests for a doctor per year, but my average has hovered around twenty since it called for the first time in 1991. Like most non-luxury chains, the Hilton has no policy for dealing with guests who want a doctor, and plenty of new competitors are offering their services. Many charge spectacular fees. As I regularly grumble in this blog, hotels pay no attention unless a guest complains which rarely happens.

But here was a complaint, and I was happy to answer. Learning my fee, the caller agreed that it was a big improvement. He would pass along the information.

When I asked about the other doctor, he gave me an 800 number. I called and learned that I was speaking to USA Housecalls, a nationwide service. When I asked for the medical director, the person who answered said he was the owner.

When the owner answers the phone, that doesn’t suggest calls are pouring in, but I introduced myself as a veteran Los Angeles hotel doctor. He immediately went into PR mode and told me he had been in business 23 years. Hearing that I’d only learned of his existence today, he admitted that he was just getting started in Los Angeles and was using two young doctors who had caused some difficulties. He urged me to send my CV.

Googling, I later learned that he had advertised for doctors on Craigslist. 


Sunday, November 10, 2013

I Have Syphilis

Those were the first words from a young flight attendant as soon as we had exchanged greetings.

Earlier, he had told his supervisor of a groin rash. I had popped a tube of antifungal cream into my bag and driven off, expecting an uncomplicated visit.

I asked how he knew this, confident that he had searched the internet and received the usual terrifying and wrong information.

“My boy friend has the same sore. He went to a clinic. They did a test and said he had syphilis and gave him a shot of penicillin.”

I couldn’t argue with that. He would need the same test and injection. Since he was flying back the next day, he could take care of it then.

“I can’t!” he pleaded. “I don’t go to Australia for two weeks.”

His destination was Cairo because he worked for an Egyptian airline. On sexual matters Arabs are less easy-going than Australians, and he was frightened of the consequences if his employer found out.

I encounter this now and then. Even in the US where discrimination is illegal, employees worry. I rarely encounter syphilis, so I don’t carry injectable penicillin, but I handed over an approved alternative treatment, and he promised to follow up with his doctor in Australia. Later, writing my medical report, I worked hard to write an accurate if ambiguous description of an acute bacterial penile infection.  

Tuesday, November 5, 2013

Doctors Earn a Lot

The average family doctor earns $189,000 a year. My 2012 physician income did not reach two thirds of that, but I’m not complaining. When friends express wonder at its size, I happily agree. When they suggest that doctors earn a great deal, I acknowledge that America pays doctors generously. 

Editorials occasionally express disapproval. Like my colleagues, I note the errors (assuming, for example, that most of the health care dollar goes into the doctor’s pocket) then move on.  It never occurs to me to respond. Among problems of our health system that infuriate Americans, the size of our incomes is well down the list. 

Others protest, and I wish they wouldn’t. I can’t remember the last defense that didn’t sound whiny. Every doctor beats two dead horses.

The first is what I call the Ophra Winfrey defense.

“Ophra Winfrey (or Alfred Pujols or the chairman of Disney) makes. . .  How many lives do they save?”

Similar excuses include:

“A plumber charges. . .”

And the traditional:

“Lawyers make three hundred dollars an hour, so. . .”

The media pour out a daily stream of outrage at the latest baseball contract, lawsuit settlement, or CEO salary. Doctors aren’t the only ones comparing themselves to lawyers, plumbers, and celebrities. Everyone does.

Worse, almost everyone who uses this argument earns less than I do. People who feel underpaid for their own honest labor are unlikely to agree that doctors are in the same boat.

Number two, equally feeble, is the trash compactor defense.
 “The average American pays more for alcoholic beverages than. . .” 
“My last malpractice premium was. . .”

“The consumer price index proves that doctors incomes haven’t. . .”
“Ten years ago, Medicare paid ... for a cataract operation.  This year it paid a mere. . .”

The trash compactor is a machine that converts a hundred pounds of trash into a hundred pounds of trash. A physician using this defense doesn’t grow less prosperous.

