Another Reason Doctor Oppenheim is not Rich

Plenty of patients have bad breath. They never tell me, and I never mention it because I have no solution better than mouthwash. If you want to know how to eliminate bad breath, google any media doctor. They all know. They’ve been delivering the same advice since I entered practiced forty years ago, and I haven’t noticed a decline in bad breath. On the other hand, they’re rich, and I’m not.

Perhaps a dozen times (mostly before I became a hotel doctor) patients announced that they had bad breath. I smelled. They never had it but were skeptical when I reassured them.

You have bad breath if someone else tells you. If you’re the only one who detects it, you have a delusion. Of course, since it’s a delusion, no one can change your mind.

The History of High Blood Pressure

For much of his presidency, Franklin Delano Roosevelt’s blood pressure was high. His doctors knew but didn’t do much.

Doctors had been measuring blood pressure since the 19^th century, but they considered it a vital sign – like pulse rate or respiration rate or temperature. They felt better if it was normal but didn’t believe that high pressure was a disease. Everyone knew (as everyone knows today) that stress makes your pressure go up, so avoiding stress was a good idea, but that’s hard for a president. His pressure was spectacularly high the day he died of a stroke in 1945 while relaxing in Georgia.

By the 1950s many doctors believed that high blood pressure was unhealthy. Doctors who act on their beliefs are no different from anyone else. They do a lot of dumb things. So not every doctor treated it.

Proving that high blood pressure kills requires observing thousands of people for years. By the 1960s it was proved. It seems a no-brainer that this means doctors should lower high blood pressure, but that doesn’t follow. After all, a rapid pulse or fever is often an ominous sign, but returning them to normal doesn’t accomplish much.

Proving that reducing high blood pressure saves lives requires observing thousands of people, treated and untreated, for years. By the time I entered medical school in 1968, this had been done, and we heard lectures urging us to treat high blood pressure vigorously.

This was not easy because the drugs available lowered many things beside blood pressure, so they made patients drowsy, dizzy, constipated, and impotent. But things have improved.  

A Japanese Guest

A check of Google Maps revealed an ominous red line from my on-ramp to downtown, so I left twenty minutes early for what is usually a half hour drive. It wasn’t enough, and I arrived ten minutes late at the Miyako in Los Angeles’s Little Tokyo.

It caters to Japanese, a big advantage when I see Japanese patients. Japanese businessmen sometimes speak English but Japanese tourists don’t, and these were tourists. I asked the desk clerk if she could provide an interpreter. Even in a Japanese-run hotel, most workers are Hispanic, and it may take half an hour to pry loose an employee, often a Japanese-American who speaks Japanese as well as I speak Hungarian, the language of my grandparents.

Luckily, as I waited, the tour leader appeared. His English was rudimentary but adequate. The guest had a fever but the major complaint was indigestion from strange American food.

I Need a Test

Asked how a doctor makes a diagnosis many would answer: “He does a test.”

This is actually uncommon. Experts agree that ninety percent of our diagnoses come from what you tell us.

Having spoken to the hotel guest over the phone, I’m certain of what’s going on when I drive off ninety percent of the time. Ten percent of the time, I’m not certain. Sometimes more talk or the exam gives me better information. Sometimes, almost always if the illness turns out to be worse than I thought, I send the guest off for a test, usually an X-ray.

I carry dipsticks that detect many substances in the urine. Once or twice in thirty years, I’ve discovered a new case of diabetes. I see guests with symptoms of a urine infection perhaps once a week. I always test their urine.

I then look thoughtfully at the test strip before announcing that the guest has a urine infection. In fact, 10-20 percent of the time the results are normal. No matter. If the guest describes symptoms of a urine infection, I make the diagnosis. Doctors often ignore tests, usually for a good reason.

Something Unforgivable

I sent a colleague to see a hotel guest perhaps thirty years ago. He didn’t carry a bag as well stocked as mine but took some drug samples from the office. He gave one out. Later the guest noticed that its expiration date was past. His anger, when he phoned me, remains a vivid memory.

Commercial prescription drugs are probably OK for years after they expire, but we don’t give them out. My bottle of nasal spray has an expiration date, and it’s pure salt water. When my aspirin expired, I kept it around.

My lawyer has tapped me on the shoulder and warned me to add that this is my personal opinion, that I have no special pharmaceutical expertise, and that you must never take an expired drug.

Keeping the Government Out of Our Hair

I was in Lexington, Kentucky, when a national agency asked me to make a housecall in Columbus, Ohio.

