How Can I Break Into Hotel Doctoring?

My first response is always: read my blog. Begun in 2009, it contains everything you need to know about hotel doctoring including how I started.

While it’s entertaining, it might not help. I began in 1983 when there was little competition. I do no marketing except an occasional letter to general managers. I have no web site; this blog, as I chronically complain, has never attracted a customer. I don’t pay hotel employees when they refer a guest (illegal but a long tradition). Yet I do fine. My database, so old it’s a DOS program, contains nearly 18,000 visits. No one will ever match that.

The quickest way to break in is to buy another doctor’s practice. Buying an office practice is bad business because patients drift away, but a doctor selling a hotel practice simply transfers the phone number. As long as the buyer responds to calls, he’ll keep every client because hotels rarely pay close attention to their house doctor.

This is no idle theory because a veteran colleague will soon retire. Another physician has purchased his clientele, a dozen of Los Angeles' and Beverly Hills’ most luxurious hotels. I have heard only good things about the buyer, but he is not an established hotel physician or a friend, so I plan to benefit.

Despite collecting Social Security for ten years, I have no plans to retire, but it’s hard to imagine me working beyond a few more years. I might entertain an offer.

A Tropical Disease

They had just flown in explained a father at 1 a.m. While in Hawaii, their two year-old had suffered mosquito bites followed after a few days by fever, restlessness, and refusal to eat. Checking the internet (my heart sank….) he learned about dengue fever.

I explained that dengue is a viral infection that produces the usual symptoms of a viral infection (fever, body aches, general misery) and has no cure. He agreed but pointed out that deadly complications, although uncommon, did occur, and he wanted the child examined.

Before leaving, I consulted a medical book to refresh my knowledge of dengue fever. I’ve never seen a case. The child did not seem terribly ill. Certainly there was no sign of shock or internal bleeding, the typical complication.

I reassured the parents.

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.

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

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? There's nothing strange about the women's fashions, but the men look like dorks. My generation had long hair and tight clothes. Nowadays it’s short hair and baggy clothes. They 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 over a third of the enrollment. They speak perfect English, so they’re clearly American. Where were they when I attended?

In my day, when you entered a university building, you found a door and entered. Today all doors 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 who comes down to escort me. The dorm rooms are tinier than I remember, and little studying occurs because the desks are piled with personal items. Delivering medical care is easy, but it’s summer, and foreigners believe that air conditioning is unhealthy, so the rooms are hot.      

Bringing the Housecall into the 21st Century

Housecall agencies spring up regularly. I keep track of them so I saw Medicast’s web site when it came to life a few months ago.

During an interview with two energetic founders, I learned that they plan to bring the housecall into the 21^st century, slashing the cost with volume, marketing, and digital technology. They would launch in June 2014 after a massive marketing campaign. 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 handle my own selection.

They gave me an Ipad Mini. All their doctors receive one. Potential customers download the Medicast app which gives them the choice of signing up for a paying program that provides free housecalls or paying nothing and summoning a doctor when they need one. Clicking the app connects them to a dispatcher who records their credit card information and sends a text message to a doctor on-call. The program then automatically dials the client.

“Hotel guests phone my cell directly, or I phone them,” 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 costs $249 during business hours, $349 during nights and weekends. While this is in the ballpark of my fee, Medicast keeps about one third. Medicines and injections cost extra, so a Medicast doctor has the opportunity to earn more – a lot more if he’s creative, and some doctors show a positive genius in this area.

The app includes a tempting feature: a button a doctor can swipe to go “off call.” I don’t mind that hotels and insurance services phone 24 hours a day, but I sometimes can’t resist flipping the button when I go to bed.

Carrying the Ipad everywhere is a minor annoyance, and software bugs still make an appearance. If another doctor answers, the app doesn’t notice, so I’ve phoned patients who’ve already set up a housecall.

Business is brisk. My Ipad chirped nine times in June to announce a call although some may have been software glitches. All were from local residents, so they don’t overlap with my clients, but employees at two hotels have reported visits from a Medicast representative.        

When Doctors Wish They'd Chosen a Different Profession

Up to age one, infants look on everyone as a friend, so they’re a delight to care for. Afterward, they become aware that some people are strangers, and it’s not a happy discovery. Frightened girls tend to keep quiet, but boys often protest the moment a doctor enters and don’t stop until he leaves.

During one occasion, I removed stitches from the chin of an energetic three year-old. His family doctor had tried, then decided to wait a few days during which time the parents traveled to Los Angeles. Now the skin around the sutures was inflamed, so they had to come out. Normally suture removal is painless, but the child began shrieking at my approach. Both parents struggled to immobilize him, but you can’t prevent someone from moving his chin if that is his intention. Everyone on that hotel floor knew something terrible was happening. It took five minutes to snip four sutures, leaving everyone exhausted.

I Don't Do Adderall

“A guest at the Century Plaza wants his Adderall refilled. Can you go?” asked someone from the office of a local concierge doctor.

“I can go, but I don’t do Adderall,” I said.

“No problem.” She would find another doctor. Prescription refills are easy house calls.

