A Creepy Frat Guy

The Andaz Hyatt had given my number, explained the caller. Could I see a member of their cast who was suffering an earache? Unfortunately, he was on location and wouldn’t return until evening.

She was delighted at my suggestion that I come to the film shoot, and I’m as eager as anyone to mingle with movie people. On the downside, I live six miles from the Hyatt; the film was shooting at the far end of the San Fernando Valley, twenty-five miles away, and I’d quoted my fee before learning this. 

The producers had taken over a run-down motel, painted it pink, and restored the coffee shop to its mid-twentieth century interior. I drove past warning “closed to the public” signs and parked among the cabins and scattered 1950s cars.

Several dozen people stood around, none over forty. You should realize that shooting a movie is boring. Filming takes up perhaps two percent of the day. The remainder involves setting up, technical changes, errands, and waiting around. Everyone looks forward to lunch. I attracted attention, being far older and much better dressed.

Earaches are easy. I followed a young man into the empty 1950s diner, made the diagnosis, handed over medicine, and took my leave.

As usual, one aspect of the experience seemed strange. The assistant who had phoned and greeted me on my arrival was a young, attractive woman. Other attractive women were carrying messages, answering phones, setting up the lunch buffet. Almost every actress in costume was beautiful; there were no exceptions for those in street clothes.

Somewhere in Los Angeles there is a creepy frat guy who handles hiring for film sets.

Getting Help, Part 3

If hotel doctoring seems romantic to you, it has the same effect on the medical profession, so a want-ad I placed in the Los Angeles County Medical Journal produced an avalanche of responses.

Many callers had a day job. If they worked at a clinic, they couldn’t help because clinic malpractice insurance never covers work outside the office. Buying their own policy was impossible because none are cheap enough to cover the modest income I could provide. For this reason, residents also couldn’t work for me. Nor could retired doctors who’d dropped their insurance.

Some callers had a practice and their own insurance, but that meant they couldn’t leave during office hours. Most assured me they’d love to make visits afterward – to hotels in their area. Since doctors live in prosperous neighborhoods, but hotels are often downtown or near the airport, this would make my life too complicated.

I never considered myself unique until I tried to find a helper. My ideal would be competent, likeable, available 24 hours a day, and willing to travel anywhere. That describes me but no applicant so far. I enjoy friendly relations with a few other hotel doctors who cover when I leave town, but it’s never ideal to turn your business over to a competitor.

A surprising number of doctors announced they were free during the day and eager to make visits anywhere. All made me suspicious. Why didn’t they have a job? Doctors have no trouble finding work. Quizzing them provided no reassurance. They had just arrived in town; they were unwilling to settle down just yet; they were searching for a congenial position… 

I take for granted any doctor with a day job possesses at least marginal competence, but what about these fellows? Every doctor scratches his head over a few colleagues, wondering how they slipped through medical school and into practice without anyone noticing. So I’m still looking.

Karma Will Find You!

My wife and I were shopping at Trader Joe’s at 5 o’clock. For all its superior features, Trader Joe’s is bagger-deprived, so check-out lines move slowly. They were very long at 5 o’clock.

Searching for the mythical shortest line, we found one that qualified but only because an overflowing cart stood at the end with no one nearby. We considered. Most likely its owner had rushed off for a forgotten item. After a minute when no one appeared, we wondered if someone had abandoned it. The line moved forward, opening a substantial gap in front of the ownerless cart. We decided that sufficient time had elapsed and took our position. Immediately, a woman appeared.

“Excuse me! I was in line,” she said.

“You were gone a long time,” said my wife.

“Not true! I wasn’t away twenty seconds. You’re in my spot.”

 “We’ll stay,” I said, provoked by her mendacious defense.

She seemed about to make a scene, but before anything developed, my wife told me to shut up and moved our cart to the end of the line. As far as we were concerned, that ended the matter. We began discussing the evening’s activities. The lady with the cart couldn’t overhear, but (in retrospect) she probably thought we were muttering about her. After a minute, she whirled angrily.

“This is clearly very important to you! So I’m going to let you have the precious position you yearn for.” She pushed her cart away but not before turning to wave her finger and add: “Bad Karma! But sooner or later it will find you.”

Having the last word in these disputes equals victory, so we were left feeling defeated.

Then miraculously, Karma found us. A clerk opened an empty register, waved us over, and suddenly we were first in line!

Looking for Help

“Your blog is funny, and you’ve got a great thing going with hotels. I wonder if we can work together.”