The best justification of our income lies in what we do:  we comfort the afflicted, relieve suffering, and save lives. I look on medicine as a noble, humanitarian calling, perhaps the noblest. Patients acknowledge this. So what’s the problem?

It’s this: humanitarians shouldn’t make a lot of money. Few laymen believe clergymen, nurses, social workers, paramedics, teachers, policemen, or firemen are overpaid. They are less certain about doctors, but it doesn’t upset them if they have good insurance and enough money.

What are we doing about those who can’t afford us? Some doctors volunteer an afternoon or two. A few genuine humanitarians work full-time with the poor at a salary unacceptable to most of us. The majority does little.

That statement produces an avalanche of disagreement. Poverty is no barrier in their practice, a chorus of doctors insists. They make allowances for anyone in financial difficulty. This is a frivolous argument. Few among us refuse a patient who pleads for charity, but it doesn’t happen often.

Why don’t the needy call? They don’t hesitate to consult clergymen, social workers et al. I believe it’s because we are so powerful and prosperous and (ironically) because no influential group objects to this. In the debate over caring for the uninsured, no one wants doctors to shoulder the burden. Repeated cuts in Medicare and Medicaid have produced enormous psychic but little material suffering. Nor has the increasing skimpiness of private health insurance. Whatever changes occur in the years ahead, Obamacare included, there’s no chance a physician’s income will come to equal that of, say, a police officer.

Doctors enjoy the best of both worlds. We care for the afflicted. For this we are widely admired and well paid. Sacrifices are expected - but only of our time and mental health. It’s hard to feel guilty because almost no one wants us to feel guilty. 

Friday, November 1, 2013

The Five Actions of a Hotel Doctor

After the door opens and I exchange greetings, my first action is to look down at the floor. If I see a pile of shoes, I remove mine. You may think this is a quaint foreign custom, but some Americans have adopted it. When you consider what people and animals deposit outside, it seems terribly unsanitary track it onto your rugs.

My second action, on entering the room, is to identify the patient. A doctor making a housecall is an exotic event even for Americans, so I often encounter a large, attentive audience.

My third is to brush off apologies as guests rush to clear a space for my bag and clipboard. Apparently no one reads or writes while traveling, so desk and chairs are piled with belongings.

My fourth action is to suggest that someone turn off the television. Time and again, a patient begins talking – and I can’t hear. Guests often seem startled at this request – and occasionally miffed. What’s the problem?.....

It’s surprising how many people around the world turn the TV on before breakfast and leave it on. It’s the background to their daily life.

My fifth action, after listening to the patient, is to announce that I will wash my hands. This produces more apologies as guests rush to tidy up the bathroom.

I hope this held your attention. You should realize that any competent blogger must write at least once a week, or his audience drifts off. Being a hotel doctor may be world’s best job, but it’s not always full of excitement. Writing is often harder than practicing medicine.

Monday, October 28, 2013

Being Awakened Twice

“How quick can be in Costa Mesa?” asked the dispatcher for Expressdoc, a housecall agency. The call got me out of bed at 11 p.m.

“In about an hour.” 

“Can’t you make it earlier?”

“Costa Mesa is forty miles away. How sick is he?”

“He has back pain. He wants to go to an emergency room, but we said we could send a doctor. Let me see if he’ll wait.”

After fifteen minutes passed, I phoned the agency.

“I’ve been trying to reach him, but it looks like he’s gone to the hospital. If he comes back, is it OK to call you?”

“No. If he comes back, tell him I’ll be happy to see him in the morning.”

I have no objection to being awakened to make a housecall, but I don’t want to be awakened twice. After breakfast, I phoned the guest. He hadn’t gone to the emergency room, but he was feeling better.

Thursday, October 24, 2013

Nearing the End of the Road

I have never denied being America’s most successful hotel doctor. No one makes as many visits (passing 16,000 in 2012) or works at it exclusively. All others do it as a sideline.