You’ve heard of childhood attention-deficit disorder. Recently psychiatrists have discovered that it also affects adults. Treatment is the same. That includes drugs related to amphetamines; the most popular for adults is Adderall. As a hotel doctor my only experience with attention-deficit disorder comes from guests who need more Adderall.

None sounded like drug-seekers. All were happy to pay my fee for a visit during which I would check them out. Since there is no way that I can examine a guest and determine if he or she suffers adult attention-deficit disorder, I told them I’d have to speak to his or her doctor. None ever called.

It’s been decades since I made a similar decision on narcotics. Guests occasionally forget their heart pills, but soon after becoming a hotel doctor, I grew puzzled at how many needed more Vicodin or Oxycontin. Some sounded suspicious from the start, but many were clearly in great pain. Their distress tore at my heart, and they often produced a sheaf of X-rays and letters from a doctor. With no reliable way to tell the fakes from the genuine, I gave up on narcotics.

No Housecalls Today

A guest dropped an ice bucket on her toe. Pain was excruciating, and blood poured out. Holding the toe under the tap didn’t help.

Over the phone, I explained that running water won’t stop bleeding. She should apply pressure over the wound and add ice to dull the pain. When I called an hour later, she was having dinner in the hotel restaurant.

A man had developed a slight cough, in his opinion a prelude to full-blown bronchitis. He wanted something to knock it out. I explained that, in a healthy person, viruses cause almost all coughs. I could come, but I couldn’t promise an antibiotic. The man said he would get a second opinion.

A teenager bumped his head on a bedpost and developed a lump the size of an egg. The parents asked that I check him for brain injury. That requires a CT scan, I explained. He would certainly get one if he went to an emergency room, but the injury didn’t seem serious enough for that. It was OK to wait. He did fine.

A guest had missed his flight because of an upset stomach. He was well now but needed a doctor’s note to avoid an expensive ticket-exchange fee. These requests arrive now and then, and they put me in a difficult position. I can’t write “The guest was unable to travel because of an upset stomach” because I don’t know if that’s true (sometimes the patient admits that it isn’t). So I offer to write the truth: “The guest states that he suffered an upset stomach and could not travel.” I sweeten the pot by offering to fax it to the hotel at no charge.

Guests usually accept. To date, no one has complained, so the note may work.

Paramedics

My personal encounter with paramedics occurred the day I fell (ironically during my morning exercise walk) and broke my hip. I might have lain there for some time because pedestrians in my middle-class neighborhood ignore the occasional bearded old man lounging on the sidewalk. Luckily, I had taken a detour through an alley behind a restaurant where two Hispanic workers noticed, came to my aid, and called 911.

I was not in great pain as long as the leg remained immobile. Any movement hurt terribly. When the paramedics approached with their gurney, I was frightened, but they scooped me up, drove to a hospital, and shifted me to another gurney with hardly a twinge. Never mind their medical skills; that showed talent.

While I admire paramedics, they have little use for me in my capacity as a hotel doctor. Paramedics almost never encounter a physician on their calls, and they don’t like finding one. Most likely, they worry he might pull rank. As a result, when paramedics arrive at my hotels, I sit quietly, never speaking unless spoken to. In turn, the paramedics go about their business, pretending I’m not there.

Siri Would Catch That

Could I visit a Quantas crew member at the Marriott in Costa Mesa, asked the answering service at one a.m. Costa Mesa is fifty miles away, but the local doctor had just been there and didn’t want to go back.

I don’t work for nothing or keep office hours, so I have no objection to long drives during the wee hours. Unfortunately, the San Diego freeway, the major route to Orange County, closes at 11 p.m. for major construction at the San Gabriel interchange. You might think that this requires a modest detour, but closing the San Diego freeway, even at 2 a.m., produces an immense backup as it contracts to one lane leading to the exit. That’s followed by a long, slow drive through city streets.

Several aggravating experiences have persuaded me to take an alternate route through downtown and the Santa Ana freeway, a bumpy truck route and ten miles longer. After driving fifteen miles, I was dismayed to discover that the Santa Ana Freeway was also temporarily closed, a fact not revealed on my computer's Google Maps.

I followed the orange cones onto Washington Boulevard, a major street that intercepts the freeway further on. It was a deserted industrial area with little traffic, but I grew increasingly uneasy as the miles flew by with no freeway in sight. Pulling over, I consulted my ancient Thomas guide which revealed that I had turned the wrong way on Washington Boulevard and driven five miles back toward downtown.

“Siri would have caught that,” my wife pointed out later. Siri, of course, is Apple’s computer voice that recites your route on the I-phone GPS. She has proved valuable on vacations despite the occasional glitch. If you wander off course, Siri immediately recalculates it and tells you how to get back.

Thirty years of making housecalls has convinced me that I know everything about driving Los Angeles streets, a confidence not shaken by the rare occasion when I get lost. There’s an I-phone in my future.

Lost In Translation

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

“Bom 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. Among foreign couples, the husband is much more likely to speak 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 apparently in a meeting she delivered a long recitation before handing me the phone.

“He have cough. He have the flu. He need something. She wants you to examine him.”