The caller was a young doctor who explained that he was starting a concierge practice and needed someone to cover when he was away. Naturally, he was available to cover for me.

I’m always looking for help. Hotel doctors keep each other at arm’s length because, while it’s considered unethical to solicit another doctor’s patients, soliciting a hotel is just business, and I don’t want them setting foot in mine.

We met at a local restaurant. He did most of the talking, describing the superb service he provided. As you may know, concierge doctors accept no insurance. In exchange for a large retainer or other cash arrangement, they provide enhanced care: immediate availability, leisurely office visits, 24 hour phone service, and house calls. House calls cost extra, and none of this money covers tests, x-rays, specialists, and hospitalization, so it’s a service aimed at the wealthy.

As it happened I planned to see a Dodger game with my brothers that weekend, July 4. The colleague who covers was attending a wedding and warned that he might have trouble getting away. I decided to give the concierge doctor a chance.

I usually call-forward my number to my colleague, but he knows how to deal with hotel guests, so I didn’t. The phone rang as we were driving to the stadium. A child was suffering a severe cough and fever. The mother wanted a visit as soon as possible. I called the concierge doctor.

“They’re in Hawthorne,” I explained. “It’s far, so I quoted three hundred dollars.”

He sounded shocked “Doctor Oppenheim! It’s a holiday!”

“Right,” I said. “No freeway traffic.”

“Doctors don’t work on holidays. Patients understand that. They know they have to pay extra.”

“And that would be…?”

“My patients pay six hundred dollars.”

“That’s not in the cards. Do you want to make the visit or not?”

“Of course, I do. But I’m celebrating the holiday with my family like everyone else. I have to earn a reasonable fee if I get called away. Patients don’t object.”

“I’ll take care of this another way.” I hung up, furious, and then  phoned the patient’s mother. The child didn’t seem dangerously ill, and she was willing to wait a few hours. That solved the immediate problem but ruined the evening because I worried about a catastrophe occurring while I indulged my frivolous love of baseball. When I phoned after the game, the child was sleeping, and the mother wanted to wait until morning. It turned out he had a routine cold.

I’m still looking for help. 

Stressful and Nonstressful Visits

Driving to a hotel can be stressful. I talk to guests by phone beforehand, eliminating obvious emergencies and unreasonable requests, but plenty of worrisome possibilities remain.

Sick babies make some hotel doctors nervous. I see them but some don’t. If, over the phone, the doctor tells you to take your baby to an emergency room, ask politely if he prefers not to see infants. If he admits this is so, try to find another hotel doctor before going off.

Elderly patients can be challenging. They seem fragile, so a doctor may lean over backwards to treat illnesses that don’t require treatment or refer to a hospital more quickly than he would a younger person. I consider eighty the beginning of fragility; other doctors begin at seventy, but this is clearly wrong because I am over seventy and not fragile at all.

If a patient has a bellyache, I worry. Without tests or x-rays I have to decide if it’s safe to wait. When I decide it’s safe, I’m almost always right, but I send guests to emergency rooms if uncertainty remains. Many endure a long, tedious, expensive experience only to learn that nothing abnormal has turned up. Some consider this good news, but others wonder why, having summoned me and paid my fee, I didn’t save them the trouble.

I’m always uneasy before seeing guests suffering an ordinary respiratory infection because a large percentage – perhaps a quarter – are obviously disappointed if I don’t prescribe an antibiotic. We feel bad when a patient believes we haven’t helped.

On the bright side, I often drive off knowing the diagnosis, knowing I’ll help, and certain the guest will deliver a satisfying dose of gratitude. Relaxing drives include those for simple urine infections, eye infections, ear infections, and rashes. I generally diagnose chicken pox, shingles, hives, and the common cold over the phone. Isolated abdominal pain is tricky, but I feel better if vomiting or diarrhea accompany it because they usually indicate a short-lived stomach virus. Guests who want their blood pressure checked rarely worry me. High blood pressure doesn’t cause symptoms, so those who make this request have other problems, generally anxiety-related.

Phrases Patients Love to Hear, Part 2

4.  “Staying in bed won’t make this go away any faster.”

Many laymen believe illness requires rest. They skip work or school. Mothers go to great (and futile) length to keep children immobile. Travelers waste days in a boring hotel room. This myth is so universal that when I reassure non-English speaking guests, I ask them to repeat what I’ve just said. Almost always, they miss the negative.

5.  “The fever (or vomiting or diarrhea) won’t harm you.”