That’s a three hour drive, but I had free time; the guest’s problem was not urgent, and the agency pays generously. A day in Columbus with my wife might have been a treat (it has a terrific zoo). But I couldn’t go because I don’t have an Ohio license.     

I’m licensed in Kentucky ($150 a year) and California ($410 a year), but it’s illegal for me to practice in any other state. The same applies for dentists, lawyers, beauticians, accountants, athletic trainers, and teachers. Some states license interior decorators.

As the recent election demonstrated, keeping the federal government out of our personal business is critical, so we can expect that local officials will take on more responsibility.

Many Americans are disturbed that not only Washington but FOREIGN COUNTRIES determine safety standards for airlines and pilots. Dozens of huge planes fly over our heads every day, yet local officials are helpless to determine if their pilots are qualified. The new administration may return this responsibility to where it belongs. In the future, woe to the pilot who flies his plane over a state where he is not licensed.

A Doctor Who Serves the Poor

People ask if I worry when I make a housecall in a bad neighborhood.

I may worry about my car, but an elderly white man in a suit carrying a doctor’s bag is such a bizarre sight that the average ruffian can only stare in amazement. In any case, everyone assumes that I’m on a mission of mercy, so they’re helpful. Access to apartment buildings is easier than usual because the door locks are broken.

Why don’t people ask if I worry when I make a housecall at the beach? That’s the real nightmare!! Especially during the summer, parking is impossible. Beach apartments are often not on an actual street, so it’s hard to pin down their location on foot. GPS is often vague. Patients are usually not permanent residents, so they can’t help.

I’ll take the ghetto any time.

The Great Credit Card Gamble

AXA insures foreign tourists but has grown fond of American insurer tactics which means it has a number of reasons for not paying me.

It took months, many phone calls, and repeat faxes to collect for previous visits, so I lost patience. After accepting a recent call and copying all the information, I told the dispatcher I’d arrive at the guest’s hotel in an hour. Then I threw the dice. I asked for AXA’s credit card.

 “We don’t have a credit card,” he said.

“Yes you do,” I said. All carriers have credit card, but they vary in willingness to give out the number.

“Let me talk to my supervisor.”  There followed a wait of several minutes before he returned.

“We’ll e-mail a guarantee of payment.”

That’s a legalistic statement describing what the carrier covers and how much it will pay. It doesn’t guarantee anything.

“Go ahead,” I said. “But I still need the card number.”

There followed another long wait.

“I’m afraid we’re unable to supply a credit card.”

I wished him good luck in finding a doctor. Since that 2009 dialogue, AXA calls once or twice a year and we have the same exchange.

I should add that I send bills to many agencies that pay reliably. When they don’t, I ask for a credit card. Some carriers agree, but it’s risky. 

Miracle Cures

As a hotel doctor, I save lives – almost always by calling paramedics or sending guests to an emergency room.

Now and then I cure someone by removing a sliver, ear wax, or a foreign body from an eye. Patients are grateful; it’s a thrill for me, too.

When laymen think of saving lives, they may picture a doctor handing out a prescription, but this is rare. Antibiotics are genuine miracle cures for infections such meningitis, endocarditis, severe cellulitis and other infections that require hospitalization.

When doctors prescribe an antibiotic in the office, it’s mostly as a placebo but even when used properly for infections we encounter (urine, skin, throat) these would usually resolve without treatment.

Cures are a surgeon’s specialty. If a part of your body is diseased, and the surgeon cuts it out, you’re cured.

Ignoring the Lab

A young woman complained that urinating was painful, and she was running frequently to the bathroom.

That sounded like the common bladder infection, my favorite disease. It’s one of the infections that antibiotics treat, and patients usually feel better within a day. Everyone is pleased.

After arriving in the room, I asked for a urine sample and took a dipstick from a bottle I carry. It can detect sugar and blood and protein and half a dozen other substances in urine, but in this case I was looking for white blood cells (a sign of infection) and leukocyte esterase, a chemical that bacteria produce. Both tests were negative. What was going on? Her story and all the evidence pointed to a bladder infection.

Every medical student learns to treat the patient, not the test. The test showed that she didn’t have a bladder infection, but I disagreed, and I turned out to be right.

Doesn't This Seem Dumb?

In the old days doctors took for granted that anyone who practiced alternative medicine (herbalists, naturopaths, homeopaths, Ayurveda, holistic healing) was a quack, but times have changed. The establishment (even the AMA) urges us to show respect. All popular media doctors (Oz, Weil, Pinsky, Chopra) emphasize that conventional medicine, while useful, ignores life-saving natural, traditional, spiritual, mind-body, and otherwise unorthodox treatments. 