In response to my question, the father insisted that this was everything she had said, but I knew he was summarizing. This is a chronic problem with amateur interpreters. 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 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 was I implying that he wasn’t sick?

I knew what she was thinking. I repeated my reassurance, and the husband translated. When, at the end, I asked if she understood she knew the correct 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 was sick.

A Brush With Disaster

A Beverly Garland guest phoned as I worked out at my gym one morning. I’m happy to cut this short to make a housecall, but the guest wanted me to come at one o’clock. I don’t like appointments, but this seemed an easy visit, and it was convenient because I could go after lunch.

After showering, I was walking to my car when a disturbing thought occurred. Exercise is boring, so I read the New Yorker while on the treadmill. When I finish an issue, I leave it in the locker room for anyone else. With a shock, I realized that I had scribbled the guest’s name and room number on that New Yorker which I later finished and absent-mindedly left behind. I rushed back, but the magazine had vanished. I prowled the gym, searching for anyone reading a New Yorker. No luck. I phoned the Beverly Garland to ask if anyone remembered referring a guest. No one remembered.

Now and then a competitor’s hotel calls when its doctor fails to show up, but I boast that this never happens at my hotels. I always tell a guest when I’ll arrive and make sure that I arrive on time. Now I had visions of the guest fuming as hours passed and eventually denouncing me to the staff.   

I racked my brain. The guest sounded Australian and had a Slavic-sounding name. Dutifully, the desk clerk checked her computer and found nothing. I asked if I could come and examine it myself; she agreed.

Guests who make appointments occasionally change their minds, so I always phone to make sure they’re in the room. With great good sense, I had told the guest I would check at noon. To my immense relief, when 12:30 passed with no call, he phoned.

Curing Hiccups

Every few years a hiccuping hotel guest appeals to me.

Hiccups rarely lasts more than a few hours, so a victim gives credit to his last effort and immediately rushes to his computer to proclaim its benefit. Literally hundreds of treatments exist: proof that all are worthless. Google “hiccups cure” to confirm that you must never look for health advice on the internet.

Long ago when an old doctor described a good treatment, I was skeptical. Even today, hotel visits for hiccups make me nervous, so I give a money-back guarantee. Once in the room, I take a tongue depressor and rub the soft palate at the back of the hiccuper’s throat. Sometimes he or she gags, sometimes not, but so far everyone has been happy to pay my fee.  

How to Remove a Sliver Painlessly

Her son had a sliver in his palm, explained a caller from the Airport Marriott. Could I come and remove it? The child was two.

Two is the worst age for a dignified doctor-patient relationship. Infants love everyone, and older children listen to reason. At two, girls are often terrified into silence, but males who don’t like doctors make for a noisy consultation.

Removing a fresh sliver with tweezers is easy, but most victims pluck at it with their fingertips, breaking off the tip, leaving the remainder nestled out of reach under the skin. 

As I unwrapped a scalpel, the parents assured the child that it wouldn’t hurt. Long experience had taught that this was a lie, so his protests became deafening.

In fact, the parents were right. Both worked hard to immobilize the child at first, but when it became clear there was no pain, he calmed. Your epidermis is dead skin, so shaving the very surface with a scalpel should be painless. I shaved enough to expose the splinter. A new safety razor works as well.

A Hotel Doctor's Christmas

I’m the only hotel doctor who loves to work on Christmas. Freeway traffic is light, always a bonus but more so on Christmas because my competitors, including those in Orange County, prefer their holidays undisturbed, so I make some distant visits.

Guests who fall ill are especially grateful to find a doctor. Employees, apologetic when they phone, are impressed when I make an appearance. Visiting a hotel that doesn’t call provides an irresistible opportunity to point out the superior service I deliver.

The only person not delighted by all this is my wife. Long ago, receiving a second call while engaged in the first, I missed the family Christmas dinner. I won’t do that again, but that’s only a matter of juggling a few hours.

You Must See "The Dallas Buyer's Club"

Everyone agrees it’s one 2013’s outstanding films. On Rotten Tomato’s site, a spectacular 42 of 42 reviewers approve. Matthew McConaughey delivers an Oscar-winning performance as a homophobic Texas good-old-boy who learns that he has AIDS in 1985.

Defying his doctor, who announces that he has thirty days to live and that no treatment exists, he pulls himself together, searches for treatments in places beyond the influence of the medical establishment (Mexico, for instance), smuggles them into the USA, and distributes them to AIDS victims despite government persecution.

Although I recommend The Dallas Buyer’s Club, I left halfway through. I couldn’t bear it because it contains every dumb Hollywood cliché about physicians and science.

Every doctor is a jerk except (a) the beautiful young woman doctor who finds Matthew McConaughey cool and (b) the seedy, unshaven doctor whom McConaughey stumbles upon running a Mexican clinic. After announcing that he has lost his US license (undoubtedly for being too compassionate), this doctor explains that his regimen of vitamins and immune boosters will help.

I am not one of those tiresome people who insist that movies stick to facts. History is boring and complicated. American movies must tell a coherent story with an upbeat ending and an admirable hero (Matthew McConaughey has flaws, but they are cute flaws: he is oversexed, a spendthrift, rude, and he lies – but only to bad people).

