What Doctors Really Think (Maybe You Don't Want to Know)

If you want to learn our deepest thoughts, join an internet physician forum. Medscape and Sermo host the largest, but dozens exist. They restrict membership to physicians, but any intelligent person can figure out how to join. Think carefully before trying, because you may not like what you find.  

Most forums divide posts into clinical and nonclinical. The clinical section discusses treatments, techniques, and difficult cases. I find these stimulating; many doctors know their stuff.

Nonclinical posts deal with running a practice, patients, colleagues, and politics. I pray they don’t represent a cross-section because most forum doctors – say 80 or 90 percent – are extremely conservative and obsessed with money. Also, they don’t much like patients, cash payers excepted. For insured patients their feelings are ambiguous; they seem to believe that using insurance is a sign of weakness; real men pay real money.

They detest anyone on welfare. One persistent theme is the prosperity of Medicaid patients. They arrive in Cadillacs, own IPhones, wear expensive clothes. Since accepting charity shows a flawed character, they are irresponsible, demanding, rude to staff, needy, fond of drugs. The single mothers make an appointment for one child but bring them all (to these doctors, a single mother is the patient from hell).

Paradise is a cash-only practice, no insurance accepted. These are impractical except in wealthy areas, but doctors love to chat about them. If you can’t sign onto a forum, google “concierge practice” for a creepy dose of these doctors’ heaven.

They hate insurance companies and malpractice lawyers, opinions I share. They see lawyers as Americans saw communists during the 1950s:  (1) evil and (2) much cleverer than we are. As an example of their cleverness, lawyers bill for phone calls. It drives forum doctors crazy that they can’t do the same. “We’re running a business,” they argue. “We’re providing a service! We should charge for it. Sensible patients won’t object!”

They hate insurance because billing requires complex paperwork for less reimbursement than they’d like. Scores of carriers exist, all with different policies, exclusions, and requirements; sensible doctors pay a fulltime employee to handle billing.

Now and then a naïve doctor wanders onto these forums with the identical question. Why, instead of billing innumerable carriers, don’t we bill one? That would be the government. It would be simpler and cheaper. Private carriers keep ten to forty percent of premiums as expenses; Medicare keeps five percent. This is called the “single payer” system. Some physicians but almost no Congressmen support it, and mentioning it on a forum is a red flag. The innocent doctor is probably stunned to read an avalanche of abuse.

Green Is Not a Big Deal

One mystery I’ve never solved is why patients worry about green bodily fluids.

Guests with a cough tell me that they wouldn’t have called if their mucus hadn’t turned green. In fact, in an otherwise healthy person, green mucus is rarely a serious sign. Ditto for yellow. Everyone’s respiratory tract produces a quart of mucus a day. When it’s irritated, it produces more, and it can change color.

If you vomit on an empty stomach you might see bile which is green. This has no great significance. Many patients believe that they shouldn’t vomit if their stomach is empty, so something ominous is happening. This is not so. The signal to vomit comes from your brain, not your stomach.

Patients with diarrhea often save it in the toilet for my examination. I consider it bad manners to refuse to look, but normal stool can turn green.

There are exceptions. Blood from these orifices is never normal, so it’s OK to show me. If your stool or vomitus is black – pitch black, never dark brown – that’s usually bleeding.

A good rule (although my lawyer insists that I add that plenty of exceptions exist) is that you should see a doctor if you feel bad. If you don’t feel bad, it’s probably not necessary. Don’t pay too much attention to green stuff.

A Hotel Doctor's Contract

People ask about my contract with hotels, but there is none. Concierges, operators, and bellmen call because they know me. 

Guests sometimes praise me, and their praise goes to concierges et al. If they decide to complain, usually because I’ve declined to give them something they wanted, they go to the general manager, often galvanizing him into one of several upsetting actions.

Referring the complainer to a competitor is tiresome. Anxious to make a good impression on his first call from Doctor Oppenheim’s hotel, he may relax his standards. 

If the manager consults the hotel lawyer, he always hears that he must never help a sick guest because guests who sue the doctor will also sue the hotel that suggested him. At any given time, about ten percent of hotels are in this my-lips-are-sealed mode, but it’s a changing ten percent because guests persist; employees want to help, and most competing hotels have doctors, so it’s bad public relations. 

