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. 

Trying to Reach the Doctor

A three-month old at the Sunset Marquis was vomiting. I care for infants, but vomiting in someone so young is tricky. It would be a cop-out to send the parents to an urgent care clinic, because its doctor would be a G.P. like me – and, by the law of averages, less competent. Emergency room doctors have more skill, but inflicting an ER experience on this guest was overkill. Fortunately, I have a pediatrician colleague who’s helped out in the past.

I phoned his office. A message urged me to call 911 if I had an emergency but otherwise to leave a message. I dialed his cell phone but reached voicemail. It was 10 a.m. on a weekday, so he was in the office. I phoned the office again and hit “zero” to connect me with the answering service who agreed to page him.

After ten minutes, he phoned and agreed to speak to the guest. I phoned the guest half an hour later. No one had called.

I phoned the office and encountered the same rigmarole. Eventually, the pediatrician explained that the guest had been on the phone, so he had left a message. He agreed to call again.

Everything worked out, and the guest was happy.

I don’t understand why I have so much trouble getting doctors to answer the phone.  

A Hotel Doctor's Contract

People ask about my contract with hotels, but there is none. Concierges, operators, and bellmen call because they know me. 

Guests sometimes praise me, and their praise goes to concierges et al. If they decide to complain, usually because I’ve declined to give them something they wanted, they go to the general manager, often galvanizing him into one of several upsetting actions.

Referring the complainer to a competitor is tiresome. Anxious to make a good impression on his first call from Doctor Oppenheim’s hotel, he may relax his standards. 

If the manager consults the hotel lawyer, he always hears that he must never help a sick guest because guests who sue the doctor will also sue the hotel that suggested him. At any given time, about ten percent of hotels are in this my-lips-are-sealed mode, but it’s a changing ten percent because guests persist; employees want to help, and most competing hotels have doctors, so it’s bad public relations. 

Some managers make up a list, instructing staff to hand it to guests but to never recommend an individual. They believe (incorrectly) that this eliminates their liability. The employee who makes up the list mostly confines her research to the internet and in no particular order. As a result, it includes doctors who don’t make housecalls and walk-in clinics with limited hours. Fortunately once the list is made the hotel forgets about it. As years pass, it gradually becomes out-of-date, but my number remains.

Be Careful What You Ask For

“Could you come and give me some penicillin?”

Uh oh.  

The guest had a sore throat. He was fifty years-old. The only throat infection that antibiotics cure is strep, largely a disease of children and adolescents. Strep in a fifty year-old is so rare that I’ve never seen a case.

Doctors who prescribe unnecessary antibiotics claim that patients “demand” them. In fact, after I’ve seen these patients, ninety percent are perfectly happy with good medical care. About ten percent seem puzzled but remember their manners. Only a tiny minority give me a hard time.

But a tiny minority of a minority does not equal zero. Over thirty years, plenty of patients have lost their temper or (in the case of women) burst into tears. While not as mortifying as being sued for malpractice, it’s in the ballpark.

Unlike doctors in an office, I have the advantage of a phone conversation before seeing the patient. If a guest hints that he requires an antibiotic, I discuss his symptoms, suggest that antibiotics might or might not work, and try to gauge the likelihood that he won’t take no for an answer.

In this case, the guest seemed particularly assertive. I didn’t want to take the risk, so I referred him to a local walk-in clinic where he’ll probably get his penicillin.