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 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. 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.  Normally, I would park and walk the six blocks 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. The Georgian guest was back in her room.

“I just flew in from London. There’s no way I can stay awake,” she said on hearing that I’d like to return later that evening.

In the end, I phoned a prescription for a urine infection into a nearby pharmacy and then drove to the airport.

Easy Visits, More or Less

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. I’ve long since stopped believing that bad decisions by people who seem intelligent have a good explanation.  

Another Perk of Hotel Doctoring

A travel insurer sent me to visit 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. These are easy visits.

I Resist Temptation

A businessman at the Hilton-Garden Inn asked a pharmacist to recommend a cream for his insect bites. To his alarm, the pharmacist informed him 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.

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.

Nowadays Americans frown upon purging, but we seem to expect a 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.

I Prefer Vomiting and Diarrhea

Two women at the Holiday Inn were ill. The mother suffered 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.

Her adult daughter also complained of 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. Patient 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.

The World's Worst Travel Insurer

International Medical Assistance has a terrible reputation despite being my leading source of business. It often calls over a hundred times per year. Almost every doctor who knows IMA 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.

IMA never pays within two months. When I call, the claims department assures me that a check will be mailed in the near future or that my invoice never arrived. When I call a week later, I might hear the same explanation.

IMA was in business when I took up hotel doctoring in the 1980s and, for obvious reasons, happy to send patients. It didn’t take long for me to grow annoyed. Payment could take six month and required persistent phone calls. In 1993, with my practice prospering, I began refusing its calls.

In 1998, IMA changed ownership. A representative called to apologize for past difficulties and promise that it would now pay promptly.

But nothing changed. Checks didn’t arrive. I resumed pestering the billing department. By that time hotel doctoring was catching on so I had several competitors. IMA was irritating 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 IMA 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. By 2014 IMA had given up bank deposits and was back to sending checks. Slowly. That’s when I realized that IMA is cheap and stupid but probably not dishonest. Delaying payments saves money in the short run, but the P.R. damage far outweighs it. On the other hand, I have no competition for its business in Los Angeles.

More Worry

At the end of a hotel visit, a guest handed over her credit card. I wrote its number at the bottom of my medical record form. Seeing this, the guest frowned.

“Do you shred that after you use it?” she asked.

I shook my head no. “It goes into my files.”  I keep it in case of a problem with payment, although so far that’s not happened.

She scowled at this answer. I phoned the credit card company and began entering my answers to its computer’s questions. She hovered, staring anxiously at my form.

“So you don’t shred my number... I thought everyone shredded credit card numbers…”

The computer announced its approval. After hanging up, I tore off the bottom of my form and handed it back. She seemed vastly relieved.

Doctor Oppenheim Explains 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 every victim 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 a chance 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 a positive attitude 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. 

You Think I Have a Soft Job

The phone rang at 1:10 a.m. An international housecall agency had a visit in Anaheim, forty miles away. I agreed to go but quoted a larger fee because of the hour and distance. The dispatcher, in Miami, said she would ask for approval and get back to me.

I dressed and waited. After ten minutes I called to ask about the delay.

“I’m sorry. We’re waiting for the E-mail.”

“E-mail!! Can’t you phone them?”

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 went back to bed.

Humor in Medicine

I had cared for a ten year-old with fever who had vomited twice. It was the usual stomach virus that might last a day. I reassured his mother and gave anti-nausea pills.

“I’m concerned about his fever. How often should I measure it?”

“Whenever you want.”

“I’m not comfortable with that. How often?”

“Are you worried about his fever?” I asked.

“Of course.”

“In that case don’t take his temperature.”

This is my usual drole response to patients frightened by fevers. It startles them, but my explanation reassures them. This lady was not startled but offended.

“I work in the medical profession, doctor, and that is dangerous advice.”

“Actually not.” I explained that when otherwise healthy people get seriously sick, they look sick. If they don’t look sick, they’re probably not sick, and having a fever doesn’t change matters. Infants and the elderly are exceptions; otherwise this is a good rule. People worry too much about fevers.

“I’ve heard different. Fever can kill.”