Temperature by itself - even to 104 - won’t damage a healthy person.  Patients should pay attention, but they needn’t worry that death is near. When patients ask for a genuinely dangerous temperature, I answer “over 105,” but this is less helpful than it sounds because at this level, patients feel very bad. Similarly, healthy laymen fear that a few episodes of vomiting or diarrhea will produce serious malnutrition.

6.  “You’ll feel under the weather for a few days; then you’ll feel better.”

Patients may suffer for a week, but once they see a doctor, they want things to move quickly, so I warn guests that this might not happen. In my experience, if I neglect this, patients become concerned if they’re not feeling better the next day and take advantage of #3.

7.  “It’s not your fault.”

All our efforts at patient education plus the popularity of alternative medical theories have convinced Americans that they are responsible for getting sick. This is occasionally true but mostly not.

Phrases Patients Love to Hear, Part 1

After years of practice, doctors learn to read patients’ minds. I’m proud of my skill, but some doctors do better than others. Here are phrases you love to hear; you should hear them more often.

1.  “You did the right thing.”

Sometimes doctors are so reassuring that patients leave the office unhappy - not at the doctor but themselves.  “I wasn’t sick enough come in,” they think.  “I wasted his time.  I must be a hypochondriac!”  Most often this happens with minor ailments or respiratory infections when we provide reassurance but no prescription. To prevent this, at the end of a visit I might say something like “You did the right thing to come in. Some patients with this symptom have.... but you just have... “

2.  “This isn’t a serious problem, and it never turns into a serious problem.” 
Doctors know that many tiresome problems such as hemorrhoids, bladder infections, migraine, or herpes are not ominous. They never turn into something worse, but many patients don’t know this. A doctor must tell them.

3.  “I want you to call me any time.”

Most patients assume doctors are constantly pestered by neurotics. In fact, almost everyone who calls me has a good reason. Anxious not to disturb the doctor, many sufferers struggle through the night, but that’s a bad idea.  The best time to call is when the urge first appears. To be honest, I don't think you'll ever hear this. 

Lost in Translation Again

As I stepped out of the elevator, a Japanese man was waiting. “Are you the doctor for the hotel?” he asked.

I was pleased. “Yes. Are you going to interpret for me?”

He stepped back in alarm and waved his English-Japanese phrase book. Hiding my disappointment, I followed him to the room. When he began flipping through the booklet, I shook my head and pointed to the phone before dialing the guest’s Japanese insurance service for an interpreter. There followed a lengthy encounter as the phone passed back and forth between me, the father, and the patient.

The patient had complained of fatigue the previous day. He was otherwise in good health with no other symptoms, and I found nothing abnormal on examination. Sudden fatigue is an ominous sign in the elderly but rarely in a child. I suspected an emotional problem, perhaps from the stress of foreign travel. This is hard to explain across both language and culture, made even harder because I didn’t give a medicine. Giving medicine is a universal language; that’s why doctors prescribe even when it isn’t necessary.

Luckily these were Japanese, so they listened with unfailing courtesy, through the interpreter, to my reassurance and advice (get a good night’s sleep, continue with their itinerary, call if the problem persisted), nodding approval, and thanking me effusively as I left.

Lack of Patience

“How quickly can you get here?”

“Pretty quick, but I like to talk to the guest first. Would you connect me?”

I didn’t assume this was an emergency; guests who make urgent requests are more often impatient than sick.

“How quickly can you get here?” asked the guest impatiently.

“Pretty quick. What’s going on?”

“It’s my assistant. He’s got the flu.”

“Could you tell me what’s bothering him?”

“I’m not a doctor. That’s why I called you.”

I suppressed a surge of annoyance. “People mean different things when they say ‘the flu.’ Is he vomiting?”

“No.”

“Is he feverish?”

“Yes. I have a dinner reservation at 6:30. Can you make it?”

It was 5:30. Unless guests feel truly miserable (vomiting, pain) they are usually willing to wait, so I like to delay dinnertime calls until rush hour traffic dwindles. But hotel doctoring is a competitive business, and if I disappointed this demanding caller, he might ask the concierge to suggest someone else.

Creeping 1½ miles to the freeway onramp took fifteen minutes, but then traffic moved steadily, and I arrived on time. In hotel doctoring, delivering medical care is the easiest part. The patient suffered a bad cold and didn’t consider it a serious problem. In person, his boss seemed congenial.