Some managers make up a list, instructing staff to hand it to guests but to never recommend an individual. They believe (incorrectly) that this eliminates their liability. The employee who makes up the list mostly confines her research to the internet and in no particular order. As a result, it includes doctors who don’t make housecalls and walk-in clinics with limited hours. Fortunately once the list is made the hotel forgets about it. As years pass, it gradually becomes out-of-date, but my number remains.

Be Careful What You Ask For

“Could you come and give me some penicillin?”

Uh oh.  

The guest had a sore throat. He was fifty years-old. The only throat infection that antibiotics cure is strep, largely a disease of children and adolescents. Strep in a fifty year-old is so rare that I’ve never seen a case.

Doctors who prescribe unnecessary antibiotics claim that patients “demand” them. In fact, after I’ve seen these patients, ninety percent are perfectly happy with good medical care. About ten percent seem puzzled but remember their manners. Only a tiny minority give me a hard time.

But a tiny minority of a minority does not equal zero. Over thirty years, plenty of patients have lost their temper or (in the case of women) burst into tears. While not as mortifying as being sued for malpractice, it’s in the ballpark.

Unlike doctors in an office, I have the advantage of a phone conversation before seeing the patient. If a guest hints that he requires an antibiotic, I discuss his symptoms, suggest that antibiotics might or might not work, and try to gauge the likelihood that he won’t take no for an answer.

In this case, the guest seemed particularly assertive. I didn’t want to take the risk, so I referred him to a local walk-in clinic where he’ll probably get his penicillin.

Converting Two Visits Into No Visits

A man at the Bonaventure was suffering an earache. The pain was not severe and had been present several days, but he wanted it checked. This seemed like an easy visit.

But it was 5:00 on Friday. My traffic app showed a solid red line for the ten mile freeway drive downtown, converting a half-hour trip into… I hated to contemplate it. I explained that I could be at his room between 8 and 9. That was fine with him.

I had barely hung up when the phone rang again. A guest at the Warner Center Hilton had diarrhea. The Hilton is fifteen miles in the opposite direction from the Bonaventure with an equally red freeway. I could have scheduled it for later, but if a third call arrived….

The guest was not terribly ill, so I pointed out that most diarrhea is self-limited. I gave dietary advice and recommended an over-the-counter remedy that was a good as the one I hand out (actually the same), and suggested we talk again in a day. Happy to get free medical advice, he agreed.

At 6:30 the Bonaventure operator called to inform me that the guest wanted to cancel the visit. When I phoned both guests the next day, they were doing fine.

You'd Better Ask How Much

Before leaving on a housecall, I tell guests my fee, but this is not universal among hotel doctors. Guests may learn when the doctor hands over the invoice at the end of the visit.

It’s often a bombshell. I recall a guest who showed me a bill for $1140, and I’ve seen higher. It takes huge balls for a doctor to do this, but it works. People who will quarrel with an unreasonable charge that arrives in the mail may keep quiet face-to-face with a doctor in a room far from home. 

Long, long ago I made visits for a national concierge agency that boasted it would fulfill a hotel guest’s every need. It was a luxury service, but not everyone in an upscale hotel is filthy rich. After collecting an immense fee from several resentful guests, I stopped accepting the agency’s calls.

Calling Paramedics

If you want reach a hospital as fast as possible, get in your car and drive.

Paramedics are slower. They’re essential if a problem might be life-threatening or requires special handling such as a fracture. They sometimes transport even if their expertise isn’t required, but it’s not guaranteed. If you have a bellyache or high fever, they might leave and tell you to take a cab.

Phoned in the middle of the night, some hotel doctors determine that everyone requires paramedics. With no office job I don’t mind getting out of bed and do so regularly, but if the guest sounds like a genuine emergency, I have difficulty persuading the hotel that it has an urgent problem.

“I just talked to a guest, Mr. Elwood, in 435. He’s confused and can’t get out of bed. He needs paramedics.”

“I’ll send a bellman up right away.”

“No, you have to call the paramedics.”

“I’ll call Security. They’ll send someone to the room.”

“You have to call the paramedics.”

“Maybe you should talk to the manager on duty.”

At any hour, the noisy arrival of the ambulance followed by a train of fire engines disturbs everyone, so convincing a hotel to make the call often takes an effort.

Sometimes This Job is a Snap

I saw a man at the Hollywood Roosevelt with a numb arm. That’s an odd complaint but unlikely to represent something serious in a 26 year-old.

He had fallen asleep on the plane, resting his head on his palm with an elbow on the arm rest. On awakening he felt numbness down his forearm. This was easy.