At that time, a hundred Mexican clinics sold AIDS treatments. None worked. Everyone who took them died. No American audience would accept Matthew McConaughey passing out fake drugs, so the screenwriters tweak the historical facts. In the movie, the drugs work.

I’m puzzled why conservatives denounce Hollywood for turning out liberal propaganda. The Dallas Buyer’s Club is a Tea Party dream. The government is a heartless oppressor. That includes the FDA which the writers confuse with the FBI because they create a menacing agent who threatens to arrest Matthew McConaughey. This FBI… I mean FDA agent never says “Your drugs don’t work!” He says “Your drugs are not FDA approved!” which, since he’s a villain, means they do work.  

Let me know how it turns out.

A Week's Vacation

Returning from a week’s vacation, I took my phone off call-forwarding. Knowing that I keep detailed records, the colleague who covered E-mailed me the information I needed.

Seven hotels phoned; he made four housecalls and took care of three over the phone.

Universal Assistance, a travel insurer, called once. He asked for their credit card number which they gave, and he made the visit.

World Aid, another travel insurer, called twice but refused to give a credit card, so he refused the calls. I fax my invoices to World Aid which usually pays in a month or two. When they don’t, I phone to remind them. Many hotel doctors hate pestering agencies for payment, so they insist on a credit card.

International Assistance called three times, and he declined as soon as they identified themselves. IA still owes him for visits in years past. International Assistance has a poisonous reputation among hotel doctors because it often took six months to pay when it paid at all. Institutions such as clinics and hospitals can deal with this (state-run Medicaid programs are not much better), but individuals soon give up.

Ironically, my patience with IA has been rewarded. After the latest change of ownership a year ago, it got its act together. It now pays reliably every month and provides a great deal of business, but a long time will pass before it lives down its reputation among my colleagues.

Inn-House Doctors called five times, and he made two visits: one to Hollywood and one to the airport area. A national housecall service, Inn-House serves a few hotels and travel insurers but many airline flight crew. In their eternal search for better hotel rates, airlines have been boarding crew further and further from Los Angeles airport which is twenty miles from my colleague’s home. He declined two visits to Long Beach (45 miles) and one to Anaheim (60 miles).

More Humor

"Can you go to Pasadena?” asked a dispatcher from Expressdoc, a housecall service. I could.

“Bloating and nausea,” was the reply when I asked for the patient’s symptoms. Once I arrived at the Pasadena Hilton, I learned that, besides bloating and nausea, the guest was suffering hot and cold flashes, difficulty breathing, dizziness, and blurred vision.

My diagnosis was an anxiety attack. She agreed that this was reasonable. She remembered similar episodes.

“I don’t have more stress than most people, but obviously I’m not handling it well. Why is this happening?”

“Because no one is perfect.”

She laughed, but I believe this. I explained that an anxiety attack is a tiresome body malfunction like a backache or allergy. You suffer, deal with it, and feel better, but it’s likely to recur. Almost everyone believes that stress causes anxiety. When it becomes chronic, victims undergo psychotherapy which sometimes works. I treat it as a simple malfunction; this also works pretty well.

Concierge Doctors

I belong to the American Academy of Family Physicians (AAFP), the leading organization for family doctors with about 100,000 members. My physician brother, more activist than I, belongs to more  liberal physician organizations which are much smaller.

I bought a lifetime membership years ago, so I’m stuck with it, but its heart is in the right place. The AAFP wants members to practice high quality, compassionate medicine and requires that they stay educated and pass a test every seven years. It expresses deep concern with Americans who can’t afford medical care but refrains from urging doctors to greatly inconvenience themselves to remedy this. Most doctors are conservative; the AAFP’s leadership is more politically sophisticated than its members, but, in the end, it reflects their interests.

That brings me to today’s subject. I was perusing the AAFP’s weekly news bulletin. One article cheerfully announced that direct primary care was piquing everyone’s curiosity and that two physician-entrepreneurs would provide the “inside scoop” in a web workshop free to AAFP members.

I was preparing to move on when, with a shock, I realized that direct primary care is a euphemism for concierge medicine. The AAFP was plugging concierge medicine!!! That’s like promoting Mexican cancer clinics!

If you’ve followed this blog you know my low opinion of concierge doctors. They don’t accept insurance. Patients usually pay a monthly or yearly retainer in addition to the usual fees; in exchange, they receive quick access, longer appointments, and, if necessary, housecalls. This money pays for the doctor but nothing else. Tests, X-says, therapy, specialists, and hospitalization cost extra. It’s a luxury service.

When concierge doctors address the public they extol the superior care they deliver to a grateful clientele. Around the lunch table with only doctors present, they extol the pleasures of a cash-only practice. I've never met a concierge doctor I could respect. 

Finishing the article, I hit the “comment” button and forgot my rule about not responding in the heat of emotion. The satisfaction of delivering my opinion which included the adjective “sleazy” evaporated when I read the avalanche of abuse that followed.

