Goodbye to the Shangri-La

“I’m not calling for a guest,” explained a desk clerk from the Shangri-La in Santa Monica. “I have a question…. In your arrangement with hotels, do you ever pay anything when we call?”

“That’s illegal,” I said. “I’m happy to give employees free medical care, but it’s against the law for a doctor to pay to get a patient.”

“Is that so? Are you sure?”

“Google it. It’s called a referral fee; it’s unethical and also against the law in California. If you use a doctor who’s breaking one law, what other laws might he break?....”  

“Oh, this is just for our own information. I appreciate your help, doctor. Thanks.”

Goodbye to the Shangri-La, I said to myself after she hung up. I’ve been going there since 1985, but the Shangri-La is not large. Since I give plenty of free phone advice, months may pass before I make an appearance, so most employees have never seen me. I don’t market myself, and most general managers leave the choice of a doctor up to the employee, so I regularly lose hotels when a competitor offers his services with the promise of a referral fee.

Sometimes, often years later, they return. Google “Doctor Jules M. Lusman.” He took a number of hotels away from me, but I regained them.    

Caring For a Physician

Having a doctor as a patient is stressful. They often suggest their diagnosis, and it’s awkward if I disagree. When I make a housecall, American doctors sometimes hint that I shouldn’t charge them.

This patient was an anesthesiologist, a good thing because he almost wasn’t a doctor at all – i.e. he’d long since forgotten how to deal with illnesses. He was foreign, another good thing. And he was Danish: the best sort of foreigner because Scandinavians speak good English. 

He had a headache and a 101 degree fever but no respiratory symptoms. I diagnosed a viral infection, perhaps even Dengue fever because he had flown in from the South Pacific. He did not object to taking pain medicine and waiting, and he recovered after a few days.

More Unsatisfied Guests

The son of two Viceroy guests was suffering a severe sore throat and fever.

I drove off in a good mood because it sounded like an easy visit. This combination often indicates “strep” which an antibiotic cures. Patients like that, so I like it, too.

In fact, sore throat and fever in a grown-up is usually a simple viral infection, my least favorite illness. Strep is overwhelmingly a disease of children and adolescents, but this patient was fourteen, so my hopes were high.

They were dashed when the boy admitted that he had a cough. Strep is strictly a throat infection; coughing is not part of the picture. Sure enough, his throat looked normal.

Rummaging thoughtfully in my bag, I pulled out a packet of acetaminophen (Tylenol), handed it to the parents, and explained that this would help his fever. I extracted a plastic bottle of Lidocaine, a gargle intended to relieve his throat pain. I gave them a cough medicine is similar to the popular Robitussin but in an immense eight-ounce bottle.

I assured them that bed rest would not help, so he should try to enjoy himself. He could eat whatever he wanted. But it was likely that he’d feel under the weather for a few days before recovering.

The parents seemed happy to receive the medicine. They expressed gratitude for my service, and thanked me effusively as I left, but I knew that this was mostly good manners.  They were on vacation. The doctor had come, given some not-very-powerful medicine, and told them the child would continue to be sick. Did the doctor realize how important this trip was to them? Maybe if he had tried harder…. Or if they’d called a better one…. 

Not a Bad Job

Awakened at night, most hotel doctors prefer to give advice, and, if that fails, they discover that the guest requires the paramedics.

I don’t mind wee-hour calls. Traffic is light, parking is easy, and since I have no office, I can sleep late. With TIVO, I can leave whatever television show I’m watching. I don’t mind calls during meals, even restaurant meals, because finishing doesn’t take much time. Calls during a movie are problematic although I’m happy to leave at least half the time. If the call arrives soon after the credits, I ask for a refund, and no one has yet refused. I credit much of my success as a hotel doctor to the rarity of occasions where I’m reluctant to make a visit.

Mostly, I dislike driving during the rush hour. Hotels between Beverly Hills and the ocean are close enough to be tolerable, but traveling downtown or further is tedious. Mostly, guests are willing to wait a few hours provided they are not vomiting or hurting.

Two For the Price of Two

An insurance service informed me that two sick children awaited in Orange. It’s a rule that if one child is sick, there’s a small chance it’s serious; for two children, never. They almost always have a simple virus.

The major difficulty was the distance, nearly fifty miles, and the fact that my wife was preparing dinner. To my delight she offered to delay it and accompany me on the visit, something she rarely does. We had a pleasant hour’s drive to Orange where I cared for two children with a simple virus, and we ate dinner at the hotel.

Lost in Translation, Part 3

“I am constipated.”

“’Constipation’ means different things to different people. What exactly bothers you?”