The ulnar nerve that supplies the hand passes under your medial epicondyle, the knob you can feel inside your elbow. It’s a poor design because the nerve is exposed. Hitting it produces tingling down your arm to the little finger. It’s the “funny bone.”

Cab drivers who spend the day with one arm resting on the door often suffer the same symptom. Once they change position, the discomfort disappears in a few days.

Drugs are Cheap

Getting a syringe from my supply closet, I noticed that only a dozen remain. I’d better order more. A hundred syringes costs $12.

I buy from an internet medical supply company. For orders under $200 it charges a fat “handling fee,” so I try to order enough to exceed it. Most of my purchases are drugs, but that presents a problem because they’re so cheap.

I notice other hotel doctors charging $50 to $150 for an injection. I carry seven injectables. The content of a single shot of all seven rarely cost more than a dollar.  

What do I need?..... I stock B12 not because it’s necessary but because guests ask for it. This doesn’t happen often, so my bottle is almost out of date. The price has gone up, but it’s still $31 for a 30cc vial. That’s thirty injections.

I’m down to a few dozen Ondansetron tablets, the best nausea remedy. Ten bottles of thirty will set me back $37.

It never hurts to stock up on loperamide (Imodium is the brand), my favorite diarrhea treatment, but I was surprised to discover the price has jumped to ten times what I paid a few years ago: $104 for five hundred. Many old but important drugs such as penicillin that once cost pennies a pill have skyrocketed to dazzling levels. The weird thing about loperamide: it’s sold over-the-counter. Walmart charges $5.00 for a bottle of 72. That works out to $35 per five hundred. I’ll buy loperamide from Walmart.

I’m not short of many drugs, and buying too many is dangerous. At over ten dollars a bottle, my most expensive is antibiotic drops for swimmer’s ear. Swimmer’s ear has been unexpectedly rare, and I recently discarded five bottles that expired in January. My remaining three expire in May. Should I buy more?  Doctors have to make tough decisions…

A Miracle

The sales manager of the Hyatt Regency was preparing to address a convention when her head turned to the right and stuck.

I had no idea what to do. Her head seemed immovable. She was in perfect health. Hysterical conversion was a possibility, but I was too polite to mention it.

The consultation took place in an alcove off the hotel’s main ballroom. I could hear the crowd murmur. Inside gathered half a dozen worried employees including the general manager who had phoned another hotel to get my name. Failure in this situation would be distressing. The sales manager vehemently denied feeling upset, and I had no reason to doubt her.

“Did you do anything recently you don’t ordinarily do?” I asked, grasping at straws.

She considered then admitted she had felt queasy an hour earlier and taken a pill a colleague had offered. It was Compazine, a common nausea treatment.

That meant nothing. Then it did. I could barely contain my exhilaration. Phenothiazine drugs - Compazine, Thorazine - occasionally cause a weird dystonic muscle spasm. It’s so rare most doctors never see one, but I remember a case that arrived when I was hanging out at the Bellevue emergency room as a first year medical student in 1969. In that incident, the patient’s tongue stuck out, and he insisted he couldn’t retract it. The residents on duty confidently diagnosed hysteria, and it took a while before they changed their minds. Treatment is the familiar antihistamine, Benadryl.

I carry Benadryl. Within minutes of the injection, her head came unstuck. Everyone was delighted.                                                                                                  

A Serious Liability

After shaving, a guest at the Ramada in Beverly Hills reached for a hairbrush and struck his nose on a clothes hook with enough force to bring tears to his eyes and blood to his nose. He noticed that the hook had been installed at nose level -- clearly a poor design decision and dangerous. A hotel that tolerated such an unsafe condition was irresponsible and perhaps legally liable. The guest was, of course, a lawyer.

As I entered the general manager’s office, the guest interrupted a harangue as we exchanged introductions.

This was awkward. My sole obligation is to my patient, but it was obvious the manager wanted help in fending off the furious guest. When I suggested privacy for our consultation the guest told me to take care of things on the spot.

Young doctors love to blurt out a diagnosis as soon as the patient walks through the door (which is possible more often than you think). Not only do patients find this offensive, they don’t believe it, so doctors learn to give the impression they are thinking deeply before announcing an opinion.

I examined the nose from several angles. I carefully palpated it. I pulled out my otoscope and peered up his nostrils. Finally I announced that he had suffered a nasal contusion that, fortunately, had done no harm. He needed no X-ray, no treatment. He could go about his business.