Later that day an E-mail from an AAFP official explained that readers were complaining at the lack of respect shown in my response, so it was being deleted. It vanished, but the angry responses remained. You can read them at http://www.aafp.org/news-now/practice-professional-issues/20130508directwebinar.html. If that’s too much of a mouthful, google “inside scoop on running a direct primary care practice” and it will turn up.    

No Easy Way to Hollywood

There is no quick drive to Hollywood. I can take the freeway north through the San Fernando Valley, a twenty mile trip. Or I can take it east through downtown for nineteen miles. A direct route is eight miles, but that’s tedious stop-and-go on city streets. Taking the long way doesn’t mean an easy drive because the freeway is often but unpredictably jammed.

When Loews in Hollywood called at 11 p.m. my heart sank less than usual. It was late enough for most drivers to be in bed.

But not quite late enough. The male fun fair in West Hollywood was in full swing, filling the streets.   

Loews in Santa Monica calls me exclusively, but the Hollywood Loews keeps a list of doctors, thus assuring that none of us will lean over backward to accommodate it by, for example, coming during the rush hour (no hotel doctor lives near Hollywood).

My immediate problem in a nonexclusive hotel is that parking valets may not recognize me, so my mantra:  “I’m the hotel doctor. They let me park here” might not work, and I would have to pay. But it worked this time.

As usual, delivering medical care was the easiest part. A perk of hotel doctoring is that I go home after seeing a single guest. During my best months, I go home a hundred times.

I like my job, but going home always feels better than going to work. I played my audio tape. I looked benignly on the midnight revelers as I crept through West Hollywood. Beverly Hills and Century City were nearly deserted, but traffic lights ensured that I would not make haste.

Ever Hopeful

I made a housecall to the Four Seasons recently. Years ago, I shared the Four Seasons elevator with Robert Duvall. He was reading a script, and I pretended not to notice.

I’ve responded to half a dozen calls from that hotel over thirty years, but this was not one. Assistcard, a travel insurer, had sent me to see an 18 month-old with a cold. I took care of the child and left without introducing myself to the concierge.

The Four Season’s house doctor is the only colleague who has been around longer than I, and he serves half a dozen premier luxury hotels around Beverly Hills. In the distant past I covered for him when he wasn’t available. My records show 45 visits to the Four Seasons and several hundred to his other hotels. I loved those calls.

I retired in 2003 and unretired in 2007. During my absence he found someone else to help out. While he welcomed me back, I’m no longer his main support, but he phones at rare intervals.

When insurance services send me to hotels that don’t call, I remind the staff of my superior qualities. This has proved an excellent source of new clients but, ever hopeful, I don’t solicit this doctor’s hotels.  

Another Year

A wave of heat poured out of the guest’s room as he opened the door.

“Another year has passed,” I reminded myself. May 13 marked Los Angeles’s first heat wave of 2013. The temperature reached 91. Since autumn I’d forgotten that people around the world, Arabs excepted, consider air conditioning unhealthy. They tolerate it as one of the exotic discomforts of travel but not when someone gets sick.

This is not a belief amenable to reason, so I go about my business, sweltering in my suit and tie. I rarely take off my jacket because I keep tools (thermometer, tongue depressor, flashlight, otoscope, syringes, prescription pad) in various pockets. Sometimes medicine is hard.

D as in "Dog"

A travel insurer sent me to Koreatown, an older area of Los Angeles, home to a mixture of Koreans and Hispanics. It’s a colorful neighborhood, and like all colorful neighborhoods, parking is a chore. I found a spot several blocks away from the apartment.

Travel insurance patients are subletting or visiting friends, so searching the directory near the locked entrance never reveals their name. Phoning her number, I heard a voicemail message. That was not bad news because insurance services pay for no-shows, but I had to make an effort. I phoned the agency to explain. The dispatcher urged me to wait while she tried to contact the client. I waited. After five minutes, a resident entered the building; I followed and knocked on apartment 1D. The lady who answered denied that anyone needed a doctor.

After another ten minutes, I decided I’d done my duty and returned to my car. My phone rang as I arrived.

The client was taking a shower, said the dispatcher. She was now ready to receive me. I recounted my experience at apartment 1D, but 1B turned out to be the correct number. In my defense, during the original call I confirmed that the patient was in 1D as in “dog.” But English was not the first language for both guest and dispatcher.

A Light at the End of the Tunnel

I’ve been warning that this blog may vanish on January 15 when my E-mail provider, Physicians On-Line, goes out of business. Google could make it easy for bloggers to change their primary E-mail, but it turns out to be nearly impossible. However, Google does allow us to invite another person to join the blog and share all contributing and editing privileges.

So I sent an invitation to myself which I accepted. Google apparently has no objection to two Mike Oppenheim’s hosting a blog, identical in all areas except E-mail. I keep my fingers crossed that one will remain after the 15th.  

Warning: This Blog May Vanish

I suspect this blog will disappear on January 15, 2013. That’s when Medscape shuts down its E-mail which I’ve been using since the 1990s. At first, I assumed this would be no problem. I would log on using my other E-mail addresses, but they don’t work.