On my drive back, the freeway stopped cold. I took an exit three miles from home.  Despite this, traffic crawled so slowly I was expecting a blocked lane ahead, but it was just the rush hour. It took an hour. On the bright side, I had finished half my dinner when the call arrived, so I wasn’t hungry. And in hotel doctoring, when you finish seeing one patient, you go home.

Too Many Cooks

As I was preparing for bed, a call arrived from one of my favorite hotels, the Palomar. It’s large and upscale but mostly I like it because it’s only a short drive. The caller explained that his nine year-old son had been coughing for three days.

“I started him on phenoxymethy penicillin,” he added.

 “Does he have a bad sore throat?” I asked. Penicillin treats strep throat and no other common childhood illness, but the presence of coughing makes strep unlikely.

“No. I thought it might help… My brother is a pediatric consultant in London. He gave me a Ventolin inhaler.”

“Did that help?”

“A little.”  That means 'no,' but it was a good idea. Asthma inhalers often relieve a cough even in patients without asthma.

“I’m a doctor who comes to hotels. Would you like me to see him?” I asked.

“My wife wonders if I should take him to a clinic for a chest x-ray and blood tests.”

“Unless he’s very sick, that’s not necessary.”

“Maybe you should come. Can you give him cortisone?”

“I carry cortisone….”

“So you could give him an injection?”

“I’d have to examine him first.”

After consulting with his wife, he said “We will wait for you.”

I exchanged my pajamas for a suit, filled out my encounter form, and was about to leave when the phone rang. It was the Palomar, and I knew what that meant. Guests don’t like to cancel in person, so a hotel employee delivered the message.

“The gentleman says he’s decided to take the child to an urgent care clinic.”

“There’s none in this area open so late. He’ll have to go to the UCLA emergency room.”

“Thanks for the information. I’ll tell him.”

I reverted to my pajamas and went to bed where I passed an uneventful night. The Palomar guest probably passed it in the emergency room.

The Wonders of GPS

My wife and I wanted to visit the Riverside photography museum, seventy miles away.

During this time there was a 50-50 chance of a hotel call, but only half require a visit. Our luck didn’t hold, and my phone rang after forty miles; someone was vomiting, not a visit I can stall. When I asked directions to the address from my iPhone, it claimed no such location existed. Since this was an insurance call, the patient was not an English-speaker. She had phoned the insurance office in Miami whose dispatcher (also not a native English speaker) phoned me. Addresses often become garbled.

I called the patient’s number and heard a busy signal, always a bad sign on today’s phones. I was forced to call the insurance number, spending a few minutes on hold before reaching a different dispatcher who spent several minutes researching before turning up the correct address.

Then the iPhone GPS worked its magic, laying out a very specific route to an obscure area near Long Beach thirty miles away. While I took care of the patient, she looked up a nearby restaurant on an iPhone App. We ate lunch and returned home.

Two days later we repeated the drive, this time successfully. Most photography museums are art galleries, but Riverside’s is part of the University of California, so it delivers large dose of history with displays of old cameras and old photographs. Driving home with the rush hour approaching, I kept an eye on the iPhone GPS, marveling at its accuracy at predicting freeway jams.

Suitophobia, Part 2

The only American doctors who don’t worry about malpractice suits are fresh out of training. They believe that practicing good medicine will keep them safe. Once they are sued, they join the worriers.

Fifteen percent of surgeons are sued every year. It’s twenty percent for high-risk subspecialties like neurosurgery and cardiac surgery. Family doctors like me do better -- only five percent per year. This means that every doctor is sued sooner or later. Mostly we win, and almost no one pays a penny even if we lose, but it’s a miserable experience. I work hard to find material for this blog, but you’ll never read about my suit.

One reason doctors are sued for malpractice is malpractice, but plenty of other reasons exist.

Hollywood generally presents doctors in a good light, but in the dozen or so movies about medical malpractice, the doctor character is always evil. Hollywood generally presents lawyers in a bad light, but in those same movies about malpractice, the victim's lawyer is always the hero. 

I once wrote a courtroom drama about a surgeon who was committing malpractice – doing hysterectomies strictly for the money. But he had a pleasant personality, so patients liked him (in the movies these doctors are always sleazy); he was a skillful surgeon, so there were no pitiful victims to testify, and he had a smart lawyer, so he won. I thought the story was deliciously ironic, but the number of editors who agree is holding steady at zero.

Why I Discourage Appointments

“The guest will be in the room at six o’clock and would like to see you then,” announced the concierge at two o’clock.

