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.

Dodging a Bullet

The army does not hand out generous transportation allowances, so it housed this officer’s family in a single room of a Days Inn. Arriving, I squeezed past stacks of luggage and between three rollaway beds where the children slept.

I suspected the officer’s wife had pneumonia. Although rarely serious in a young patient, she looked sicker than usual: feverish and short of breath. 

Doctors make most decisions based on evidence or gut feeling, but sometimes a third factor intervenes: inconvenience. For example, as a patient it’s risky to be the final appointment before lunch or at the end of the day. There’s a small chance the desire to get out of the office will influence the doctor. Rarely, this leads to a decision that comes back to haunt him. I’ve been around long enough to think twice before making a decision that saves aggravation.

Leaving after giving an antibiotic for pneumonia was a reasonable option, but, reluctantly, I announced that the wife needed to go to an emergency room.

Aggravation followed. The father did not normally care for the children, so I sat patiently for half an hour as he woke them, struggled with their clothes, made several phone calls to reschedule his flight, and then shifted a dozen boxes between his wife’s bed and the door. After this was well under way, I left to fetch my car, parked two blocks away. Fitting six people into a tiny Honda took additional effort.

It was a relief to usher them into the waiting room, explain matters to the clerk, and say my goodbyes. It was a greater relief to learn, when I called the hospital later, that the wife lay in the intensive care unit and on a respirator, fighting a catastrophic pulmonary infection.

Can I Submit This to My Insurance?

The guest’s symptoms suggested a urine infection, one of my favorite diseases. They’re miserable but respond quickly to antibiotics. This looked like a good visit. I quoted my fee.

“Oh… I didn’t realize it would be so much.”

This happens. I remember guests from the Four Seasons where room rates start at $600 who didn’t want to pay half that. In any case, once I mention the fee, I consider it tacky to refuse someone who complains. I quoted a lower fee. That was OK.

It was a good visit. I tested her urine, announced she had an infection, and handed over her medicine. She was grateful. As I left, she indicated my invoice.

“Can I submit this to my insurance?”

“You have travel insurance?”

“I think so. They made us buy something for this trip.”

It was too late to ask why, if she had insurance, she had objected to my fee. But this also happens. In every developed country except Russia and China, if you need a doctor you don’t first decide if you can afford it, so foreign tourists often pay little attention to insurance.

Really Good Luck

I was leaving the Universal City Hilton when the elevator stopped. The door opened, and a young man rushed in, blood dripping down his face.

“I have to get to a hospital. How do I get to a hospital?” he cried.

I told him to calm down and peered at his bloody scalp, but the light was too dim to make out anything. “I hit my head on the edge of a table,” he added. “I have to get to an emergency room!”

We left the elevator at the ground floor, and I looked more closely but couldn’t see anything alarming. Introducing myself as a doctor, I led him to the men’s room, and cleaned away the blood. There was no laceration, just a long scratch along his scalp that was oozing blood. I patted it dry, applied a dressing, and assured him that it was not serious and didn’t require a trip to an ER. He felt better.

Happiness is Fleeting

The owner of a West Hollywood boutique hotel called to explain that he was suffering another herpes outbreak and needed a prescription for Zovirax. He added that, since outbreaks occurred every few months, he’d like five refills. Would I fax the prescription? After sending it off, I decided I needed to examine him to justify such a large amount. He agreed, adding that he was staying at the Beverly Hills Hotel.  

I perked up. I’ve been the doctor for the Beverly Hills Hotel four separate times since the 1980s. But I don’t market myself aggressively, so four times a more enterprising doctor has snatched it away. It’s been years since it called. I hurried to the hotel; afterward the owner thanked me for my concern. Naturally, I didn’t charge him. Leaving, I stopped by the concierge to inform him that I’d seen a guest and to mention my availability.

“I remember you, Doctor Oppenheim. From the Bel Age a long time ago.” We had a short, pleasant exchange, and he accepted my business card. I walked to my car with a light step. Not only had I pleased the owner of one hotel, there was a chance I’d acquire the Beverly Hills again.

Happiness is fleeting. A few hours later, the owner called. Angrily, he informed me that he’d gone to three pharmacies which had refused to fill the prescription. I was puzzled, and then I realized what had happened. Early that year I had purchased the new, high-tech prescriptions that the law now requires. They look like ordinary prescriptions, but if a thief tries to duplicate one, “void” appears faintly on the copy. Faxing apparently triggers the same process. I apologized and telephoned a pharmacy to give him his medication.

A Guest From Hell

As I introduced myself, the guest suggested we not shake hands because he didn’t want to give me lice. He had lice.