According to the law, a person has no grounds to sue unless he has suffered damage, but a competent lawyer can discover damage in any situation. I doubt visions of profit had brought the guest to the manager’s office. He was upset at his pain and wanted sympathy. The manager had offered to comp the guest’s bill but had maintained his dignity when a humble apology would have worked better.

Still fuming, the guest asked my opinion of the danger in installing clothes hooks at precisely nose level. I agreed the matter deserved attention but added that noses come at many levels.

I Save a Life

After apologizing for waking me, the caller explained that his companion couldn’t sleep because she felt short of breath. Shortness of breath in an otherwise healthy person is either anxiety or a serious matter. The caller added that she was prone to respiratory infections. Maybe she has pneumonia, I thought. I can cure pneumonia.

She didn’t appear ill, but she was English, not a demonstrative people. She had no fever. Her heart was racing. Listening to her lungs, I heard the crackle of fluid which is audible in pneumonia but also in heart failure. I suspected heart failure. When the heart beats weakly, blood backs up into the lungs waiting to pass through, so victims have trouble breathing.

Calling paramedics was risky because they might decide she wasn’t sick enough to transport. Leaving after obtaining her promise to go to an ER was not an option because I would worry. Long experience has convinced me that if guests need to go to a hospital, I must make sure – with my own eyes – that they go. So I drove the couple in my car. Watching them disappear through the emergency entrance made it certain they were now another doctor’s responsibility. 

When I phoned later, the doctor explained that she was suffering rapid atrial fibrillation, an irregular, inefficient cardiac rhythm. He had performed cardioversion – delivering an electric shock to the heart – and she was now in a regular rhythm and feeling better. They were scheduled to fly to Las Vegas the day after my visit, and when I called they had checked out.

A Contagious Disease

I cared for a flight attendant in an airport hotel suffering a cough, high fever, runny nose, and sore throat. It seemed like the usual upper respiratory infection until I saw the spotty rash over her body. She had measles.

Does that ring a bell?... Measles may be the world’s most contagious disease. If you’re susceptible and enter a room someone with measles passed through hours earlier, you’ll probably catch it.

It’s also nasty. Even today, one or two per thousand victims die and a larger number are left deaf or brain damaged. I grew up before children were vaccinated against most childhood illnesses; we actually caught them. I had measles in 1946 and still remember how sick I felt; my chicken pox and mumps were trivial by comparison.

I informed the airline that a flight attendant fresh from a crowded plane had measles and also told the hotel management. You can imagine the reception.

Burned

A guest in a hotel restaurant asked a waiter to light her cigarette. When he complied, her forefinger burst into flame. She had recently put on acrylic nails, and the fresh cement is very flammable. Drunk and enraged, the guest refused to go to an emergency room. By the time I appeared, she had grown tired of hurling abuse. Head resting on the table, she was sobbing. Spilled drinks and broken glass littered the area.

Security officers had cleared the room. Near the entrance, a crowd of clerks, patrons, and the night manager parted to allow my passage and observe my performance. Although not a master at handling drunks, I understood the soothing effect of an old man with a grey beard and carrying a doctor’s bag.

Patting her shoulder until she looked up, I introduced myself and suggested we go to her room. After dressing the burn, I stayed long enough for her pain to give way to the effects of alcohol, and I could assure everyone she would cause no more trouble.

Paying My Fee

It’s less than the going rate, but no one considers it cheap.

When guests phone, I focus on their problems. Half the time, a housecall isn’t necessary. Once we’ve agreed that I should come, I mention the fee. About ten percent of callers reconsider, but almost no one does so directly. I hear….

“Let me talk to my husband and get back to you.”

“Our tour leaves in half an hour. I’ll call when we’re back and set up the appointment.”

“I’m going to try to ride this out, but I’ll let you know.”

“I need to check with my insurance.”

All doctors maintain that they never turn away a patient unable to pay. This is not an actual lie - provided we’re the ones who decide who’s unable.

I’m generous with guests from motels and youth hostels who are clearly not affluent, but plenty of callers are paying a daily hotel bill well in excess of mine. They object to my fee just as they hesitate at $5.00 coffee at Starbucks or $200 for an orchestra seat at a hit play. They know that $1.00 coffee at McDonalds or a $50 balcony seat provides a similar experience, more or less. I direct them to urgent-care clinics that accomplish this.

