A Dog-Eat-Dog Business, Part 4

Danielle, chief concierge of the Ritz-Carlton, calls when her allergies are acting up, but this wasn’t the reason. It was an awkward situation, she explained, but she hoped I’d understand. A guest has complained, I thought. I racked my brain to think who it might be.

If it were up to her, she added, I would be the Ritz-Carlton’s doctor no matter what. Unfortunately, other concierges were putting pressure on her. Another hotel doctor had approached, offering thirty dollars for every referral. She had brushed him off, but her colleagues objected. They reminded her that vendors who want a hotel’s business (limousine services, tours, florists, masseurs) routinely tip the concierges. Why should doctors be exempt?

Here’s a suggestion, she said. Why didn’t I simply match his offer?

I told her that I’m happy to provide free care to hotel staff, but it’s unethical for a doctor to pay for a referral. It’s also illegal. No problem, she assured me. I would still be the Ritz-Carlton’s doctor.

Danielle might continue to call, but I’m less certain about her colleagues.

This exchange reminded me that I hadn’t written the California Medical Board in a few years, so I sent off another letter complaining about other hotel doctors paying referral fees. I’ve sent several. The board is legally obligated to respond to every complaint, and it duly responded, assuring me that it was aware of the problem.

It has never taken action, probably because the Medical Board gives priority to protecting patients from doctors. It shows less interest in protecting doctors from each other.

A Miracle Drug

Handing me a vial of an injectable medication, a guest explained that he needed a refill. Its label was in Spanish, but technical terms are recognizable in any language, so I had no trouble deciphering its mixture of vitamins and minerals. And cortisone.

That was disturbing. The guest’s wife’s rheumatoid arthritis occasionally flared up, and her doctor in Argentina wanted to make sure this didn’t spoil their vacation.

Discovered in the 1940s, cortisone seemed miraculous. Patients crippled with arthritis saw their pain melt away. Ugly psoriatic plaques disappeared. Hay fever vanished. Eczema victims who had been scratching for years stopped after a few doses of cortisone.

A cure for cancer could not have produced more excitement. The Nobel committee, which prefers to wait decades, rewarded cortisone in 1950 - just as doctors were realizing that symptoms return with a vengeance when the effect wears off, and repeated use produced disastrous side-effects.

Creams are fairly safe, and cortisone taken internally remains a life-saver for many serious diseases but a bad idea for ongoing symptoms (generalized pain, itching, inflammation). Large amounts for a short period are safe provided the problem is also short-lived. I give a huge dose for poison ivy but stop after two weeks. By that time the poison ivy has run its course.

A rare shot is probably OK for arthritis, but this family’s G.P. used it generously, a common tactic because the short-term effect is so good. There are no benign treatments for rheumatoid arthritis, but many are safer than cortisone. I prescribed enough for one shot.  

A Treatment Better Than the Best

She had a fourteen hour flight to Australia, explained a woman with a thick French accent. Unfortunately, she had thrown her back out again. Would I come and give something to relax her muscles for that long journey?

I don’t know any medicine that does that, but she was certain that, in the past, her French doctor had prescribed something that did the trick. 

She was already taking the usual pain remedies, so there was no point in a housecall. The woman agreed, but she was clearly disappointed. I know she wondered if I was truly on the ball.

It’s a popular medical belief (remember reader: all popular medical beliefs are wrong) that if you are sick, the doctor will do his best. But if you absolutely must feel well – you have a vacation, important business, a wedding – a smart physician will make a special effort and come up with something even better.   

As a hotel doctor, I deal with this yearning all the time. Since doctors are tenderhearted, it’s tempting to prescribe a placebo if no useful medicine exists. Placebos work although not as dramatically as enthusiasts claim.

The problem is that they’re not available. Decades ago, drug companies sold pills labeled “placebo,” but, perhaps for medicolegal reasons, they stopped. The result is that when a doctor decides you need a placebo, he prescribes a real medicine in the full knowledge that he’s doing something wrong. As I’ve written repeatedly, the advantage of alternative, folk, holistic, and herbal healing is that their medicines are a hundred percent safe. Medicines from real doctors have side-effects, so we’re not supposed to prescribe them unless they’ll help.

Life is easier for doctors who ignore this, so many do.

An Unwelcome Visitor from the Past

A young man at the Chateau Marmont had been coughing for two weeks. He had a fever, and my stethoscope revealed lung noises typical of pneumonia.

I enjoy diagnosing pneumonia because, in an otherwise healthy person, it’s the only common illness with a cough that doctors can cure. Everything else is a virus. 

I didn’t like this particular diagnosis. It takes a tough germ to cause pneumonia in most people, so unpleasant symptoms begin quickly. This man’s cough had persisted for some time. Furthermore, he was gay and admitted to having unprotected sex. I suspected that he had a pneumocystis infection. Pneumocystis is a fungus so benign that it lives in the lungs of most of us, causing no trouble.

Until forty years ago, it was rare, affecting patients already sick with cancer or serious diseases requiring drugs that suppressed immunity. Doctors were mystified when Pneumocystis began attacking previously healthy young men during the 1980s. It turned out to be the most common sign of AIDS.

It’s rare again today because we track immune cells of HIV patients and prescribe preventive drugs when the numbers drop. This young man had not been tested, but he was no fool. He cut short his visit and returned home.

