I've Quit Doing Telemedicine

Organizations like Amwell or Teladoc or Doctor on Demand pay doctors to answer phone calls. Sitting at home, we can earn $40 for a conversation that lasts a few minutes. It’s easy money, and I’ve had many satisfying experiences answering questions, helping with minor illnesses, assuring callers that something that seems ominous is not ominous, or sending them for medical care if they need it.

What spoils the experience is that nearly half of these callers are suffering a respiratory infection: cough, sore throat, congestion, “sinus,” “bronchitis.” Since their doctors routinely prescribe antibiotics, these callers know what they need. Phoning saves a trip to the office. What a convenience!

When, after discussing their symptoms, I give my diagnosis and explain how to help, many are puzzled. When, in answer to their hints, I assure them that antibiotics don’t help, most remember their manners, but they don’t believe me. Some point out that their family doctor takes their illness more seriously. A few question my competence or suspect they’ve fallen for another internet scam (“Are you a real doctor?.... What am I paying this money for?!!...).

When guests at my hotels phone, respiratory infections are also the leading complaint. But phone calls to me are free, and I spend a good deal of time answering questions and giving advice. By the time guests agree to a housecall, they understand that I know my business. If they don’t understand, I direct them to another source of care.

Telemedicine guidelines forbid doctors from prescribing narcotics and tranquilizers but say nothing about antibiotics which are far more toxic. If you sign up for one of these services and want an antibiotic but have the bad luck to reach a doctor like me, simply thank him, hang up, call again, and tell whomever answers that you want a different doctor. That should work.

A Message From a Stranger

“A guest would like to meet you at 4:15 in the lobby.”

The caller was a concierge at the L.A. Hotel.

“Is that all?”

“I’m sorry, Doctor Oppenheim. The guest just made the request and walked off.”

This really happened a few years ago. Doesn’t it sound like a bad novel? Retired CIA agent, Skip Oppenheim gets a message from a mysterious stranger as he unwinds at a luxurious hotel. The adventure begins.

As a hotel doctor, I am allergic to adventures. Sick guests rarely schedule a consultation in a public place. Most likely he had a request. I prefer to handle these over the phone at no charge. This is good P.R. but it’s also self-defense. If I travel to the hotel, and the guest makes a request I have to refuse, the consequences may not be life-threatening but they are not pleasant. Also, it’s hard to collect my fee.

“I don’t make appointments without talking to the guest first. Do you have his number?”

“I’m afraid not.”

“Have him call when he gets back. I’m sure we can work out something.”

The concierge agreed. Sadly for this post, there is no punch line. I never heard from him.

How a Hotel Doctor is Like a Prostitute

I make the majority of my calls at the request of national housecall agencies, international travel insurers, airlines, and a sprinkling of miscellaneous sources including other hotel doctors. That’s fine with me.

A few dozen Los Angeles area hotels call me exclusively. That leaves over a hundred, all of whom have my number but who call another doctor or no doctor and sometimes me. Competition for these hotels has become so cutthroat that I’m happy to leave it to others.

If you’ve followed my posts you’ve learned about my excellent skills and low fees. Why would a hotel bother with anyone else? The answer is that service and price are useless marketing tools in medicine where the law of supply and demand doesn’t work. 

Providing a doctor produces no revenue for the hotel, and guests don’t demand one, so most general managers pay no attention. Asked for help by a guest, employees are on their own. 

They may simply give out a number, but many prefer the traditional arrangement once used to summon a prostitute. A bellman made a phone call. As the lady left, she stopped at the bell desk to drop off a portion of her fee.

It’s illegal for a doctor to pay for a referral, but what are the options for someone yearning to break in to the glamorous and lucrative world of hotel doctoring? Claiming to deliver superior medical care sounds weird. Advertising a low fee is vulgar. Whoring works better.

Good Doctors Do It

“I’m coughing my head off. My head is plugged. I have a fever. I’m on vacation, and I need something.”

I’ve seen over 4,000 guests with respiratory infections. To the average hotel doctor, this is an easy visit. He arrives, performs the traditional exam, prescribes the traditional antibiotic, and accepts his fee and the guest’s thanks. What’s not to like?