Innocently, I went to a Google forum to ask how to transfer the blog to another E-mail. Almost immediately a responder explained that I must use the permissions wizard – “carefully.” My heart sank as I read an entire page of instructions, links, and warnings plus the suggestion that it works best using two computers and two browsers. I didn’t understand.

My current plan is to recreate the blog which will probably require a different name, so keep your eyes peeled.

Bad Credit Cards

A member of an Argentine soccer team fell while roller staking, wrenching his ankle.  A doctor from their travel insurer in Buenos Aires determined that he needed an orthopedist but that this could wait until office hours the following day. However, the doctor wanted someone to examine him that evening, so my phone rang.

The team was staying in Long Beach, 35 miles away, but the rush-hour had passed, and the agency did not object to the extra fee. This was International Assistance. I’ve made 896 of its visits, but after an ownership change, it became extremely slow to pay. Losing patience, I insisted it give me a credit card number, so I could pay myself. This is always a critical request, because some agencies refuse and disappear from my radar. But International Assistance agreed.

As soon as I hung up, I remembered that IA’s current credit card had expired in August. When I called back, the dispatcher put me on hold to consult her superior. After a few minutes, she returned with a new number.

I phoned the credit card company and entered my identification and the credit card number only to hear the computer declare: “Do not honor! Do not honor!” I phoned IA again, awaited the consultation, and received another card. “Do not honor!” intoned the computer a second time.

“Invalid credit card number” I heard on my third attempt. This turned out to be my mistake; in my increasing frustration, I made an error entering her third number. After correcting it, I heard the satisfying: “Approved” following by a confirmation number. Insurance agencies often give me bad credit cards. I suspect their business is as competitive as mine, so many are in perilous financial condition.

My patient was reclining on a couch, an ice pack on his ankle, his teammates gathered around. The ankle was massively swollen, and he was in pain. Waiting would not have caused permanent harm, but people with painful injuries deserve quick attention.

Fortunately, IA is an agency that takes my advice even when it costs money, so his companions took him to an emergency room to deal with fractures of both leg bones. 

Adventures in Parking

In parts of Los Angeles, especially downtown and the Sunset Strip, street parking is impossible. I dislike turning my car over to an attendant because it can take fifteen minutes to retrieve it from the parking garage. Also, although it’s irrational, I’m willing to pay $15 for a movie or book but not for twenty minutes of parking. I try to leave my car near the entrance, a small area where only VIPs are permitted. When the attendant doesn’t recognize me (“Welcome to the Biltmore; are you checking in?...”), I do not accept the voucher he holds out, explaining “I’m the hotel doctor visiting a sick guest. They let me park.” This sometimes works, but if he insists, I take it. Sometimes the hotel will validate, but it’s unpredictable.

Searching for a spot on the street, I follow the position of the sun as closely as a sailor because I must park in shade. I keep extra supplies in the car, and an hour in blazing sun will melt my pills and ruin batteries. I don’t mind walking a few blocks if I find free street parking (and I know all the secret places), but since I wear a suit and tie, hot weather discourages this. Rain does the same because carrying an umbrella is awkward in addition to my doctor bag and clipboard.

One advantage of wee-hour calls is that parking restrictions vanish and valets grow somnolent or disappear entirely. I’ve never felt in danger, but downtown parking remains problematic because homeless men invariably rush up and offer to watch my car.

My most upsetting parking experience occurred during a visit to the Ramada in Culver City at 4 a.m. I left my car at the deserted entrance, cared for the guest, and returned to find a parking ticket on my windshield. The hotel’s driveway was private property, so ticketing a car requires phoning the police. Looking around the lobby I noticed a security officer looking innocently away. There was nothing to be done.

Why I Am a Patriot

Hot summer days remind me of why I love America. We appreciate air conditioning. Citizens of most other nations consider it unhealthy. They tolerate it as an exotic American quirk, but as soon as someone in the party falls ill, the air conditioning goes off.

Wearing a suit and tie, I conduct my business in suffocatingly hot hotel rooms. When I extol the benefits of machine-cooled air to foreigners, they listen politely with an expression identical to that of Americans hearing me explain that antibiotics will not cure their bronchitis.

Satisfying and Unsatisfying Problems

A guest interrupted my questioning to dash into the bathroom, and I heard the sounds of gagging as she vomited.

While waiting, I took a vial of ondansetron from my bag and began filling a syringe. After a few minutes I heard the toilet flush.

“Why don’t I give the vomiting injection now?” I said when she reappeared. “You’ll probably want one.” She agreed with enthusiasm.

I finished my exam, made a diagnosis – the common stomach virus – and delivered advice and a packet of pills. I also went to the ice machine down the corridor and filled her ice bucket, so that she could suck on the chips for the next few hours. She was very grateful and equally grateful the following morning when I phoned to learn she had recovered. Most stomach viruses don’t last long, a day or so.

Vomiting and diarrhea are usually satisfying problems for a doctor. Most skin problems are easy. I rarely have a problem with earaches, backaches, minor injuries, common eye inflammations, even most urinary and gynecological complaints. A hotel doctor’s patients are healthier than average, but serious problems occur. It turns out that these are not necessarily “hard.” When I encounter someone with chest pain, eye pain, sudden weakness, difficulty breathing, or an injury that may be serious I know what to do. At the end patients receive the care they should receive, and we both know it. That’s a satisfying feeling.