I settled myself to listen. He explained that when he stayed in a hotel he always asked Housekeeping for the temperature at which they laundered bedding. To save money, they often kept it under 150 degrees, too low to kill the eggs. He was susceptible to lice, an affliction that mystified doctors. Treatment only worked for a short time, but this was a cross he had to bear. At home he laundered bedding and clothes daily. Although he fumigated his house once a month, this barely kept the infestation at bay. He concluded by handing me a sheaf of printouts from internet medical sites discussing lice and their treatment.

This was delusions of parasitosis: rare but not terribly rare. I’ve encountered half a dozen over thirty years. Confronted with a delusion, no one, doctors included, can resist the urge to point out the facts, a useless tactic. As anyone familiar with the debate over vaccination knows, faced with a deeply held belief, facts are worthless.

“Can you show me a louse?” I asked.

“I pick them off so fast they’re hard to find. But let’s look.”

I pulled out my flashlight, and together we peered at his pubic area.

“There’s a nit (egg),” he said after a long search.

“That’s a flake of skin.”

We turned up other bits of debris. Finally, I straightened up. “A louse infestation isn’t subtle, and I don’t find one.”

Having heard this from every doctor, he was not offended. “I need a prescription. Over-the-counter remedies don’t work.”

I wrote the prescription and held it out.

“Give it to the hotel,” he said. “They’ll pick it up and pay for it.”

“I’m not sure they will,” I said.

“They’ll do it. I’ve already told them I plan to sue.”

Doctors hate hearing that word. “That costs a lot of money,” I said. “And I doubt you’ll win.”

“Right on both counts,” he responded pleasantly. “It costs five or ten thousand dollars to hire the lawyer and file the suit, and usually the hotels won’t settle. But I can’t let them get away with filthy bedding.”

How Many Pills Were in the Bottle?

“I came back to the room, and my Vicodin was gone.  The maid threw it out when she cleaned.”

“And how many pills were in the bottle?”

“Almost two hundred. I’ve had four back operations.”

“That’s a lot of Vicodin.”

“Check me out. I’ll show you the scars. I need your help.”

Plenty of drug abusers lead productive lives although it depends on the drug. You can’t do this for long with speed. Amphetamines and cocaine poison tissues, the brain most of all. Alcohol is also a toxin; alcoholics wreck their health. This doesn’t seem true for narcotics (Vicodin, Percodan, Oxycontin, heroin, etc). One can consume high doses for a lifetime with no noticeable harm except chronic constipation. Street addicts die from overdoses, contaminated drugs, disease, and violence. In countries that provide clean narcotics to addicts, they have a normal life expectancy.

Narcotics are probably OK for selected patients with chronic pain and a competent doctor. But there’s no denying that too many people are taking more narcotics than they need. Good doctors object because there are better ways of treating chronic pain. Moralists object on the grounds that doctors should make patients feel normal but never better than normal.

“As a hotel doctor, I encounter this problem now and then...”

“I swear I’m not a junkie, Doctor Oppenheim. I have chronic spinal pain, and I’m under a doctor’s care.”

“I’m glad to hear that, because I’ll have to speak to him.”

“He’s in New York. It’s midnight in New York.”

“I know. So I’m going to phone ten Naproxyn to the Walgreen’s at Santa Monica and Lincoln. Tell your doctor to call me tomorrow.” 
  
“The damn hotel threw out two hundred pills! They said you’d replace them!”

“I don’t work for the hotel. It sounds like the Naproxyn is unacceptable to you. So…”

“I’ll take the ten.”

This would satisfy him temporarily, but the odds were one hundred percent that his doctor wouldn’t call, but he would. There was a small chance he’d be in another hotel and pester another doctor. There was a large chance he’d behave in a sufficiently obnoxious manner that the staff would take any complaint about me with a grain of salt.

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 Dog-Eat-Dog Business, Part 8

I was delighted to receive a call from a large Beverly Hills hotel that hadn’t called in years.

I hurried over and was attending a guest when there was a knock. The guest was not dressed, so I opened the door and found myself face to face with one of the young concierge doctors who had entered the field. I suspected that this was his hotel.

Hotels occasionally summon another doctor when the first is slow arriving. Since I’m never slow, I’m always the second doctor called, and I’ve usually come and gone by the time the original appears.

“Looks like a communications slip-up,” he said. “I’ll take care of it.”

I closed the door and went back to work. When I returned to the lobby, the concierge apologized for the mix up, blaming the impatient guest.

She handed me an envelope. This was one of the few hotels that pay the doctor directly, adding the fee to the guest’s bill. Since I hadn’t told her my fee, I was puzzled that she was already paying. Then she explained that she had given half the “usual” fee to the other doctor, and I was getting the rest. Since his is apparently a good deal more than mine, I didn’t do badly.