Yet time is passing. I’m not the only Los Angeles hotel doctor collecting social security. A new generation is muscling in, displaying the energy of youth, fierce marketing skills, and a useful absence of ethics. All are concierge doctors, building cash-only practices that serve patients willing to pay to have a physician at their beck and call.

Even in Los Angeles, these are a limited resource, so concierge doctors have cast an eye on hotels, a major source of cash-payers.

“I guess no one’s been sick,” is the lie I hear when an employee explains why her hotel isn’t calling. I’ve been hearing it lately. Despite this, 2013 looks to be a record year with calls running twenty percent over 2012.

Partly it’s because my field is consolidating. National housecall services are expanding, and almost all use me. This is no news to my competitors, but marketing to these firms presents difficulties for a concierge doctor.

One obstacle is their spectacular fees: double or triple mine. This may strike you as terrible business practice, but it’s no problem with hotels. Hotels don’t care what a doctor charges unless guests complain. They rarely do.

In addition, when concierge doctors introduce themselves to a hotel employee, extol their virtues, and perhaps offer an amenity for every referral, they have a receptive audience. This doesn’t work so well at a corporate office.

Finally, concierge doctors are young and busy. Immediate 24-hour service is a concierge doctor mantra, but providing it is impossible for anyone with a practice and active social life. My leisure activities are reading and writing.

The result is that concierge doctors ask my help regularly. They send me to their patients but increasingly to my hotels and those of my colleagues. When I retire, it won’t be because business is declining.       

Saturday, October 19, 2013

A Plug for a Book

Try to find The Hotel, A Week in the Life of the Plaza by Sonny Kleinfeld. Published in 1989, it’s long out of print, but you’ll love it. Kleinfeld is a journalist who spent a week in the famous New York hotel and wrote about twenty chapters describing every position from the doorman, desk clerk and laundry worker to the kitchen staff, concierge, security, bellhops, housekeeping, and management.

I was impressed at the difficulty of keeping such an institution running smoothly and satisfying demanding guests (not you or me but some). If you want to know the hardest job in a hotel, there’s no contest. It’s the housekeeper’s.  

The book includes a chapter on the hotel doctor that kept me scratching my head. Mostly, he complains.

It infuriates him that guests call at 1 a.m. with a bad cold. Any call from an exclusive Los Angeles hotel like the Four Seasons would thrill me. Why was he upset? Did he volunteer for the job? Is he working for free? I have no problem seeing guests who aren’t very sick no matter what the hour.

I take for granted that doctors go into medicine because they want to help people, and unlike other helping professions (clergymen, firemen, social workers) we’re paid very well. Almost no one calls me during wee hours unless they’re feeling bad. That may represent poor judgment, but who thinks clearly when they’re miserable?   

Tuesday, October 15, 2013

A Weird Letter From My Doctor

I take good care of myself, but I’m 73, and the best life-style only postpones the inevitable.

I’ve been seeing a cardiologist at the Pacific Heart Institute, a four-man group in Santa Monica. He is excellent. I would be seeing him still but for a strange letter that arrived last month.

Insurance companies and Medicare have been reducing payments, it began, and more cuts are threatened. In response other cardiology groups were merging, lowering the quality of their care. Pacific Heart Institute vowed to maintain its standards. But how to do that while continuing to accept insurance?

The solution was to offer an “Enhanced Access Program.” An accompanying sign-up sheet listed three levels of benefits.

For $500 a year I could choose the “SELECT” level. Among its features are priority in appointments, prompt notification of test results, waiver of miscellaneous office fees, a special internet portal, and a customized wallet card with my EKG tracing.

$1800 per year would bump me to “PREMIER” status: same day appointments, direct e-mail and phone access to my cardiologist, and a free vascular risk assessment.

At $7,500 a year (that’s not a typo), the deluxe “CONCIERGE” level gives 24 hour access to my “personal” cardiologist, same day visits, same day tests, and a call from my personal cardiologist to discuss results.