That the antibiotic is unnecessary doesn’t bother the doctor, but it would bother me. Despite my colleagues’ insistence that patients demand an antibiotic, most of mine don’t. A small minority appear disappointed when I don’t prescribe one, and a tiny number make it painfully clear that I’ve missed the boat.

For decades, solemn editorials in medical journals have urged us to stop prescribing useless antibiotics, warning that they’re poisoning the environment, producing nasty, drug-resistant germs that are already killing thousands. 

Despite this, giving antibiotics for viral respiratory infections remains almost universal. Almost every doctor whose prescribing habits I know – admittedly a limited sample – does it. None believe they help. All tell me that patients expect them.

“I don’t want an antibiotic if I don’t need it,” patients often tell me. “But how do I know?”

“You don’t, but bacterial respiratory infections are rare in healthy people.”

“What if it’s bronchitis? I get that a lot.”

“Antibiotics don’t help bronchitis.”

“That’s what my doctor gives me. Are implying he’s incompetent?”

“No. Prescribing unnecessary antibiotics is so common that one could call it the standard of practice – meaning competent doctors do it.”

Easy Visits, Mostly

Every day a thousand airline flight crew spend the night in a Los Angeles hotel. Sometimes they get sick and call their supervisor. If they’re American, he tells them to take their American medical insurance and find a clinic. If they’re foreign, he tells them to stay put and wait for the doctor.

That will probably be me. I average half a dozen of these visits per month. I enjoy them because airline crew are young and healthy. Three-quarters suffer respiratory infections and upset stomachs. Since a doctor must certify if they’re fit to fly, I see plenty of ordinary colds.

A minor drawback is two pages of forms to fill out in addition to my medical record. A more serious problem is vomiting: the most common symptom. I hate driving during the rush hour, but vomiters don’t like to wait, so I often find myself creeping on the freeway.

Recovering From Cocaine

He had turned bright red, a frightened guest informed me. His search of the internet revealed that this indicated dangerously high blood pressure. Could I come…?

This was as accurate as most internet medical advice, so I was not alarmed. In response to my questions, he admitted using cocaine earlier but emphasized that he had never turned red before. His heart was pounding, his skin tingling, and his head pulsating but he denied having a headache or chest pain. Could I come?

What to do…. Allergic reactions turn patients red, but this is accompanied by itching which he didn’t have. Otherwise, his symptoms were typical of cocaine use. They didn’t sound life-threatening, but it’s a bad idea for a doctor to dismiss the possibility.

I do not like to make housecalls to frightened hotel guests. Waiting often becomes intolerable, so they dash off to an emergency room or call the paramedics before I arrive. When I suggested these possibilities, he refused, urging me to come quickly. I asked him to count his pulse. It was 100:  not terribly fast. I kept him talking, and he grew more calm.

A hotel doctor’s nightmare is a guest dying after he leaves the room, but dying before he arrives may be worse. It was a stressful drive.

When he opened the door, he didn’t appear bright red, perhaps faintly pink. When I took him to a mirror, he agreed that he had improved. His blood pressure was high, but not too high. His heart sounded normal. He was recovering from the cocaine.

A Sad Story

A Chinese caller wanted a medicine to take back home. He gave the name which, through his thick accent, sounded like “desitin,” an over-the-counter treatment for diaper rash.

That didn’t seem right, so I coaxed him through the spelling (“S as in Shanghai….? “T as in Taiwan…?). The result was “dasatinib.” This turns out to be a treatment for leukemia, FDA approved a few years ago and superior to other treatments. A sick friend in China had asked the guest to obtain some.

I fulfill these requests if they sound legitimate, and this qualified. I made sure he understood that he must find a pharmacy and explain exactly what his friend needed including the dose and instructions. This sometimes involves phoning back to the home country. The pharmacist would then call me, and I would approve. A trip to the hotel wasn’t necessary.

The guest had phoned in the evening and mentioned that he was returning to China the following morning. When the day passed with no call, I had the sinking feeling that, by delaying till his departure day, the guest had waited too long. The average CVS or Walgreens might not stock these high-tech, chemotherapeutic drugs, so the pharmacist might have to order it or send him to another specialized pharmacy. This might take hours. With a plane to catch, the guest probably realized that there wasn’t time.