Here’s something that puzzles me. Alternative medicine is respectable, but no one gives a damn about alternative surgery.

If a cool guy breaks his leg or cuts his face or suddenly can’t pee or gets a piece of dirt in his eye or sees blood pouring out his anus, he never ramps up his yoga or seeks a healing herb.

He heads straight for a conventional doctor like me. We take out our tools and fix him.

Doesn’t this give the impression that orthodox medicine works for urgent problems and those visible to the naked eye? Alternative medicine is OK if your problem is not urgent and not visible.

An Upscale Client

The phone rang as I sat down to breakfast at 6 a.m. The caller was Le Montage, a super-luxury hotel in Beverly Hills. The hotel is only a few miles away. Traffic was light. Street parking was easy. It was a good visit.

This was the eighth guest I’d seen at Le Montage in a year and a half.

But there was something odd. All calls arrived during the wee hours. Perhaps five percent of a hotel doctor’s business comes at these times. What was going on?... It’s a rule that once staff realizes that phoning Doctor Oppenheim always gets Doctor Oppenheim, they see the light, but this hadn’t worked at Le Montage.

I know who serves that hotel, and if the regular, daytime staff continues to call him, it’s undoubtedly because he’s a skilled, compassionate physician. 

Obscure Colleges

The lady who answered the door had no idea who I was.

“Carlos! Did you call a doctor?” she shouted over her shoulder.

He had. Carlos was a 19 year-old student from Chile renting a room in Hollywood. His hay fever was acting up.

Foreign students often have health insurance from their native country administered by agencies that call me, so I make many trips to UCLA and USC. Carlos was not attending either.

His room contained an amplifier, guitars, and an electronic piano synthesizer. He was studying composition but not at a university. It turns out Los Angeles contains music colleges that attract international students. These seem to operate like traditional schools; I often write doctor notes to justify missed classes.

Now that I think about it, Los Angeles contains plenty of obscure but internationally known educational institutions. Acting and film production come to mind, but they mostly enroll Americans so I rarely hear from them. I’ve cared for a dozen students studying jewelry and others in fashion design, architecture, cooking, graphic design, and business.  

"I Need a Shot"

Mostly, these callers are wrong, but now and then I hear from a guest undergoing legitimate treatment – usually for infertility – who needs a regular injection. They have the vial in their possession.

Invariably, they told their doctor that they must leave town, and the doctor messed up. He didn’t teach them how to self-inject or (if they recoiled at this) warn that finding someone to give an injection in a strange city guarantees frustration, wasted time, and massive expense.

Hotel doctors are in it for the money. Most guests are not terribly sick, and delivering an injection is only a little easier than the usual visit, so there’s no great reason to give a discount.

A walk-in clinic is less convenient and cheaper but probably futile. The doctor (a G.P. like me) is likely to examine the vial of medicine and say to himself:

1.     This is a medicine I don’t prescribe.

2.     I’m supposed to give it on the patient’s say-so.

3.     If she sues me, (1) and (2) will not help my defense.

If you think a letter from your doctor will change his mind, read my blog post “A Letter from His Doctor.” (April 20, 2016).

Nurses earn less than doctors, but nurses do not give medicine without a doctor’s order. A guest must convince a doctor to order the shot (good luck with that). Then a nursing service will send one of its nurses to give the injection. This will cost more than a hotel doctor’s visit.

If the medicine seems reasonable and being a nice fellow, I give injections free if the guest comes to my house. Don’t depend on that anywhere else. 

Work That Pays Very Well

How many of you would take a job that paid 200 dollars an hour for driving your car? (for my international readers that’s 200 euros, 1400 yuan, or 12,000 rubles).

All of you, right?... But no doctors.

$200 an hour is what I earn for a distant housecall. It may take three hours to drive fifty miles to Newport Beach, care for a patient, and return.

I’ve made hundreds, but the colleague who covers for me refuses them, and no other housecall or hotel doctor in Los Angeles will drive far.

I’m not exaggerating when I write that I’m paid for driving. 95 percent of my patients suffer minor illnesses – respiratory infections, rashes, upset stomachs – that I’ve seen a thousand times. So it’s a matter of (1) a long, boring drive, (2) doing some easy stuff, and (3) another long, boring drive.   

Doctors get into trouble when they assume no one is sick, so I try to pay attention. And five percent of patients describe symptoms that might be serious. I worry on those drives, but usually everything works out.