I could check a fourth box. Lacking a title, it merely stated “I choose not to participate… No fee.” The doctor would continue to see me if I decided not to pay up.

Paying extra to get the doctor’s attention is routine where doctor incomes are low. It was the norm in the old Soviet Union and remains so in Russia, China, and Eastern Europe.

American doctors are the world’s richest, but they didn’t get that way by ignoring sources of income. If you follow the news, you know that cash-only or “concierge” practices are a growing niche. They’re so popular that professional organizations such as the AMA have set up ethical guidelines. As I wrote on June 27, this seems like setting up guidelines for operating a Mexican cancer clinic, but mine is a minority view.

I’m angry, but mostly I’m frightened about my heart which will require major surgery in the near future. I need to believe my doctor is focused on caring for me, and I thought I had found one. Then he suggested I pay him extra.     

Friday, October 11, 2013

Seriously Burned

I awoke at my usual time, wrote for a few hours, ate breakfast, and went back to bed. I had answered a wee-hour request from a distant hotel, and I was sleepy.

When business is slow, I take actions that encourage calls such as going to a movie or trying to take a nap. Unfortunately, this works when I don’t want it to, so the phone rang as I drifted off. It was a lady at the Custom hotel whom I’d seen the day before for vomiting and diarrhea. She was better and desperate to return home, but her insurance insisted on another exam before allowing her to travel. Visiting guests who aren’t sick is a perk of hotel doctoring, and I was happy to comply.

Returning home I headed straight for bed, but the phone rang as my head touched the pillow. A lady at Le Parc explained that had undergone eyebrow waxing, and a clumsy cosmetologist had inflicted serious burns. I suggested that serious burns around the eye require more care than I could deliver on a housecall, but she demanded a visit.

I consoled myself with the knowledge that guests often exaggerate their problems. This proved to be the case when she showed me several pink spots over her eyelids and forehead. These were mild, first-degree burns, I explained, similar to sunburn. I handed over a tube of soothing cream and assured her that they would heal completely in a week.

I was wrong, she said bluntly. Because of her extremely delicate skin, she would be scarred for life.

Monday, October 7, 2013

An Odd Foreign Custom

When I finish caring for American guests, I accept their thanks and money, and I leave. With  guests from another country, I often find myself discouraging them from accompanying me to the elevator or down to the lobby or (if it’s a private house) to my car.

I mentioned this excessive politeness to a colleague from South America.

“They probably thought you were in a hurry to get away,” he said.

When I protested, he explained.

“When I first came to the US and visited an acquaintance, I was disturbed when he shut the door behind me after I left. Did I offend him, I wondered. Is he happy to get rid of me….? In my country, you always accompany an honored guest when he leaves and make sure he is safely on his way. To stay behind is not courteous. But this is what Americans do.    

Friday, October 4, 2013

Another Freebie

A guest at the Georgian hotel in Santa Monica wanted a housecall, said the desk clerk. She had a urine infection.

That was good news. The Georgian was not far, and urine infections are usually easy.

“The guest has gone to dinner,” the clerk added. “She’d like you to come at 9 o’clock.”

I hate it when hotels make an appointment without consulting me. I want to talk to guests before a visit. It’s surprising how often their self-diagnosis is wrong. They need to know how much I charge and that they’ll have to pay directly. Learning this, some guests reconsider. A few guests assume the doctor is in the hotel, so it’s no big deal if they’re late or decide to skip the consultation entirely. Finally, it’s stressful to kill time at home, hoping another call doesn’t arrive to complicate matters.

Sure enough, at 8:30, as I was about to leave, the phone rang. A guest at the Airport Hilton was vomiting. Vomiters don’t like to wait. There was no way to contact the Georgian guest to suggest a delay, but I decided I could make the visit and reach the Hilton in an hour. I hurried off.

Freeway traffic stopped cold at my exit. Santa Monica was holding an arts festival. The streets were jammed; the police were out in force directing traffic and manning barriers. After half an hour, I had advanced two blocks when I realized the beachfront, including the Georgian, was sealed off. Normally, I would park six blocks away and walk to the hotel, but this would make me outrageously late for the poor vomiter at the Hilton.