The Glamorous Life of the Call Girl

At one a.m. in 1994, I received a call from Le Montrose, a boutique hotel in West Hollywood. The guest told me the problem was “personal.”

The man who opened the door was past sixty, short, plump, balding, and tieless, wearing a rumpled suit which I suspected he’d put on to greet me. Across the room, wearing a bathrobe, a young woman sat on the bed, staring sullenly at the floor.

“There’s been an accident,” he said.

Neither guest seemed injured, so I knew I wasn’t going to get off easy. This proved true as he explained that his friend seemed to have an object in her rectum. He provided no details.

Bizarre incidents fascinate doctors no less than laymen. Around the cafeteria table, interns compete in relating the latest. Outside of working hours, they remain a mainstay for impressing girls at parties.

Central to this adolescent obsession is the genre of things-that-end-up-in-people’s-rectums. I no longer find these amusing, not only because I’m a grown-up but because they make me nervous. I hate situations that I might not be able to handle. Removing something from the rectum often requires tools such as a proctoscope which I didn’t carry. Also practice. I had never done it.

But I had to try. After introducing myself to the woman, I put on a rubber glove and went to work. There is more space than you’d think inside a rectum; I felt a hard object touch my fingertip and then drift away. When something lies out of reach, it’s natural to stretch, and my desperate efforts caused her to groan with pain.

Suddenly, I snagged something and pulled out a shot glass. I almost danced with joy and relief. Although I expected an outpouring of gratitude, none appeared. Gathering up her clothes, the woman disappeared into the bathroom. The man nodded agreeably as if this were routine business. Filling out my invoice, I asked the woman’s name.

“Elizabeth Anderson.” He hesitated before answering, revealing that he had invented the name. Call girls lead a glamorous life in the movies, but the reality is often miserable. I handed him the invoice. He examined it thoughtfully. “That’s a lot of money,” he said. “You only spent five minutes here.”

In 1994 my fee for a wee-hour call was $180. He had not objected when I had informed him over the phone. When guests balk, I say I’ll accept whatever they consider fair. They often reconsider and pay my regular fee.

I told him I’d accept whatever he considered fair. He handed over $80. I don’t want to think how the woman made out.

Lost in Translation Again

“Bom dia” said the woman who opened the door.

“Bomn dia,” I responded. That’s the limit of my conversational Portuguese. My heart sank as I looked around the room which contained a toddler but no adult male. When I see a couple from a foreign country, the husband is likely to speak some English.

The mother pointed at her child, made coughing noises, tapped his chest, and produced a thermometer which she waved significantly. Once she understood that I needed more information, she took up her cell phone. 

After some effort because her husband was in a meeting she delivered a long recitation before handing me the phone.

I heard “He have cough. He have flu. He need medicine.”

In response to my question, the father insisted that this was everything she had said, but I knew he was summarizing. I asked more questions and received short versions of her long answers. The child looked happy and not at all sick, and my examination was normal. He had a cold. He’d coughed for four days and might cough for a few more, I explained. She was already giving him Tylenol, and no other medicine is safe for a two year-old. Luckily, he didn’t need medicine or bed rest or a special diet. It wasn’t even necessary to stay in the room.

If I had handed over a bottle of medicine, every mother from Fiji to Mongolia to Nigeria would understand that I was behaving like a doctor. But I wasn’t. What was going on?

I’ve encountered this hundreds of times, so I work very, very hard to communicate that the child has a minor illness (husband’s translation: “Doctor says child is OK…”), that no treatment will help (husband’s translation: “Doctor does not want to give medicine…”) and that being stuck in a hotel room is boring, so she should try to enjoy herself (husband’s translation: “Doctor says go out; child is OK…”).

Tap, tap, tap…. The mother beat a tattoo on he child’s chest in a wordless appeal. Everyone knows that a sick child must be confined and given medicine. Why did the doctor keep saying that he wasn’t sick?

I repeated my reassurance, and the husband translated. When, at the end, I asked if she understood she knew the proper answer: yes. She remembered her manners as I left and thanked me effusively.

I left feeling as discouraged as the woman. She was in a strange country, trapped in a hotel room with a sick child. Despite her best efforts, the foreign doctor didn’t understand that her son needed help.

An Untypical Case of Stomach Flu

I once cared for a Fiji Airline flight attendant suffering stomach flu. These are miserable episodes of cramps, vomiting, and diarrhea that rarely last long. She was better the following day, but on that day I returned to the hotel to see another flight attendant with similar symptoms.

In the hotel room, I repeated my stomach flu exam, delivered the usual advice, and handing over medication. She asked if the medication was safe if she were pregnant.

Doctors are human. Having made a diagnosis, my inclination was to stick to it, but I asked a few questions. Her period was overdue. She admitted that her nausea, although worse today, had begun a week ago. Her cramps, also worse today, had also been present.

One of many rules medical students learn is that when a young woman has abdominal pain, one always considers an ectopic pregnancy. That’s usually a pregnancy in the fallopian tube which, unlike the womb, had no room for the growing fetus.

I told the flight attendant that she needed a test to see if she had an ectopic pregnancy which is an emergency. She did not disagree. I phoned the agency that handles airline crew. Their medical department agreed that this was appropriate, and it turned out positive.