When a Doctor Sees a Doctor, Part 2

Doctors enjoy chatting about diseases but not their own. We’re as frightened as you, and we want a doctor who sympathizes and makes it go away.

Some doctors don’t understand this. They assume that, being in the business, we don’t require any touchy-feely stuff and that it’s OK to talk shop.

Twenty years ago my dermatologist biopsied a bump near my ear. When he revealed it showed a basal cell carcinoma, he had me look through the office microscope at the biopsy slide, and I saw my cancer cells. Ik!....

Five years ago, my internist heard a heart murmur and sent me to a cardiologist. After determining that I had a damaged mitral valve, he led me into an adjacent room to show the ultrasound. Since I was a doctor, he took for granted that I wanted to know the technical details, but I absolutely did not want to see a film of my poor, diseased heart in action. As he happily pointed out the leaky valve I tried not to look.

We returned to his office where he extolled the skills of a cardiac surgeon at the nearby university hospital who had great success repairing heart valves. While it wasn’t urgent, he was certain I’d enjoy talking to him.

I found another cardiologist whom I like much better. I might need surgery in the future, he explained. He’ll let me know. I see him for an ultrasound every six months. Otherwise I try not to think about it.

A Hotel Doctor at the Movies

My phone buzzed. 

I sit on the aisle in theaters, so I can hurry out before speaking.

“Can you see a guest at the Sheraton?”

“Which Sheraton?”

The insurance dispatcher gave an address that I didn’t recognize. It turned out to be in San Francisco, so I was back in the theater in less than a minute. This doesn’t happen often. Mostly, when a call arrives, I leave.

When hotel guests phone directly, the conversation always takes a few minutes. Even if a housecall isn’t necessary, I’ve missed too much of the movie.

When insurance agencies phone, a housecall is almost always necessary, and it takes a few minutes to copy the information. 

What to do then…. Most patients are willing to wait a few hours until the movie ends, but I never ask them. While I don’t deny that I’m a deeply caring person, I’m also a Type-A personality. If there’s work to be done, I can’t relax until it’s done, so I always leave. This does not sit well with my wife, so we usually go to the movies in two cars.

Cashiers give me a refund if I explain that I’m a doctor on-call, but once the movie is under way, I don’t ask. My fee for a visit is much higher than a movie admission. Most of the time I’m happy to get away. I doubt if I return to a quarter of the movies after I’m called away.

When a Doctor Sees a Doctor, Part 1

You might believe that doctors deliver better care to other doctors, but I’m not sure that’s true. It might be worse.

As a hotel doctor, I’d rather not care for a guest who happens to be a physician. For one thing, he’s likely to hint that I shouldn’t charge him.

He’s also less likely to give up his authority. Non-physicians often tell me their diagnosis and the proper treatment. Sometimes they’re right, but they rarely object if I disagree. They assume I know more than they do. When physician hotel guests tell me their opinion on the initial phone call, I’m tempted to let them have their way and avoid a housecall. Once in the room, I’d rather not be treated as a colleague. 

When I go to new doctors, I never reveal my profession (under “work” I write “self-employed”). They’re supposed to ask, but it’s not a priority.

My current dermatologist doesn’t know I’m a doctor, so I listen patiently to many explanations that aren’t necessary, but that’s fine with me. I want her to treat me like everyone else. After five years, my family doctor casually asked what I did for a living, and I could detect his surprise when I answered. But I’m satisfied with the medical care he delivers. On the rare occasion he makes a suggestion that I disagree with, I behave like any other patient. I keep my mouth shut and ignore it.

Some Lawyers are not so Smart

I hate doctor TV series except out-and-out comedies such as Scrubs. All TV doctors say things doctors never say and do things doctors never do. 

I’m certain everyone with expertise, whether in the law, plumbing, or stamp-collecting, rolls their eyes when TV writers portray them.

Having said this, I confess that my wife and I love The Good Wife which is about lawyers. It’s brilliantly written, but I have no quarrel with legions of lawyers who fill the “comment” section of web sites with furious denunciations of its inaccuracies. I acknowledge that those in The Good Wife do things lawyers never do (such as sleuthing), and they are dazzling in courtroom cross-examinations.

I sympathize because, in the years before I became a hotel doctor, I was cross-examined twice. I was not the defendant but one of the doctors who cared for the patients whose misfortune produced the suits.

Having watched TV lawyers tear witnesses to shreds, I was nervous. Asked certain questions, I would have had to think hard to defend my actions, but those questions never came.

