The Kiss of Death

Malpractice insurers look with suspicion on doctors who operate pain clinics or diet clinics or who perform botox injections or liposuction. My brother saved $12,000 on his premium when he gave up obstetrics – and that was thirty years ago. Doctors pay a fat surcharge if they engage in controversial practices, perform legitimate if risky procedures, or have personal difficulties such as numerous malpractice suits.

None of this applied to me. From a malpractice carrier’s viewpoint, I was easy money. I saw perhaps one fifth as many patients as an office doctor. Being travelers, they were younger and healthier than average. Even better, most were foreigners who don’t sue.

Except writing for a large check every year, I ignored this area until a letter arrived in 2003 from my malpractice carrier. It was a routine survey with questions about the nature of my practice: hours of operation, employees, office locations, number of patients, hospital affiliations, procedures.

I made certain they understood that I was a full-time housecall doctor who cared for a small number of healthy, nonlitigious patients.

A few weeks later I opened a certified letter cancelling my insurance. It was a terrible shock. When I applied to other carriers, all turned me down. I contacted an insurance agent who was very helpful and obtained a policy from a company in Illinois that specializes in difficult cases. It cost three times what I had been paying.

Each year when she applied to the regular malpractice carriers, they declined. They won’t insure a housecall doctor, she explained.

How did this affect my competitors? It didn’t. They cared for hotels as a sideline, usually from an office practice. If asked, none would deny that they make housecalls, but no carrier forbids them, and they’re so uncommon that applications for malpractice insurance don’t ask about them.

Boasting that I was America’s only fulltime housecall doctor produced flattering feedback but got me the kiss of death from my malpractice carrier. Perhaps they remember celebrities from Michael Jackson to Elvis Presley whose lurid final moments involved a doctor who made home visits.

Listomania

I once made sixty to eighty visits per year to the Crowne Plaza at the airport. Then they dropped to about five.

During a recent visit I noticed a printed handout on a bedside table, a long list of clinics and doctors which the reader was invited to peruse. Given a list, guests tend to call the first number first and then work down. My name was sixth.

When consulted, hotel lawyers always forbid staff from recommending a doctor. Should a guest ask for help, they insist, an employee should silently hand over a list, the longer the better. In this way, when the guest sues the doctor, he or she won’t sue the hotel. Lawyers admit that this doesn’t work, but they can’t help themselves. 

Told to make up a list, employees take the easy route by consulting the internet where they find clinics, local practices, and entrepreneurial physicians who charge spectacular fees. They won’t find me, so it’s a crapshoot where on the list I’ll end up.

Having produced the list, management forgets about it. Lists always contains doctors and clinics that don’t make housecalls. As time passes, some numbers no longer work; for the rest, guests who want to speak to a doctor end up speaking to an answering service or receptionist.

It might take years for calls to return to normal, but I am patient. 

The Old Man's Friend

A guest was coughing and feverish, and I heard crackling noises when I listened to his lungs, a sign of fluid. I suspected pneumonia.

I prefer diagnosing pneumonia to an upper respiratory infection because I can prescribe an antibiotic and skip the stressful explanation of why I’m not prescribing an antibiotic.

Unfortunately, this guest was 85. Most victims of pneumonia don’t need hospitalization. Even without treatment, most recover. This is not the case with the elderly where, long ago, pneumonia was known as “the old man’s friend.” Dying of pneumonia when you’re already feeble is apparently not a bad way to go.

The son did not like hearing that his father must go to an emergency room, but they went. When I phoned the following morning, I learned that the diagnosis was pneumonia. The doctor had prescribed an antibiotic and sent them out.

I was shocked. Hospitals always admitted elderly patients with pneumonia. What incompetent was on duty?...  The son assured me that his father was resting comfortably and promised to return to the hospital if symptoms worsened. When I called that evening, they had checked out.

If something bad happens, they will sue the hospital, but they will also sue me. It takes a long time for a malpractice lawyer to organize a suit, so his letter wouldn’t arrive for about a year.

Is Murder Cost-Effective?

At a medical conference, a speaker came up with a radical proposal.

People regularly come to an emergency room complaining of chest pain, he said. Most are not having a heart attack, but doctors do a careful exam and many tests and often observe them for hours. Even if little turns up, doctors lean over backwards to admit someone with a possible heart attack. In the end, some are so obviously not having a heart attack that the doctor sends them home.

But medicine is not perfect, he added. Three percent of those sent home are having a heart attack. They sue the hospital and win.

Over the years, hospitals have become more liberal about admitting patients with chest pain. But, in the end, some are sent home.

No matter. Three percent are having a heart attack, and they sue. The average payout is over $400,000.

“It’s an impossible situation. What can a hospital do?” asked the speaker. He went on to suggest a tactic for a doctor who decides that a patient isn’t having a heart attack and can be sent home. Current hit-man rates are $10,000 per.

“Do the math,” he said.  

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.

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.

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.  

Fear

Leafing through mail revealed a letter from a law office. I broke into a sweat and then calmed myself. Malpractice suit announcements rarely arrive in ordinary US mail. Sure enough it was simple request for records. Someone was having trouble with an insurance company. I get these once or twice a year, and they never fail to upset me.

Whether they win or lose, sued doctors rarely pay a penny, but it’s a horrible experience which they all dread. Doctors worry if something is not going right – say a patient who should get well is not getting well or seems dissatisfied. We all want to do better, but never absent from a doctor’s thoughts is that he doesn’t want to be sued.

You may wonder about the odds that this will happen. The answer: a hundred percent. Five percent of American family doctors are sued each year. The highest risk specialties are neurosurgery and cardiac surgery: 19 per cent sued each year.

To make sure your doctor has never been sued, find one who has just entered practice. If you want to investigate, most states make it easy. You can look me up at the California Medical Board site by entering my name. Feel free to do so. I’m clean.

But state boards are not terribly efficient, and many have time limits – say ten years – after which they drop the information.

Every bad thing that’s happened to a doctor is in the National Practitioners Data Bank in Washington. Hospitals and clinics query it when they’re checking out a doctor. When they don’t, you often read the results on the front page. 

The NPDB is off limits to the general public. Activists yearn to change this, but every professional organization would fall upon any legislator who agreed.