Silence…. When a caller doesn’t answer, it usually means he doesn’t understand.

“Do you have pain?”

Silence.  I knew the word for pain in French is ‘douleur.’

“Pain….douleur?”

“Yes.”

“So you have pain in the abdomen.”

“Yes,” he answered without conviction. He made it clear he wanted a visit, so I quoted my fee (“yes”) and made the trip.

Half of my hotel guests are foreign, but usually one person in the group speaks enough English to get along. Men do better than women. Guests from Asia cause the most trouble. South Americans are the easiest because every hotel has Hispanic workers. I can’t remember the last time I drew a blank from a European male.

“When was your last bowel movement?”

Incomprehension. The wife handed me an Ipad with a translation app. I typed “bowel movement” and the screen obligingly displayed “movement de l’intestine.” Even I knew that this meant “movement of the intestine” in French. He looked blank.

He had no fever, and my examination of his abdomen was normal. His urinalysis was unremarkable. He wasn’t old enough to be at risk for the many abdominal catastrophes that affect the elderly. I concluded that it wasn’t an urgent problem. He seemed to understand that he should go to the hospital if he weren’t better in a few hours. The hotel promised to keep an eye on him. Everything worked out.

A Stoic Patient

This patient lived on the edge of Beverly Hills, far up Topanga Canyon Road. Turning into a side street, I stopped at a guard house. It was not impressive – a tiny shack next to a commercial port-a-potty, but a genuine uniformed guard asked my business. According to Google, the street beyond held only a dozen houses, but they were big. Really big.

Following the lady who greeted me at the door, I walked and walked, passing through room after room with polished wooden floors, high ceilings, exquisite furnishings, bookshelves and paintings lining the walls. Movie stars and Arab princes live in such places. Visit Hearst’s Castle to share the experience.

But sick people are just sick. A lady was suffering excruciating right eye pain. She hadn’t injured it. My diagnosis was acute glaucoma, an emergency.

You may know about glaucoma, a disease where fluid drainage from the eye is blocked, increasing pressure, eventually causing blindness. Experts advise you to have a yearly check, but this is for common, chronic glaucoma where pressure rises slowly, so doctors can make an early diagnosis and treat it with eye drops. It’s painless. Acute glaucoma, where drainage stops abruptly, is rare and very painful.

This was not news to the patient who explained that many family members were blind from the disease. She agreed to go to UCLA’s emergency room but asked for something to help her vomiting; severe pain often causes vomiting. I gave an injection and took my leave.

Phoning the next day, I was flabbergasted to learn she had stayed home. She didn’t want to travel because of the vomiting, she explained. By evening it had diminished, but so had the pain. She decided to wait. She had an appointment at the ophthalmologist for the afternoon.

Twilight of the Hotel Doctor

Uber is driving taxi companies out of business. Air Bnb is putting stress on hotels. A stream of retail chains are declaring bankruptcy in the face of online competition. No one doubts that this trend will continue. Online services are cheaper if sometimes inferior. Uber drivers earn less than traditional cabbies – not a notably prosperous profession. But customers aren’t complaining. They like cheap.

It’s absolutely certain that housecall doctors like me are doomed. We’re expensive and often – at least in my case – the quality of our service is too good.

Los Angeles residents already have a choice of two phone apps. Tap either one, enter your credit card information, and a doctor will arrive within hours. The fee will be less than mine – and I charge less than the typical hotel doctor.

One consequence of a low fee is that they pay doctors less than the going rate. As a result, they attract residents in training or just beginning practice, but these seem adequate.

As you know I work for everyone, and I worked for both. I didn’t care for the low pay, but I’d still be working if it weren’t that I had no control over the patients I saw.

When hotel guests phone, I always talk to them. If the problem is minor, I give advice and suggest that a housecall isn’t necessary. If it requires a simple service such as a prescription, I take care of it over the phone. If it requires a test, x-ray, or emergency room visit, I can usually determine that.

If the guest has unrealistic expectations, I can avoid an unsatisfying encounter. I can warn a hoarse singer that she probably won’t be better by evening.

Many callers request treatments that they don’t need. You might think of narcotics, but mostly it’s an antibiotic for their respiratory illness. I only prescribe an antibiotic if it will help which puts me at odds with most of the medical profession, so many patients will be disappointed and a few upset if I don’t treat their “bronchitis” or “sinus infection” as their doctors do. When this seems likely I direct them to a local clinic where they’ll get their antibiotic or (if they stumble on a competent doctor) express their disappointment to someone else.