The lawyers seemed not terribly sharp. It was clear that they hadn’t boned up on their client’s medical problems. I had no trouble.

One lawyer enlarged a xerox of a page in the patient’s chart and displayed it before the court. Unlike the other illegible scrawls, my entry was neatly typed. Clearly that was suspicious, he proclaimed. How did I explain that?

This did not show great acumen. How much IQ would it have taken to learn that I typed all my chart notes?   

Don't Harm My Child

Examining a sick child during a routine hotel visit, I asked about previous illnesses, allergies, and hospitalizations. I asked if his immunizations were up to date.

“They’re not,” said the mother. “We don’t do vaccinations in this family.”

Evidence that immunization saves lives is overwhelming. Evidence is also overwhelming that people with deeply held beliefs are immune to evidence, so using it to change their minds is fruitless. I’ve never succeeded.

Sticking to straightforward common sense, I explain what these parents must do.

“Your family doctor is a menace. It doesn’t matter that you like him or that he agrees not to immunize your children.”

“He believes that immunization is good. Your research convinces you that he’s wrong, and you’re certain you’re preventing him from harming your child. But if this doctor believes one horribly wrong thing, there must be others. We use thousands of injectables, drugs, and procedures. There’s no way you can check them all out.”

“The only logical solution is to take your child to someone who will never do anything that might harm him. M.D.’s and osteopaths are hopeless. Even alternative schools – herbalists, naturopathy, acupuncture, chiropractic – do stuff. You should consider a psychic healer.”

In truth, I’ve never said this. I take care of the immediate problem and keep my mouth shut.

You Don't Want to Know

A doctor should wash his hands before examining you. If he doesn’t, do you remind him? I’m sure you don’t although popular health writers urge you.

A doctor in the office has seen someone who may be sicker than you before he arrives. You may not want to know this, but studies confirm that handwashing is rare.

I wouldn’t be writing this if I weren’t an exception. Ironically, before most visits I’m at home where no one is sick. My hands are less likely to transmit an infection, but I wash anyway.

In a hotel room, I have no high-tech office and subservient staff to proclaim my charisma. It’s all on me, so I wear a dark suit and tie, carry a traditional doctor’s bag, and maintain a quiet dignity. After interviewing the guest, I excuse myself to wash my hands.

I also wash before leaving. In this case, I’m looking out for myself. Perhaps half of sick hotel guests suffer upper respiratory or GI infections, and I don’t want to catch them. For the same reason, I ask the guest to open the door for me.

A Bright High School Student

The Kentucky legislature recently required doctors to pass a course in abusive pediatric head injuries. I’m licensed in Kentucky as well as California.

With an afternoon to spare, I found an approved course on the internet, paid $30, and spent an hour reading a mass of information on the causes, symptoms, treatment, prevention, and my legal obligations when I encounter babies with brain injuries from abuse. I can’t remember any, but doctors regularly miss them.

I couldn’t possibly recall more than a fraction of that material, but there would be mass confusion if too many doctors failed, so the test at the end was easy. I printed a certificate of completion and filed it in case the Medical Board checked. They do that but not very often.

California requires every physician to pass a course on domestic violence and another on care of the elderly. After finishing Kentucky's mandatory AIDS course, I discovered that the Board had cancelled the requirement.

Doctors grumble about activists who persuade states to add their favorite subject to the education hours that we must all fulfill. But no one has solved the problem of keeping us up-to-date. Ninety percent of problems a G.P. sees are easy. A bright high school student could handle them. The remaining ten percent require thought, but even if we mess up, most patients do OK over the short term. That’s why fakes with no medical training but a professional manner can practice for years before a disaster unmasks them.

Drilling a Hole

A guest stubbed her toe.

Her big toenail turned black. This was a subungual hematoma: bleeding under the nail. If blood can’t escape, pressure builds, and it hurts.

The solution is to make a hole. Medical books have long told us to heat the end of a paper clip until it is red-hot and then burn through the nail.  

I don’t know about you, but I wouldn’t allow anyone near my flesh with a red-hot instrument. One can also dig with something sharp such as a scalpel. That takes work.

The solution is an electrical drill. One can buy one with a tiny bit, but I don’t see many subungual hematomas, so I borrow my wife’s. The smallest bit is 1/16^th inch which is larger than necessary.

It’s a hefty instrument that makes a loud noise. Guests look uneasy when I approach, but the operation is painless, and when the breakthrough produces a spurt of blood, pain vanishes.