Guests usually agree to wait when I explain the problem.

“I just flew in from London. There’s no way I can stay awake,” said the Georgian guest, hearing that I’d like to return when traffic eased.

In the end, I phoned a prescription into a nearby pharmacy and made my way to the airport.

Sunday, September 29, 2013

Major and Minor Tranquilizers

Guests often ask for something to calm them, and I try to comply by stocking Valium.

Tranquilizers relieve generalized anxiety but not the pain of a terrible event such as a family death. Unhappy victims regularly ask for something to “put me to sleep,” but only general anesthesia does that. Even sleeping pills merely produce drowsiness; if you’re miserable, sleep comes hard.

I give a Valium injection if asked, but I have a low opinion of its tranquilizing properties. Valium pills work better because the more you take, the drowsier you get. The effect of the maximum Valium injection does not impress me. I prefer Thorazine.

Valium and its relatives are minor tranquilizers; the Thorazine family belongs to the major tranquilizers. “Major” and “minor” have nothing to do with strength; they refer to the seriousness of disease. Thorazine helps schizophrenia, a major mental illness. The first of a numerous class of drugs called phenothiazines, its discovery in 1952 marked a huge advance because it calmed schizophrenics enough so many could leave mental hospitals and live on the street, thus saving tax money.

People who deny schizophrenia is a brain disease claim Thorazine works because it makes patients somnolent. In fact, many newer phenothiazines aren’t sedating, but they work as well. Thorazine and its family turn off the positive symptoms of schizophrenia:  hallucinations, delusions, bizarre behavior. Movie schizophrenics seem to enjoy themselves, but hearing a voice inside your head frightens most people even if it’s God.

Despite their dramatic effects, phenothiazines don’t cure schizophrenia because they don’t eliminate the negative symptoms such as apathy, social withdrawal, and self-neglect. Being around a well-behaved schizophrenic remains an uncomfortable experience. Something is missing.

Wednesday, September 25, 2013

A Week's Vacation

Returning from a week’s vacation, I took my phone off call-forwarding. Knowing that I keep detailed records, the colleague who covered E-mailed me the information I needed.

Seven hotels phoned; he made four housecalls and took care of three over the phone.

Universal Assistance, a travel insurer, called once. He asked for their credit card number which they gave, and he made the visit.

World Aid, another travel insurer, called twice but refused to give a credit card, so he refused the calls. I fax my invoices to World Aid which usually pays in a month or two. When they don’t, I phone to remind them. Many hotel doctors hate pestering agencies for payment, so they insist on a credit card.

International Assistance called three times, and he declined as soon as they identified themselves. IA still owes him for visits in years past. International Assistance has a poisonous reputation among hotel doctors because it often took six months to pay when it paid at all. Institutions such as clinics and hospitals can deal with this (state-run Medicaid programs are not much better), but individuals soon give up.

Ironically, my patience with IA has been rewarded. After the latest change of ownership a year ago, it got its act together. It now pays reliably every month and provides a great deal of business, but a long time will pass before it lives down its reputation among my colleagues.

Inn-House Doctors called five times, and he made two visits: one to Hollywood and one to the airport area. A national housecall service, Inn-House serves a few hotels and travel insurers but many airline flight crew. In their eternal search for better hotel rates, airlines have been boarding crew further and further from Los Angeles airport which is twenty miles from my colleague’s home. He declined two visits to Long Beach (45 miles) and one to Anaheim (60 miles).

Thursday, September 19, 2013

It's Just a Stomach Virus

“I’m worried about sunstroke,” said a guest at Maison 140 last week. Her husband was vomiting, and they had returned from a walking tour of Beverly Hills. The temperature was in the 90s.

Sunstroke is life-threatening, and it takes much more than a hot afternoon walk in Los Angeles to bring it on. I’ve never made the diagnosis, but hotel guests worry about it.