Hotel Doctor to the Stars

Now and then an agent expresses interest in my memoirs.

You don’t think I have memoirs?... I’ve been hotel doctoring since the 1980s, and I had literary ambitions long before. My proposal has been making the rounds for decades, and agents often respond. Our conversation always covers the same ground.

“‘Memoirs of a Los Angeles hotel doctor.’ That’s a great idea! It sounds like you’ve seen celebrities.”

“A few.”

“Did you see Michael Jackson?”

“Many hotel doctors saw Michael Jackson.”

“Tell me about him.”

“Doctors can’t do that.”

That ends the conversation. I suspect agents dislike hearing that my memoirs don’t discuss famous people, even those who’ve died. It’s correct that you can’t libel the dead, but you can anger surviving loved-ones; they’ve been known to sue. 

My book proposal continues to make the rounds, but it’s possible that you will be my only audience.

Cancelling a Housecall

A guest at the Doubletree wanted a doctor to examine his son’s ear. I was getting in my car five minutes later when the phone rang again.

“I’m really sorry,” said the guest. “The hotel called another doctor, and he’s on his way, so we have to cancel.” That was a shock. The Doubletree is a regular. Was another doctor poaching? This is not a rare occurrence.

I asked the doctor’s name. The guest wasn’t certain. What was his phone number? He didn’t know. I phoned the hotel. The operator assured me that she had given out my number and no one else’s.

To my relief, I realized that the guest had simply changed his mind and wanted to cancel. He assumed that a blunt cancellation would upset me, so he invented an excuse – not realizing that the excuse was more upsetting.

Why I Hate Appointments

“We have two guests with a cough and sore throat, but they’re at a conference. They’d like you to come at three.” This news arrived at nine a.m.

I love seeing two patients at the same time, but I prefer going immediately. Things happen if I wait….

 “No one asked for a doctor,” said the person who answered the door. Shown the names, he recognized them but added that they were at a meeting. He phoned and reported that they had lost track of time but would hurry back. Their conference was at a university five miles away. Their transportation was by city bus. 

I didn’t want to wait, but I have an exalted view of the medical profession. We are humanitarians, a superior breed.

All doctors agree but many feel that if they’re treated with disrespect (by the government, insurance companies, or a discourteous patient), their humanitarian obligations vanish, and they’re free to become jerks (google “concierge doctor”).

After weighing my options and taking no pleasure, I drove to the university, picked them up, drove back to the hotel, and performed my exam.

The Superiority of Alternative Medicine

At the Ramada, I cared for a lady whose eyes were red and itchy. She had no allergies, and I saw no evidence of an infection. I suspected something was irritating them, and she had been using several over-the-counter eye-drops. Drops themselves can irritate eyes, especially with persistent use, so I told her to stop.

No eye drops for an eye problem?.... She looked uneasy at this suggestion, so I left a bottle of antibiotic drops but told her to call in two days if she still felt bad and wanted to use them. This is another occasion why so many patients prefer alternative medical practitioners (herbalists, nutritionists, acupuncturists…). No alternative healer tells a patient: “Don’t do anything. This will go away.” There’s always a treatment.

Security Hell

I’ve been to Park La Brea Towers a dozen times. Navigating its maze of twisting private streets, tall apartments, and rows of bungalows is not exactly a nightmare but always difficult.

It was after midnight, so the drive passed quickly but a barrier blocked my entrance. For security purposes, Park La Brea restricts access during wee hours. I drove until I found a barrier with a kiosk and a security officer. 

Another car was ahead of me. Checking out visitors turned out to be no minor matter, so several minutes passed before the officer handed the driver a pass and waved him in. I pulled forward only to encounter a problem. My patient was visiting, so her name was not on the list of residents, and there was no answer when the officer phoned. Nervous about speaking English, foreign guests often don’t answer.

He explained that regulations did not permit my entry. The sight of my doctor bag, suit, tie, and elderly appearance did not change his mind, but he assured me that his supervisor had been summoned. I parked behind the kiosk and waited. The supervisor never appeared.

My patience exhausted, I phoned the travel insurance office in Miami to warn that I might have to return home. Urging me to wait, the dispatcher contacted the lady on her Brazilian cell phone. Eventually, she contacted the security officer and vouched for me.

Describing the pleasures of wee-hour visits, I always mention easy parking. This applies everywhere except large apartment complexes where everyone and their guests are at home, so all spaces are occupied. After a long search, I parked illegally.