“You see life-threatening fevers in diseases like meningitis and rabies, but these patients look very bad. I haven’t seen a life-threatening fever in thirty years. Sick people look sick. Make your decision on calling a doctor on that basis. Never mind the fever.”

“We’re done here.” She held out her credit card.  

Three More Great Sins of the Medical Profession

 4. Doctors order too many tests and prescribe too many drugs.

Correct. We love tests, but so you. Most patients with a painful injury assume they need an X-ray, but they don’t.  Those with a high fever (“flu”), sore throat (“tonsillitis”), cough (“bronchitis”), or stuffiness (“sinus infection”) assume they need an antibiotic, but they usually don’t. Doctors hate to disappoint patients, so they lean over backwards to “do” something like order a test or prescribe.

 5. Doctors order too few tests and prescribe too few drugs.

We can’t win.  Some clinic directors and insurance plans restrict the tests and drugs we can order. This infuriates doctors as well as patients, but the sad fact is that experts set up guidelines to discourage useless tests and wrong or unnecessarily expensive drugs. They sometimes work.

6.  Doctors ignore alternative and folk medical practices.

I notice enthusiasts treat folk medicine with respect, but no one advocates folk dentistry...  It turns out that many alternative practices work but less dramatically than advocates claim.  Acupuncture definitely relieves pain. Unfortunately, its action is unpredictable and not always complete. Despite vivid reports, Chinese surgeons rarely use it for anesthesia. Chiropractic manipulation relieves some backaches for a limited time.

Three Great Sins of the Medical Profession

Critics regularly denounce us for certain practices. These denunciations are more or less correct, but they miss the point.  Examples -

1. Doctors give treatments that relieve symptoms but don’t cure the underlying problem.

Right, but sometimes this is the best we can do. The cure for severe menstrual cramps is menopause, hysterectomy, or pregnancy. Drugs only relieve the pain, but patients appreciate it. No doctor cures migraine, asthma, emphysema, osteoporosis, or the flu, but we relieve a great deal of misery.

2. Doctors don’t pay much attention to diet, liquid intake, rest, and other natural treatments.

We don’t, and it’s the right thing to do.  Diet, rest, etc. help prevent disease but don’t do much once you get sick... A perfect example were tuberculosis sanitariums, the oldest government supported medical program. They began appearing in the nineteenth century. Patients received nutritious food and plenty of rest in a healthy, rural environment. They were discharged (sometime after years) when their TB became inactive. No one was cured, and many relapsed. When drugs appeared after 1945 sanitariums closed. Nowadays doctors encourage TB patients to adopt a healthy life-style, but they’ll get better if they don’t – provided they take their drugs.

3. Doctors spend too little time explaining how to relieve stress.

Perhaps....  Stress makes everything worse but doesn’t cause anything. Seeing a doctor for stress results from what I call the “medicalization of society” - the notion that life’s difficulties (a hateful job, unsatisfying sex life, shyness) represent a medical problem. There’s no harm in this; a good doctor can listen sympathetically and make sensible suggestions which require no medical training.

More Guests I Didn't Help

A travel insurer asked me to see nine sick hotel guests. My first thought was food poisoning, but their symptoms turned out to be coughing and sore throat.

I love multiple visits at the same hotel, but I wouldn’t love these. I visualized the scenario: a large group arrives for an expensive vacation where many fall ill, and in America you need a prescription for an antibiotic. Luckily, they tell themselves, we have travel insurance. The doctor will come and give us our Amoxicillin, and we’ll be fine.

My philosophy on antibiotics is that I prescribe them if they’ll help, and I don’t prescribe them if they won’t. This puts me at odds with doctors around the world not excluding the US.

When I see victims of a respiratory infections (fifteen percent of a family doctor’s business) I do my best. Almost all seem satisfied, but a few make it clear that I have failed them.

Luckily, there was a nearby walk-in clinic where these guests would get their antibiotics.

A Guest I Didn't Help

A flight attendant at the Airport Holiday Inn was suffering an allergy attack. She couldn’t fly because of the congestion, and her airline required a doctor’s exam and note. This is a common request which I fulfill regularly, but I couldn’t fulfill hers because she was American.