“Someone put something into my drink.”

You might think no one outside of a bad movie would say this, but I hear it perhaps once a year. It’s alarming to fall violently ill after a night on the town, and Los Angeles is an exotic locale to many patients, so anything can happen.

“The sushi tasted funny…”

It’s common sense that food your stomach rejects must be noxious, but if you’ve been paying attention you know that using common sense to explain an illness is proof that you don’t know what’s going on.

Food poisoning is not rare, but the responsible toxins are tasteless. Also, infections such as Salmonella are not the result of spoilage but contamination of ordinary food with feces.

It’s impossible to diagnose food poisoning unless more than one person is sick. Almost everyone blames an upset stomach on the previous meal, but it’s most likely a virus. Google “viral gastroenteritis.”

Monday, September 16, 2013

Isn't Science Wonderful: continued

As I wrote last time, doctors treat strep throat with an antibiotic. Does it work?

That seems a no-brainer. After all, antibiotics definitely kill strep. But the answer turns out to be….maybe. In scientific studies, giving antibiotics to patients with strep throat is not dramatically effective. Some doctors suspect they don’t work. This contrasts vividly with treating strep infections in other areas such as the skin where it’s often lifesaving.

“Wait a minute!!” assert experts including my professors in medical school. It’s true that strep throat goes away in three to five days even if not treated, they point out, but doctors must treat in order to prevent rheumatic fever, a disease that can produce devastating heart disease. Scientists don’t understand why, but a small percentage of strep victims go on to develop rheumatic fever. Antibiotics lower the risk.

Are they right? Again science delivers the answer: maybe. Evidence for preventing rheumatic fever in America comes from a study conducted sixty years ago when rheumatic fever was common in the US. It’s rare now. I’ve never seen a case. Everyone agrees it wasn’t a terrific study.

Some doctors believe that rheumatic fever is so rare in the US that giving an antibiotic is more likely to cause harm (yes, antibiotics can cause harm) than benefit.

While it’s fun to make controversial statements in this blog, with patients I stick to the standard of practice. Inevitably, this means I sometimes give treatments whose scientific basis is weak. If you prefer therapy that’s guaranteed, you must stop seeing scientific practitioners like me and seek out alternative or complementary healers. Google “alternative medicine.”  You’ll notice that their treatments always work.

Thursday, September 12, 2013

Isn't Science Wonderful?

“He has pus on his tonsils, so it’s probably strep,” said a guest, calling about her teenage son. I hear this phrase regularly. It causes me some stress because I know that later I might find myself delivering a why-antibiotics-won’t-help explanation to a disappointed audience.  

One popular (i.e. wrong) medical belief is that pus on tonsils is a sign of strep throat. In fact, this is true only ten to twenty percent of the time. Viral infections produce identical exudates.

Arriving in the room, I discovered that the boy had pus on his tonsils but also a fever, swollen, painful glands on his neck, and no cough. Good scientific studies show that the presence of these four signs: pus on tonsils, fever, swollen neck glands, and NO cough raise the odds of strep to over fifty percent, so prescribing an antibiotic is appropriate. I prescribed an antibiotic. The family made it clear they were in the presence of an astute physician who knew what to do. Everyone was happy.

Isn’t science wonderful? The answer is yes. But it’s wonderful in ways that are often not satisfying. More in my next post.

Saturday, September 7, 2013

Today's Visits

My phone rang as I walked into the gym. A guest at the Sunset Plaza wanted a doctor to “check out” her 9 year-old daughter who’d awoken with a fever and vomited once. This was a good call. Multiple vomits can be worrisome, but one is OK. I jumped at the chance to skip my morning exercise.

Sunset Plaza parking is indoors and free, a bonus on a hot day and on the Sunset Strip where street parking is impossible. The daughter was recovering, so I reassured the parents, a pleasure for everyone.

