A Case of Domestic Violence

A lady’s arm injury seemed straightforward until she explained that her husband had twisted it during an altercation the previous night.

“It was a case of domestic violence,” she said in exactly those words.

That was disturbing news. California law requires that a doctor who suspects a patient is a victim of domestic violence must inform the police. When I told her, she merely shrugged. The husband looked depressed.

I returned to my car, took out my Iphone, and asked Siri to find the nearest police station. She complied. Although the nearest, it wasn’t the correct police station for that area. I was directed to another where an officer told me a car would be sent.

The Hotel Business in 2014

My records show 685 calls during 2014, slightly fewer than 2013. This represents my first decline since 2001 (the months after 9/11 were bad for tourism).

In my defense I took more time off because we bought and remodeled a house in Lexington, Kentucky where I plan to retire in the future. The distant future.

While this is comforting, the painful truth is that hotel doctoring has grown brutally competitive.

If you google “Los Angeles house call doctor” half a dozen names appear but not mine. Furthermore, these newcomers are amazing: Christlike in their empathy, compassionate, brilliant. For proof, read comments on Yelp or Healthgrades: five out of five stars every time, unanimous praise.

These doctors market aggressively. They have web sites. They visit hotels, speaking to concierges, bellmen, and desk clerks, undoubtedly emphasizing their compassion and brilliance.

Most hotel managers ignore this area, so when a guest asks for a doctor, the choice is up to the employee. While I’m the best choice, most doctors are adequate although you must google “Jules Lusman.” He arrived, acquired a flourishing hotel practice, and left the country in 2003 in a flurry of publicity and minus his license.

Every Los Angeles hotel has called me. About twenty call exclusively, but even their employees are not immune to the charm of these newcomers.

Luckily, calls directly from hotels make up less than half my business. I’m the doctor for half a dozen travel insurers with offices around the world. I also work for national housecall services which solicit the general public as well as hotels. I care for airline crew when they lay over. When Frenchmen living or passing through Los Angeles get sick, they call a French lady who calls me.

These businesses pay attention to the bottom line: quality of service and fees. They have less interest in charm or the amenities that appeal to hotel employees. I don’t foresee a problem with them.

A Hotel Doctor's Thanksgiving

I had finished breakfast at 7 a.m. on Thursday when the phone rang. A Quantas pilot at the Hilton in Anaheim was suffering a respiratory infection. This was a great call in many ways.

That Hilton is forty miles away, but I don’t mind long drives provided traffic moves smoothly. Holiday mornings are a good time, and I could take the Santa Ana freeway which is two miles shorter than my usual route. I avoid the Santa Ana because it’s often jammed and in poor repair except for a tiresome five-mile stretch of construction. But it was fine at 7 a.m. on Thanksgiving.

Leaving the freeway, I drove past Disneyland where sidewalks overflowed with crowds streaming toward the entrance.

Unlike most patients with a respiratory infection, airline crew give priority to getting home, not to getting medicine. They hate being stuck in a hotel room, so I try to accommodate them.   

The drive home was easy. Unlike other clients, the airline agency requires a special form which I must fill out and fax to get paid. Happily, I checked boxes for “distance,” “after hours,” and “sat/sun/holiday,” all of which get me extra money. I have no objection to any of the three and actually prefer the last two because traffic is light. I’m perfect for this job.

It's Not an Ear Infection!

When I peered into the guest’s ear, the drum looked normal, so there was no middle-ear infection. When I pulled his earlobe, it hurt but not a great deal. In an external infection (swimmer’s ear), pulling is very painful.

Many adults with ear pain don’t have an infection (children are a different matter). I pressed a finger to his temple in front of the ear and asked him to open his mouth. That hurt badly. He had pain in the temperomandibular (jaw) joint.

The jaw joint is no different from the knee, ankle, or shoulder joint. You can injure it, or it can hurt for no obvious reason. This is common, but I can’t remember the last time someone complained of jaw pain. They tell me it’s an earache.

Flying with a middle-ear infection is a bad idea but no problem with jaw pain, so the diagnosis is good news, but guests are skeptical. Ear pain means an ear infection, and pain medicine lacks the cache of an antibiotic. Guests often make it clear that they’re not getting their money’s worth.

Housecalls Are Not Cheap

A lady fell, catching herself on outstretched palms. That often breaks the tip of the radius where it meets the wrist, and she felt pain in that precise area. She needed an X-ray and an office visit.