When a British Air, Virgin-Atlantic, Emirate, Singapore, or Cathay-Pacific crew member falls ill, the local supervisor calls a national housecall service who calls me, and the airline pays. US airlines never do this. Their employees are on their own in a strange city with no transportation and their American insurance which is deeply suspicious of housecalls. 

I occasionally make a charity visit to an American flight attendant too sick to leave the room but not sick enough for the paramedics. Mostly I refer them to an urgent care clinic.

Caring for Celebrities

Searching my housecall database (over 18,000 visits) for “celebrity” turns up 92 hits although that includes wives and children.

You recently read about my encounter with a famous person. I mentioned him by name because I was never his doctor, but I’m sure you don’t expect stories about celebrities I cared for. Unfortunately, literary agents do expect it. News that it’s forbidden has proven the kiss of death for my memoirs.

Most celebrities are nice, but over forty years I’ve cared plenty of misbehaving luminaries including several who died under dramatic circumstances. Agents have assured me that “you can’t libel the dead.” This turns out to be a legal fact, but the dead’s loved ones have been known to sue after reading unflattering remarks.

Why You Get Sick, Part 2

You do get sick because:

        1.  No one is perfect.  The healthiest human is full of clumsy design defects.  Our back muscles are too weak, so even normal activity can injure them.  Human veins are too flabby to resist a normal blood pressure; that’s why we get hemorrhoids and varicose veins.  Roughage may be good for you, but humans can’t digest some carbohydrates.  That’s why a high fiber diet causes gas.

        2.  Your “resistance” is too strong.  Don’t blame a fever on that infection you caught.  Your body itself generates extra heat whenever an invader is present.  Some experts claim fever is good for you, but the evidence is thin.

        The human immune system is too strong for its own good - and trigger happy!  Allergies occur when it tries to defend you against an innocent pollen, drug, or food.  Even worse, it may decide one of your own organs is the enemy.  Thyroiditis, the most common cause of thyroid deficiency, is an “autoimmune” disease.  An overactive immune system may also assault the heart (rheumatic fever), liver (autoimmune hepatitis), kidney (glomerulonephritis), joints (rheumatoid arthritis), or skin (eczema, hives).

        3.  Nature plays no favorites.  It assumes germs and viruses have as much right to exist as you.  Catching the flu, for example, is not a sign of weakness.  Most healthy people exposed to a new flu virus get sick.  Then they recover, but this is not a defeat for the virus.  Multiplying during the illness, many escape into the air to infect others.  The flu virus normally infects a victim for a week or so, then moves on.  That’s the role it plays in nature.  Your role is to get the flu now and then.

        Medical science works to give humans an advantage in this competition, and we’ve done pretty well.  But nature is impartial.

Why You Get Sick

When I walk into a hotel room, guests often tell me why they fell ill. They also blame themselves. In both cases they’re usually wrong.

You don’t get sick because:

        1.  Your “resistance” is low.  You got that cold because another person gave it to you.  If it’s your fifth cold of the year, this is a sign of what we in the medical profession call bad luck.  It’s not a defect in your immune system.  People with poor resistance suffer terrible diseases.  There is no immune defect that gives victims too many minor infections.

        2.  Your diet is missing something.  Americans suffer plenty of nutrition-related ailments, but most result from too much rather than too little of some element.  Examples are obesity, high blood pressure, coronary artery disease, and tooth decay.

        3.  You don’t get enough (sleep, exercise, water, leisure).  Researchers have proved beyond a doubt that lack of sleep makes you sleepy.  Subjects kept awake for days become very drowsy.  They don’t get sick.  Exercise improves your sense of well-being and strengthens muscle and bone, and it probably slows osteoporosis.  Vigorous, long-term activity may protect against coronary artery disease and prolong life.  Among younger people, sloth is not responsible for any disease.  Drinking x glasses of water a day is a harmless folk remedy. Doctors often suggest it to prevent bladder infections, but that’s common sense (i.e. it sounds good, but there’s no evidence that it works).   

