Is Murder Cost-Effective?

At a medical conference, a speaker came up with a radical proposal.

People regularly come to an emergency room complaining of chest pain, he said. Most are not having a heart attack, but doctors do a careful exam and many tests and often observe them for hours. Even if little turns up, doctors lean over backwards to admit someone with a possible heart attack. In the end, some are so obviously not having a heart attack that the doctor sends them home.

But medicine is not perfect, he added. Three percent of those sent home are having a heart attack. They sue the hospital and win.

Over the years, hospitals have become more liberal about admitting patients with chest pain. But, in the end, some are sent home.

No matter. Three percent are having a heart attack, and they sue. The average payout is over $400,000.

“It’s an impossible situation. What can a hospital do?” asked the speaker. He went on to suggest a tactic for a doctor who decides that a patient isn’t having a heart attack and can be sent home. Current hit-man rates are $10,000 per.

“Do the math,” he said.  

Going Back to College

Every summer, a hundred Brazilian adolescents descend on UCLA’s dormitories to study English. When one gets sick, a counselor phones April Travel Insurance which phones me.

I graduated UCLA fifty years ago, and returning is a strange experience. Crowds outside the dormitories shriek, laugh, and chatter. It sounds like a kindergarten. Were we that noisy? Women’s fashions don’t seem to have changed, but the males look dorky. My generation had long hair and tight clothes. Nowadays it’s short hair and baggy clothes. Men wear shorts. Don’t they realize how silly they look? We kept books in lockers. Now everyone has a backpack. Especially odd is the number of Asians who make up a third of the enrollment. Most speak perfect English, so they’re clearly American. Where were they when I was a student?

In my day, when you entered a university building, you found a door and entered. Today all except the main entrance are locked. Students manning the front desk consider names and room numbers privileged information. Using the elevator requires a key which all students carry. This is identical to hotel security and probably no more effective.

On arriving, I phone a counselor from the lobby who comes down to escort me. The dorm rooms are tinier than I remember, and I suspect little studying occurs because desks are piled with personal items. Delivering medical care is no problem, but it’s summer, and foreigners consider air conditioning unhealthy, so the rooms are hot.

Middle-class teenagers suffer respiratory infections, upset stomachs, and minor injuries almost exclusively, so, once I learned to deal with UCLA’s draconian parking policy, I found these easy visits.

Turning Bad News Into Good

A glum eleven year-old sat on the bed. His glum parents and two glum adolescents sat nearby. The eleven year-old had developed a sore throat, casting a pall over their vacation. They hoped I would make it go away.

Doctors love making things go away, and this would happen if the child had strep, the only throat infection (diphtheria aside) that medical science can cure.

Parents assume that a child with pus-covered tonsils has strep, but many viruses do this. Researchers have determined that a doctor can diagnose strep by observing four signs.  (1) pus-covered tonsils, (2) swollen neck glands, (3) fever, and (4) absence of cough. Since it’s strictly a throat infection, other respiratory symptoms such as cough or congestion make strep unlikely.

This patient had zero out of four. His throat and neck glands were normal; he had no fever; he was coughing.

Working hard to turn this into good news, I explained that the child had an ordinary virus. He would feel under the weather for a few days before getting better. I handed over some remedies, assuring them that these would help. Staying in bed wasn’t necessary. They should try to enjoy themselves.

When the father politely asked if something might speed things along, I explained why it wouldn’t. Never forgetting their manners, the parents expressed gratitude. I left them my cell phone number and urged them to phone if any problem developed. 

We parted on good terms, but I could sense their disappointment. No matter what the doctor said, everyone knows that sick children must rest. So they would wait.  

Bringing the Housecall into the Twenty-First Century

I keep track of competitors, so I saw Medicast’s web site when it came to life.

During an interview with two energetic founders, I learned that Medicast planned to bring the housecall into the 21st century, slashing the cost with volume, marketing, and digital technology. Doctors were rushing to sign up, they added.

I agreed to join them but declined the canvas carry-all they were offering, preferring to keep my traditional doctor’s bag. A handout listed required drugs and supplies which Medicast would sell to its physicians, but they agreed that I could use my current selection.