When hotels phone, I make a housecall less than half the time. Guests love the free service. Even better, when I drive off, I know that I’ll be able to help, and – no less important – the guest will feel helped.

Working for these Uber services, I had to make every visit they assigned. All I learned was a symptom (“cough” “allergy”). The result is that I walked into situations where a housecall was not appropriate (“granny hasn’t seen a doctor in thirty years; would you check her out?...”). Many had problems I could have handled over the phone; others required more than a housecall could provide. And there were the usual unreasonable requests.

My faithful readers know that hotel visits don’t always work out. I’d estimate that five percent are less than satisfactory. Working for housecall services, the percentage was much higher. I didn’t like the stress of wondering what I would encounter.

But I see the writing on the wall. Hotels that emphasize superior service (i.e. expensive ones) will continue to refer guests to a specific doctor. Otherwise, ironically, the old days will return. When I began in 1983, motels and chains (Holiday Inn, Ramada, Hilton, Best Western…) had no interest in a hotel doctor. At least in Los Angeles, I was the first to approach them. By the 1990s, they were calling me and an increasing number of competitors, but managers of these hotels still pay little attention, so employees are on their own when guests ask for help.

Although my faithful clients continue to call, I’ve noticed a decline from the great mass of hotels that never called regularly. But I already collect Social Security, and I’ll be fine when I retire.

Easy Money, Part 2

“I need an eye doctor,” said the caller. “A big red spot came out this morning!”

The guest added that the eye felt fine. The spot didn’t affect his vision but looked terrible.

I’ve encountered several dozen subconjunctival hemorrhages, a fancy name for a bloody patch on the eyeball. Googling turns up a dozen causes from injuries to coughing, leukemia, high blood pressure, and clotting disorders. In reality, if there are no symptoms and the person is in good health, the blood appears for no reason and disappears in a few weeks. That’s happened in every case I’ve seen, including my own.

The guest was staying at the Mondrian, a luxury hotel. He was in room 500 which I knew was a suite. If he’d been at a cheap motel, I might have been more reassuring, but I confined myself to suggesting he might have a subconjunctival hemorrhage and that this was probably not as serious has he thought. He wanted a visit.

It was, of course, entirely satisfying. I examined the eye, paused thoughtfully, and then assured him that it was a subconjunctival hemorrhage and that he had nothing to worry about. He was thrilled. I collected my fee. Everyone was happy.

When the General Manager Consults the Lawyer

The concierge expressed relief when I answered. A lady’s 11 year-old son was seriously ill, but the mother had refused to take him to an emergency room. She had been pestering the hotel staff all day.

“What’s the problem?” I asked. “You only had to phone me.”

I’d made over 300 visits to that hotel since the 1990s. But even as I spoke, I remembered that it hadn’t called in six months. As I feared, the concierge explained that a new general manager had decreed that, for liability reasons, sick guests would be directed to the local emergency room unless calling 911 was appropriate. Doctor referrals were forbidden.

At any given time, about twenty percent of Los Angeles hotels have this policy, but it’s never the same twenty percent. Hotels adopt and then discard this rule because it causes public relations problems. Most guests don’t require 911 and don’t want to go to an emergency room, so they stay in the hotel, sick and resentful. A few persistent guests make so much trouble that, as in this case, a desperate employee disobeys her boss. I’ve made a dozen such visits.

Calling me would have saved everyone trouble. The child had a fever and a bad cough, a routine viral infection. It was an easy visit.

Afterward, as I was commiserating with the concierge, my phone rang with an example of how things are done right. A man at the Langham in Pasadena wanted a doctor to check out his cold. I told him I’d arrive in 45 minutes.

A Rule of Medicine That Didn't Apply

I give out medicines gratis. Mostly, they’re cheap, but exceptions exist. For unclear reasons my supplier charges $17 for antibiotic ear drops but $1.50 for antibiotic eye drops. Experts agree that it’s OK to use antibiotic eye drops in the ear, so that’s what I do.

I felt pleased handing over a bottle to a lady with swimmer’s ear. Ear infections are easy visits, and guests appreciate that they do not have to hunt for a pharmacy.

My heart sank when the guest’s insurer called the following day. She wanted another visit. I phoned the guest who admitted that her ear was no worse, but now she had a fever, headache, and sore throat. That was disturbing. Had I missed something?

I returned to the hotel. She had a 102 temperature with swollen tonsils and swollen neck glands. Since she was barely out of her teens, Strep throat was a reasonable diagnosis.

It’s a rule of medicine that a doctor who makes two separate diagnoses is not thinking clearly. Patients have one thing, but this woman definitely had swimmer’s ear and Strep throat.