As I returned to my car, the phone rang again. This was a perfect time for a second call. Lunch was two hours away. Late morning traffic is the day’s thinnest. I could thrill the guest by announcing a speedy arrival.

The caller was a national housecall service. The patient was a Quantas flight attendant at the Hilton. While there is a Hilton at Los Angeles airport, this one was in Costa Mesa, 45 miles away. This was not so good, but there were compensations.

As I’ve written, in the old days airlines called me directly, and I billed them directly. No airline does that now. They call a national housecall service which, of course, calls me. I’m happy to work for the service because, being a better marketer, it’s acquired far more airlines, so I receive more calls. It also pays much more. This is possible because it charges airlines triple my former fee. You may wonder why airlines are willing to pay so much more, but I don’t. As someone who follows the news, I’ve long since stopped believing that stupid decisions by people who seem intelligent have a good explanation.  

Tuesday, September 3, 2013

Another Perk of Hotel Doctoring

A travel insurer sent me to a woman complaining of asthma. When I arrived, she admitted that she had a little wheezing. She didn’t seem ill, and my exam was negative. She added casually that she had left home without her asthma inhaler, so I wrote a prescription for another.

When guests phone me directly because they’ve forgotten a medicine, I call a pharmacy to replace it at no charge. Guests who phone their travel insurance are often reluctant to admit their mistake, so they claim they’re ill. I like these visits.

Friday, August 30, 2013

Resisting Temptation

A businessman at the Hilton-Garden asked a pharmacist to recommend a cream for his insect bites. To his alarm, he learned that what looked like insect bites might be Lyme disease and that he should consult a physician.

This provided another delicious temptation in the life of a hotel doctor. I could make a housecall, assure the man he did not have Lyme disease, and collect my fee. He would feel vastly relieved and grateful. Everyone would be happy.

The businessman described half a dozen itchy pimples around his ankles. Even over the phone, it was obvious that they were insect bites. I reassured him, and he was relieved and grateful, but no money changed hands.

Monday, August 26, 2013

We Yearn to Help

If a prescription gave you diarrhea or made you vomit, you might complain. But until well into the twentieth century, the average American looked on a good “purge” as a way to expel disease. Physicians took pride in their cathartics, and when patients discussed a doctor’s skill, they gave high marks for the violence of his purges.

A person who visits a doctor expects certain behavior. Nowadays Americans frown upon exorcism, bleeding, or purging, but we expect medicine. It should be one only a doctor can prescribe; over-the-counter drugs don’t count. Pills are good, but an injection is better. Of course, modern drugs often work, but this is a minor matter compared to the deep human desire that a doctor do something.

I apologize if this sounds mildly insulting; I suspect most of you will deny expecting a drug. You want whatever will help. If nothing will help, you want to know.

Such sensible patients do appear, but no day passes when I don’t see disappointment in a patient’s eyes when he or she realizes I don’t plan to “give them something.” 

Doctors genuinely want to help you, and we feel bad when we can’t. We also feel bad when we do our best, and it’s obvious a patient doesn’t feel “helped.” So many of us add a prescription to convince you that we’re doing what a proper doctor should do.

Friday, August 23, 2013

I Prefer Vomiting and Diarrhea

Two women at the Holiday Inn were ill. The mother suffered several hours of severe low abdominal pain with vomiting and diarrhea. It seemed like the usual stomach flu. I assured her it wouldn’t last long and gave medication to relieve her symptoms.

Her adult daughter also complained of severe low abdominal pain but without other symptoms. Viral gastroenteritis can occur without vomiting or diarrhea, but I feel reassured when they’re present. It’s a good rule that when two members of a family are ill at the same time, it’s the same illness, but no rule is absolute.

The problem is that isolated low abdominal pain in a young woman can indicate an urgent problem such as ectopic pregnancy or twisted ovary. This seemed unlikely, but I couldn’t rule it out. If she weren’t better in a few hours, I explained, she must go to the local emergency room. She did not object.