They gave me an Ipad Mini. All their doctors received one. Potential customers downloaded the Medicast app which gave them the choice of signing up for a paying program that provided free housecalls or paying nothing and summoning a doctor when they needed one. Clicking the app connected them to a dispatcher who recorded their credit card information and sent a text message to a doctor on-call. The program then automatically dialed the client from the doctor’s phone.

“Hotel guests phone me directly,” I said. “Wouldn’t that be quicker?”

“Doctors hate giving out their private numbers,” they explained. “This way you don’t appear on caller-ID, so patients can never bother you.”

A Los Angeles housecall cost $249 during business hours, $349 during nights and weekends. While this was in the ballpark of my fee, Medicast kept about one third. Medicines, supplies, and injections cost the patient extra, so a Medicast doctor had the opportunity to earn more – a lot more if he was creative. My hotel doctor competitors show positive genius in this area.

Carrying the Ipad everywhere was a minor annoyance, and software bugs made an appearance. If another doctor answered, the app didn't notice, so I phoned patients who had already set up a housecall.

Business was brisk. My Ipad chirped nine times during the first month to announce a call although some may have been software glitches. All were from local residents, so they didn’t overlap with my clients, but employees at two hotels reported visits from a Medicast representative, extolling their service.

I posted the above five years ago on this blog. Calls faded out over the next several months. Someone came by to collect my Ipad. Sometime in 2016 or 2017 Medicast went out of business.

It Never Hurts to Check

Universal Assistance asked me to visit a sick Costa Rican in Downy, a suburb of Los Angeles about thirty miles distant.

She gave the hotel address: 9640 Bell Avenue.

“Is that B – e – l – l?” I asked, spelling it out because English is never the native language of travel insurance dispatchers.

“Yes,” she said.

On Google maps (“29.4 miles; 39 minutes”), that address turned up in an adjacent city five miles away but not Downy itself. My first instinct was to accept it. As a visitor, the Costa Rican was unfamiliar with local geography. But several unhappy experiences persuaded me that it never hurts to check. 

“Not ‘Bell,’ said the desk clerk when I phoned. “It’s B – u – e – l – l.  Buell.”  Google found it in Downy.

"I Can't Afford That!

I hear this now and then when a guest learns my fee, more often in the form of a hint (“I’ll talk to my husband and call you back…”).

My routine when hotels call is to listen to a patient’s symptoms, deliver an opinion and advice, and discuss options (only half my callers require a housecall). Once a guest agrees to a visit, I reveal the cost.

Hearing a reluctance to pay, I mention local walk-in clinics. Their basic charge is less than mine, although that difference disappears if the doctor does anything (i.e. orders a test, gives a shot, writes a prescription, applies a dressing).

I feel uncomfortable suggesting leaving the hotel room if it’s a struggle – for example if someone is vomiting or dizzy. This guest had been dizzy all day. In these cases, I insist on coming, telling them they can pay whatever they feel is fair. Many guests end up paying the usual, but I’ve taken as little as $5.00.

Since she had already protested the fee, my expectations were low. They dropped to zero when I approached the hotel and saw paramedics loading her into an ambulance.

The guest’s symptoms were not life-threatening, but paramedics lean over backwards to take patients to the hospital, having been burned in the past when they didn’t. 

I wondered if she had called them because of worries about my fee. She may not have realized that paramedics will send a whopper of a bill.

Making the Doctor Feel Bad

If a prescription gave you diarrhea or made you vomit, you would complain. But until well into the twentieth century, people looked on a good “purge” as an excellent way to expel toxins. Physicians took pride in their cathartics, and when patients discussed a doctor’s skill, they gave high marks for the violence of his purges.

People who consult a doctor expect him to behave in certain ways. 21^st century Americans frown upon purges, but this is not a mark of superiority because we seem to expect medicine. It should be one only a doctor can prescribe; over-the-counter drugs don’t count. Pills are good; an injection works better.

Most of you will deny expecting medicine whenever you see a doctor. You want help. If you’ll get well without medicine, you won’t be upset… I often encounter such patients, but the other sort turns up regularly. I’m slower to prescribe than most, so I have many opportunities to see disappointment in patients’ eyes when they realize I don’t plan to “give them something.” This makes me feel bad.

Doctors genuinely want to help you, and it depresses us when we can’t. We also feel bad when we’ve done our best, and you don’t feel “helped.” So we often add a prescription or order a test to convince you that we’re doing what a proper doctor should do.