What is the most unsatisfying problem a doctor faces? Rare diseases? Puzzling symptoms? Neurotics? Drug addiction? None of these. Most doctors would agree that it’s the common viral upper respiratory infection. About twenty percent of everyone who consults a doctor suffers. Hotel guests are no exception. No one tries to educate me about heart attacks, but everyone is an expert on these. Patients tell me how they acquired theirs (“I got caught in the rain”), or why (“I’m not eating right; my resistance is low”), the proper treatment (“my doctor gives me a Z-pak”), and what will happen if I disagree (“It’ll go to my chest”). These explanations are always wrong.

You catch a virus from another person. The illness lasts from a few days to a few weeks. If you see a doctor, he or she will prescribe an antibiotic at least half the time. The antibiotic is useless. Doctors know this but prescribe them anyway.

No patient agrees. “I have a good doctor,” they reply. “He would never do that.”

My response is that prescribing useless antibiotics is not necessarily a sign of incompetence. It’s so common that good doctors do it. One expert calls this avalanche of unnecessary antibiotics one of our greatest environmental pollutants. It’s producing a growing race of “superbugs:” germs resistant to all antibiotics.

Here’s a professional secret. When doctors chat among themselves, we often bring up the subject. Challenged by colleagues like me, prescribers never claim that antibiotics cure these infections. They know they’re a placebo, but they respond with a powerful argument. “When I’m finished, I want patients to be happy, and they are happy. One hundred percent. What’s your experience?”

It’s not as good. When I deliver sympathy, advice, and perhaps a cough remedy to patients with a respiratory infection, most seem genuinely grateful, but a solid minority drop hints (“Isn’t there something to knock this out….?” “My regular doctor gives me…..” “I have a meeting tomorrow, and I can’t be sick…”).

Doctors love helping patients. That’s why we went into medicine. Equally important, we want you to feel “helped,” and we are super-sensitive to your gratitude. Almost everyone is too polite to argue with a doctor, but we can detect the tiniest trace of disappointment as you leave. It hurts us. Every doctor knows that he can eliminate this pain and produce heartfelt gratitude by prescribing an antibiotic. This is terribly tempting, and after a few dozen or few hundred or few thousand disappointed patients, most doctors give in.

Avoiding the Rush Hour

A guest with a respiratory infection was staying in a Whittier hotel, thirty miles away. The call arrived at 5:00. Driving sixty miles in rush hour traffic is an experience I prefer to avoid if the problem isn’t urgent. I told the insurance dispatcher I would arrive between 8 and 9.

Usually I explain that “I won’t get out of the office till 7.” That’s an excuse patients usually accept. This time I slipped up and merely explained that I didn’t want to get caught in the rush hour. This is less acceptable and, sure enough, the patient cancelled in favor of going to an emergency room. I felt bad, but that turned out to save me from a difficult evening.

At 6 o’clock, a guest in West Hollywood announced that he was having a gout attack. The rush hour was in full swing, but West Hollywood is only five miles away. Before I walked out the door, the phone rang again, and I agreed to see a Swede suffering flu symptoms at the Sheraton in Santa Monica. The Sheraton is ten miles from West Hollywood and not a convenient drive, but I hoped traffic would have diminished.

Gout is an easy visit, and I carry the treatment, so the visit ended happily for everyone. After a passable drive, I arrived at the Sheraton where I answered a call from the Hong Kong office of Cathay-Pacific Airlines. I care for their crew in Los Angeles, and they are a joy to work with. Being young, they suffer simple ailments; all are Asian but speak good English; best of all, every request comes with a credit card number, so I don’t have to send a bill. A mild downside is that every visit also comes with a sheaf of documents evaluating the employee’s fitness to work.

After caring for the Swede’s flu, I drove ten miles to the Airport Hilton to treat a flight attendant’s sore leg and fill out paperwork. I arrived home at 10:30, weary but pleased at the night’s work. No sooner had I taken my phone off call-forwarding than it rang with news that an elderly lady at a Sunset Strip hotel was ill. Not everyone who wants a doctor needs a doctor, and I often convince guests that a visit isn’t necessary. I yearned to do that in this case, but she was vomiting, not a symptom patients can tolerate.

In the room, I was prepared to diagnose a routine stomach virus until I pulled back the covers and saw her swollen abdomen.

“Is this how your stomach usually looks?” I asked.

She denied it. She also had more pain than I expected, and I heard loud intestinal noises through my stethoscope. It seemed like a bowel obstruction, I explained. She needed to go to the hospital. Immediately she reconsidered my question, remembering that she was constipated, a condition that often made her abdomen swell.

Hearing they must go to the hospital, guests often work hard to change my mind, but I persisted. She went off in an ambulance, and I left hoping I’d made the right decision (doctors worry about these things). I phoned the next day to learn she had been admitted to Cedars-Sinai where she remained several days.