Tactfully, I suggested that she not make appointments without consulting me. The Torrance Marriott is eighteen miles away, and I didn't want to drive across town during the rush hour to see someone who wasn’t sick enough to leave work. I phoned to tell the guest that I could come immediately or at nine p.m. She chose nine.

Arriving ten minutes early, I knocked, and no one responded. Reached by cell phone, the guest reminded me that the visit was scheduled for nine. She was dining nearby, she added, and would hurry back. Twenty minutes passed before she arrived, but during that time another hotel phoned with a visit on my way home, so it looked like a good evening.

The guest arrived, apologized, and described her problem, a minor eye irritation. After I finished she mentioned that her husband felt under the weather. This is usually pleasant news because this couple had travel insurance. My routine is to ask the patient to phone the insurance to obtain approval, so I could care for him and be paid. But obtaining authorization takes time. It was late, and I was anxious to see the next patient who seemed genuinely ill, so I treated the husband’s cold gratis and hurried off.  

Suitophobia

“I’m Doctor Oppenheim….”

“Welcome to the Intercontinental, Doctor Oppenheim. Are you checking in?”

Damn. Another employee who doesn’t recognize me. This happens in hotels that have called for decades. Who knows what she’ll tell a guest who asks for help?

I don’t market myself, but years ago I decided to hand a copy of my latest book to general managers of my regular hotels and explain, modestly, that writing allowed me free time to serve their guests. They listened politely, made flattering comments, and went back to work. It was clear many had no idea who I was. My tenth visit, to the downtown Hilton, was my last. 

“What do you mean ‘serve our guests?’” snapped the GM. “We don’t have a hotel doctor. We don’t want a hotel doctor. You’re going to get a letter from our lawyer!” He snatched my book and marched off. I was a familiar figure to Hilton staff, having made over 100 visits, but I never made another.

That was my first encounter with the epidemic of suitophobia that rages among hotel managers, compelling them to forbid staff from helping sick guests except by getting them off the premises. At any given time, about ten percent are affected. Most recover after a few years, but in the meantime both guests and hotel doctors suffer. I made over 600 visits to the J.W. Marriott in Century City before calls abruptly stopped. I learned the reason from concierges who swore me to secrecy when they snuck me in to see a particularly demanding guest.  

Shots Guests Need and Shots They Request

Long ago a man phoned to inform me that he was on his honeymoon and would like a shot of testosterone. I explained that this was unlikely to solve his problem. 

He did not want to leave any stone unturned, and I’m happy to make a housecall to deliver a harmless injection, but I couldn’t because I didn’t carry testosterone. I bought some on my next drug order. Sadly, I never received another request. I discarded the vial after it expired and never replaced it.

Also long ago, a woman whose hot flashes were acting up asked for an estrogen injection. I explained that pills work as well, but she was willing to pay for an injection which I couldn’t provide. I ordered estrogen, but no one has asked for it since.

I carry two sorts of medication: those guests need and those they ask for. The second category is tricky as these examples illustrate. Another: bereaved guests or those in great emotional distress often beg for a shot to “put them out.” Unfortunately, although movie doctors use it regularly, there is no injection that makes you go to sleep.

B12 remains a hotel doctor’s only reliable moneymaking placebo. I’ve never encountered an illness that required it, but requests arrive several times a year. Celebrities often ask for an injection before a performance, always a thrill.

How a Hotel Doctor Collects His Fee

Many guests pay cash; most foreigners have travel insurance, and I accept credit cards. Technology makes this easy although the company takes about six percent for the convenience. Using a phone, I dial a computer whose automated voice instructs me to enter half a dozen codes (my bank number, my merchant number, the credit card number, the fee…).

In the past I used the room phone until I noticed guests looking uneasy and remembered that hotels charge for phone calls. Now I use my cell phone, an awkward alternative because the small keypad encourages mistakes. At the end, the computer announces its approval and recites an authorization code which I dutifully copy.

Occasionally it denies approval – not by telling me the card is bad or that I’ve entered the wrong number but by announcing cheerfully, “please hold on while we transfer you to a customer service representative.” Hearing this, I immediately hang up because the company charges anytime someone speaks to customer service. I then dial again and re-enter the numbers. Sometimes this works. If it doesn’t, there is a scramble as guests search for another card or their wallets.

The Most Common Phrase a Hotel Doctor Hears

That would be “Sorry for the mess.” Sometimes I hear it as I step into the room, more often when I look for a place to set down my paperwork because all surfaces are piled with discarded clothes, toilet articles, food wrappers, luggage.