A man accidentally bent his forefinger far backwards lifting a heavy box. He suffered excruciating pain over the knuckle. I suspected a fracture or torn tendon. He needed the same follow-up.

Both patients lived in Santa Ana, a fifty mile drive. The director of the housecall service who phoned admitted that these were not typical clients, but someone wanted the visits and was paying generously.

The next day, the director informed me that a mobile X-ray van had gone to both apartments. The patients’ employer wanted to know my plans. That’s when I realized that I shouldn’t have made those visits. These patients had been injured at work, and the employer had decided a housecall was the cheapest way to handle them. That was his first mistake. The major advantage of a housecall is convenience; it’s cheap only for trivial problems.

Far worse was his failure to know that job-related injuries must be handled through Workers Compensation, a system most doctors, me included, take care to avoid. It is a bureaucratic nightmare, wildly expensive and corrupt. Your state legislators, Republican and Democrat, know this but keep quiet. Workers Compensation is the state government equivalent of Israel: no elected official in Washington dares criticize Israel.

I told the housecall service that I was out of the picture and that the employer should read the law, and find a doctor who deals with Workers Compensation.    

Customers Come and Customers Go

American doctors complain about paperwork, but it’s no problem with me. I give guests a copy of the record I write in the room. I fax the same to housecall agencies and foreign travel insurers. American insurers look with deep suspicion on housecalls, so I don’t deal with them, and when foreign carriers feel the urge to adopt American techniques (complex codes, lengthy invoices, deductibles, fee schedules), I stop working for them.

This is less of a sacrifice than you’d think because they switch to a national housecall service, most of whom call me. I earn my usual fee, and the service bills the insurer more, often much more. The logic of this is unclear to me.  

Assistcard, an international insurer that has called for twenty years, stopped recently. When I phoned, a representative explained that Assistcard had made arrangements with other Los Angeles doctors who accepted less than I charged. I expressed congratulations, but this seemed unlikely. I charge less than the going rate, other hotel doctors do not work with travel insurers because they pay slowly, and doctors who agree to make housecalls on the side are not likely to drop everything and go. A week after that exchange, Assistcard resumed calling.

Calls from the Biltmore, once a regular, vanished in 2010. Last May the general manager phoned to announce that I was now the hotel’s doctor. I can’t remember the last time a manager did that. Sure enough, the hotel resumed calling. I’m sure an incident in the hotel convinced her that having me as the house doctor would be a good idea. Sadly, I forgot to ask for details.

Bringing the Housecall into the Twenty-First Century, Part 2

My July 2 post concerned Medicast, a service that arrived in Los Angeles with the goal of bringing the housecall into the internet age. Anyone can download the Medicast app. Clicking connects you to a dispatcher who records your credit card information and sends a text message to the doctor on-call who arrives at your “home, office, or hotel” within two hours. You can Google Medicast.

Its fees are less than those of traditional hotel doctors (who don’t advertise) and much less than the entrepreneurial concierge doctors who do.

Always alert to competition, I contacted Medicast whose directors expressed delight at my experience and welcomed me aboard. I attended an orientation where doctors learned to deal with their software. We left carrying an iPad.

Over thirty years, a dozen national housecall services have come to Los Angeles and, mostly, gone. Size is their great obstacle. When I collect a fee, I keep it all. After paying the doctor, a service has other people to pay. Success requires either a high patient volume or high fees.

My maximum volume has been about 2,000 calls per year, and I have never grossed more than $130,000 – a great deal to most of you but peanuts for a doctor. It’s unlikely any organization can match my volume.

One national housecall service has operated since the 1990s. Its site emphasizes the quality of its doctors, and this was certainly true when I was one. It called 26 times between 2000 and 2002 when I stopped working for them. I collected my usual fee. The service charged three times more, but dispatchers often failed to tell guests how much. As a result, when I handed over my invoice they expressed shock. Worse, they blamed me for the fee and did not hesitate to express their displeasure to the hotel. This cause me some difficulty. I'm sorry not to mention its name, but I'm as paranoid about being sued as the average doctor.

Getting back to the present, over the next two months, I received 16 calls from Medicast, the last in mid-July. Last week a director phoned to explain that calls were increasing but not to the extent they expected, so they were adopting a different business plan. Two days later, a courier arrived to reclaim the iPad.