The Time I Didn't Care for Woody Allen

“Woody Allen needs a doctor. How quickly can you get here?” The caller was the concierge from the J.W. Marriott.

                                                                                                                 

“Ten minutes,” I replied. The J.W. Marriott was in Century City, near Beverly Hills, a five minute drive.

“I don’t know….” She seemed doubtful. “I guess you should come.”

That sounded strange. How many doctors would appear at your door that quickly…? I threw on my suit and raced to my car. Turning into the hotel entrance drive, I encountered a sight that made my heart sink: a paramedic ambulance.

                                                                                                                 

“We couldn’t wait,” the concierge called out as I hurried past. There was still a chance. Most 911 calls are not emergencies. Long ago, paramedics declined to transport anyone who didn’t seem seriously ill. Sadly, they were burned in several cases when someone died after they left. Thereafter, their refusal rate plummeted, but I never lost hope.

Leaving the elevator, I headed for the inevitable crowd. As I approached, it parted providing a fleeting glimpse of Woody Allen rolling past on a gurney. I returned home, disappointed and unpaid.

                                                                                                                 

My experience with movie stars is that their screen personality owes much to reality, so I theorized that he had suffered an anxiety attack. Agitated guests make hotel employees nervous, so they’re quick to call paramedics, but this is overkill. I have a soothing manner, white hair, and a white beard (less white when I saw Woody Allen in 1993). Once I arrive and settle into a chair, I rarely fail to calm a panicky guest. Phoned in the middle of the night, I do the same without getting out of bed. Woody Allen should have waited for me.

Having the Proper Credentials

A Brazilian woman suffered abdominal pain, but her doctor in Rio found nothing wrong. It went away, so she flew to the US where it recurred.

Her host lived in the Hollywood Hills and spoke excellent English. She may have been a show business personality because her walls were covered with celebrity photographs and posters. After examining the guest, I explained that she needed a further evaluation, perhaps including an ultrasound, because one possible diagnosis was gallstones.

Her host spoke up. “You are ordering an ultrasound? Where must we go?”

I explained that I wasn’t ordering an ultrasound but referring her to a doctor who could do whatever tests were necessary. I added that my next step was to go home, fax my report to the insurer’s American office in Miami, and follow it up with a call to alert the dispatcher. He would phone doctors in Los Angeles, preferably the ones I recommended, until he found one willing to accept the Brazilian insurance and then call her. It might take a few hours.

“I have a fax machine. Why not do it now?”

I didn’t know the insurer’s fax number. It was at home.

“Then I will call.” Examining her guest’s insurance papers, she found a phone number, but it looked foreign. As she dialed, I warned that the Brazilian office probably didn’t handle referrals, but she waved me off. 

There followed a long conversation in Portuguese. Afterward, she explained that she had laid out the problem. They promised to get back to her.

I returned home, faxed my report, and called the Miami office. Before I could report back to the Brazilian lady, she called me.

“What is your license number?” she asked.

“Why do you want that?”

“Brazil never called, so we came to Cedars-Sinai. The ultrasound department needs your license for the test.”

“Don’t do that!” I said. “The first step is to see a specialist. And the test will be very expensive unless the insurance approves.”

I phoned the Miami office to urge them to settle matters with Cedars-Sinai. Within minutes my phone rang. It was the Brazilian lady again.

“There is something serious…. Cedars-Sinai has no record of you.”

“I’m not on their staff.”

“They cannot find your name. I am very disturbed.”

I assured her I was a real doctor.

“How do I know that? When I called for a doctor, you came in an hour.”

She could Google me, I suggested.

I phoned Miami to warn that the patient had gone to Cedars. The dispatcher delivered equally bad news. He had phoned Brazil to obtain approval for the expense. Unfortunately, the Brazilian office had had an earful from the Brazilian host who emphasized her friend’s past suffering. This provided an irresistible excuse to claim a pre-existing condition and deny approval. 

After hearing this news, the patient and her host went home. I warned that she still needed an evaluation and offered to refer her to a colleague. The Brazilian host remained polite but informed me that the next doctor she consulted would have to have better credentials.