A messy room does not greatly embarrass guests. This is not the case when, after introducing myself and listening to the complaints, I put a thermometer in a guest’s mouth and announce that I will wash my hands. That invariably produces a minor panic as someone hurries into the bathroom to clear away another mess and search, sometimes in vain, for a clean towel.

The Luxurious Langham

Mid-level chains (Hilton, Hyatt, Holiday Inn, Sheraton) provide most of my business. I love luxury hotels, but these have traditionally formed the bread-and-butter of hotel doctoring, so my competitors love them more. The result is that when one of them notices an iconic Los Angeles hotel (Bel Air, Beverly Hills Hotel, Peninsula, Sofitel, Four Seasons) calling me too often, he steps in and points out the error of its ways.)

My colleagues don’t care to travel, so I’m the doctor for one of the most opulent hotel in the county: the Langham (formerly Ritz-Carlton) in Pasadena 25 miles away. It sits on twenty acres that includes a beautiful Italianate-style main building, luxurious Spanish Revival-style cottages, and a historic garden.

A Langham concierge once asked me to speak to a guest with an upset stomach. The guest sounded weary and hoarse after vomiting for several hours, but she was in good health, so odds favored the usual stomach virus, miserable but rarely life-threatening. Most vomiters want quick relief, but she preferred to wait it out. I gave the usual advice (don’t eat, don’t drink, suck on a piece of ice) and left my number. Fifteen minutes later the concierge connected me to another vomiting guest who also declined a visit.

This would have been a rare treat – two patients at the same hotel. Sadly, both were American. Since Pasadena lacks the international tourist caché of Los Angeles, the Langham houses mostly Americans who are less inclined to pay for a housecall.   

When I phoned later that day, both had recovered. They were grateful for my concern, but they would have been more grateful if I’d cared for them. Although you might not think so, I consider vomiting a good visit. It usually doesn’t last long, and the doctor gets the credit when it stops.

Another Shot Request

The guest had the medicine and syringes; all I had to do was draw it up give the injection. The drug was a blood thinner she needed after hip surgery, so it was a legitimate request (some guests, usually from third world nations, arrive with weird stuff).

Giving a shot is easy, but most guests don’t want to pay my fee. Long ago, I explained that a hotel doctor spends ninety percent of his time driving and parking, so delivering a shot takes as long as other routine visits. This never convinced anyone, so I offer a discount.    

It’s a mystery to me why doctors prescribe injections and then – hearing that the patient is traveling – advise them to find a doctor or nurse to administer it. A nurse won’t give an injection without a doctor’s order, and most doctors will refuse.

In our suit-happy society, why would a doctor give medicine to someone he’s never seen strictly on the patient’s say-so? As a result, I hear from plenty of guests steaming from frustrating encounters at local clinics. They remain convinced that giving a shot shouldn’t cost much, so these are not visits that produce much gratitude.   

Don't Do Anything!

The guest was feverish, and his abdomen felt tender and rigid, a sign of peritonitis. He needed to go to an emergency room. I phoned his travel insurance to let them know.

This particular agency was a slow payer, usually a sign that it would be hard to deal with. Sure enough, after hearing the news, the dispatcher informed me that the patient must first go to the Airport Medical Center, an urgent care clinic. It’s not part of a hospital, and the doctor on duty has the same training as I.

Getting a second opinion before sending a client to an emergency room saves the agency money, but it wouldn’t in this case because my patient needed to go. There was always a chance the AMC doctor would send him home, so I phoned the clinic to make sure he thought twice.

No sensible doctor tells another doctor what to do, so I chose my words carefully. I was sending a man with bad abdominal pain and peritoneal signs, I explained. I felt he needed to go to an emergency room and be admitted, but his insurance insisted on an urgent care clinic. He thanked me for the information. “We don’t have too many facilities here,” he added. “But we’ll do what we can.”

“Don’t do anything. Send him to the hospital,” would have been tactless, so I didn’t say it.

Once a doctor decides a patient needs emergency care, allowing a test to change his mind is a bad idea. For example, an abnormal blood count points to an infection. Good. But what if the blood count comes back normal? The answer: send him anyway. Doctors shouldn’t order a test that won’t change the treatment, but we do it all the time.

So the man spent a few miserable hours while the doctor ordered tests that doctors order when a patient has a fever and bellyache: blood work and an abdominal x-ray. I have no idea of the results, but I checked to make sure he’d gone to the hospital, and he had.