When I phoned a few hours later, the mother’s symptoms had vanished, and the daughter told me she felt a little better. Patients tend to tell doctors what they believe we want to hear, so “…a little better,” does not reassure me. Pressed, she admitted that she wasn’t feeling better. When urged to go to the emergency room, she worried about her lack of insurance and the late hour but promised to give it serious consideration.

I passed a restless night. When I phoned the next morning, she had recovered.

Tuesday, August 20, 2013

The World's Worst Travel Insurer

International Medical Assistance has a terrible reputation despite being my leading source of business. So far in 2013, it’s called 118 times. Every doctor who knows IMS, including the colleague who covers when I’m away, refuses its calls because it’s so hard to get paid.

Most travel insurers pay within a month or two. If they don’t, a call to the claims department corrects matters.

In the past, IMS never paid within two months. When I called, the claims department assured me that a check would be mailed in the near future or that my invoice had never arrived. When I called a week later, I heard the same explanation.

IMS was in business when I took up hotel doctoring thirty years ago and, for obvious reasons, happy to send patients. It didn’t take long for me to grow annoyed. Payment took six month or a year and required persistent phone calls. In 1993, with my practice prospering, I began refusing its calls.

In 1998, IMS changed ownership. A representative called to apologize for my difficulties and promise that it would now pay promptly. I was convinced.

But nothing changed!! Checks didn’t arrive. I resumed pestering the billing department. By 1998 several competing hotel doctors had appeared. IMS was infuriating to deal with, but it provided plenty of business and – eventually – paid.

My frustration tolerance has diminished with age. In 2012 I was considering dropping IMS when a representative called to announce that it was again under new management. Payment would now be made every month directly into my checking account.

Sure enough, in January 2013, December’s payments appeared – minus several visits. Wearily, I picked up the phone. The problem remained when the February payment appeared, also for too little. The March payment was too much but it didn’t even out. April’s payment was also excessive; now I owed them. The May payment again missed several visits.

That’s when I realized that IMS is cheap but not dishonest. It’s simply incompetent. Its claims department will never get my invoices right. Sometimes it pays too little, sometimes too much, never exactly what I bill. I’ve stopped phoning. As long as payments are in the ballpark of what they owe, it’s good enough for me. 

Saturday, August 17, 2013

The Meaning of Life

I believe that things happen because they happen. We weren’t put on Earth for a purpose. You’re born, you do your best, you die.

This is not a popular point of view. Every writer and TV personality you’ve heard of disagrees, including several with a medical degree. Yet I’m convinced that searching for an explanation is the best way to understand natural phenomena but useless as a personal philosophy.  

“I’ve got cancer!!!...  Why me?” This is the first question almost everyone asks. If you believe the universe (God for those less cool) cares about you, everything happens for a reason, so this question has an answer.

But now the cancer victim has an extra job. Besides confronting the disease, he must look deep inside and learn how this is part of the plan. If he’s successful, he’ll feel better. Or she.

You’ve read essays by people who have (1) gotten cancer, (2) reexamined their lives, and (3) achieved inner peace. I’m sure this happens, but in my experience most of us do not find misfortune an opportunity for spiritual growth.

Exhorting patients to find themselves only adds to their burden. I especially dislike media doctors who urge victims to fight their disease, asserting that optimism aids healing. Be happy or die.

Most cancer patients pull themselves together and deal with immediate problems. That’s the best they can do, and it’s not bad. 

Wednesday, August 14, 2013

You Think I have a Soft Job

The phone rang at 1:10 a.m. A national housecall agency needed a visit in Anaheim, fifty miles away. I agreed to go but quoted a larger fee because of the hour and distance. The dispatcher said she would request approval get back to me.

After ten minutes I called to ask about the delay.

“I’m sorry," she said. "We’re waiting for the E-mail.”

“E-mail!! Can’t you phone?”

Apparently not. Approval had to come from Madrid or Buenos Aires. I waited another fifteen minutes before calling again. Learning that the E-mail still hadn’t arrived, I told the dispatcher I had changed my mind, and I went back to bed.