Loyalty

As long as they do good work, doctors assume patients will remain loyal, but hotel doctors learn not to be so trusting. Helping sick guests produces no income for the hotel. Ninety percent are not terribly ill; if rebuffed they rarely make a fuss, so the manager never hears about them. Paramedics deal with emergencies. Years may pass before a GM encounters an imbroglio that only a doctor on the spot can defuse; I’ve recounted a few. Although the best marketing tool, they never happen when I need them.

So how does a doctor keep a hotel’s loyalty? You might think that practicing good medicine is the best P.R. That’s not necessarily so because, ironically, people take for granted that doctors are good. In fact, most are competent, and that includes my competitors. Patients are usually grateful after seeing me, and over thirty years I’ve acquired plenty of flattering letters, but when patients feel the urge to tell the world about a doctor, they are generally less happy. When a GM hears from a guest, it’s almost always a complaint.

Assuring bellmen and concierges of $20 for every referral is a long tradition. It’s illegal, and my last competitor who definitely took advantage lost his license in 2003, but hotel staff continue to drop hints.

Other doctors tour hotels to extol their virtues to the staff, but I don’t. Three or four times a year I write to a hundred GMs but stop once a hotel starts calling. I dislike merchants who keep telling me how much they love my business, so I assume this feeling is general. Perhaps fifty hotels call during a typical year, but I doubt if five GMs know me by sight.

In 1994, I bumped into the doctor who serves a dozen crème de la crème luxury hotels around Beverly Hills. As we talked shop, he mentioned that he knew most of his general managers since he encountered them at social engagements. That’s a marketing tool I can’t match. It turns out that, when a hotel opens, he chats up the manager, and matters are settled. I send my usual letter of introduction, but I never acquire a new hotel in his territory.

During that conversation, he grumbled that a colleague who covered for him recently had left a business card at every hotel. I sympathized, adding that I’d be happy to cover, and I promised not to solicit afterward. Since my leisure time activities are reading and writing, I rarely decline his calls, so we’re both pleased with the arrangement. I still have no answer to the question at the beginning, but at least someone else is responsible for keeping the loyalty of many hotels I visit.

"Welcome to the Biltmore. Are You Checking In?"

That is not my favorite greeting, because it means the valet doesn’t recognize me. My response is always: “I’m the hotel doctor. I’ll be here twenty minutes. They hold my car.”

That’s my mantra to parking attendants, delivered a thousand times and followed by a moment of tension. Will he smile, accept my key, and park my car nearby? Or will he hand over a voucher, jump behind the wheel, and drive off into the bowels of the parking structure?

I have no problem tipping attendants, but I hate paying ten to twenty dollars to park. Accepting the voucher makes that a possibility, so I repeat the mantra, hoping he will reconsider or appeal to his boss who might know me or decide an elderly doctor with his bag deserves VIP status.

Once I accept, my next step, after caring for a guest, is to ask the desk clerk or concierge to validate. Sometimes they comply, but now and then…

“Sorry. The hotel doesn’t handle parking. It’s a separate company.” Hotels often outsource parking, but luxury hotels always accommodate me. Chains are unpredictable, even those where I go regularly. But once I hear this, I pay because I have a rule against arguing with hotel staff. Validation sometimes requires only that the employee scribble “comp – hotel doctor” on the voucher. Once, when refused, I scribbled it myself, and it worked, but I don’t do it. The chance of getting caught is very low, but the consequences are so humiliating that it’s not worth the risk.

After thirty years, I know the nearest street parking for every hotel; if it isn’t hot or raining, I’m willing to walk a few blocks. Downtown is a problem because, even during wee hours, homeless men hurry up, offering to watch my car. In the immense wasteland near the airport and hip entertainment sections of the Sunset Strip and Hollywood, street parking is often impossible. As with so many amenities, Beverly Hills is a pleasant exception.

I loved the temporary handicapped pass I used for six months after breaking my leg in 2003. Its benefits are no secret to the able-bodied; it turns out that eleven percent of Los Angeles drivers have one including not a few running the treadmills at my gym.

Human Nature, Part 2

Cynicism is a cheap substitute for sophistication, but I find it as tempting as most people... The lady just phoned, full of apologies, and we're working on ways to get the money. It hasn't arrived, but I assume it will.

Human Nature

An elderly Mexican psychoanalyst was attending a psychoanalytic convention, but a cold was making her so miserable that she wanted to return home early.

This seemed an excellent call in many ways. It arrived during the evening rush hour, but the Royal Palace was only two miles away. It was my first visit to that hotel, always a delight, and I planned to introduce myself to the management. Finally, the lady’s stuffy ears dominated her concerns, so she probably wouldn’t demand useless antibiotics which Latin American doctors prescribe for colds as often as we do.

Everything proceeded smoothly. I finished my traditional lecture on preventing ear pain when flying (generous use of nasal sprays); she expressed gratitude and laid down an American Express card.

American Express charges a larger service fee than other credit cards, so some companies that handle transactions don’t cover them. That includes mine, but I wasn’t concerned. So far everyone has had cash or another credit card, but on learning that I only accept Visa or Master Card, she expressed dismay. She only used American Express, she explained. Her plane left the next morning, and all she had was cab fare.

While I considered my next move, she snatched the phone, dialed the front desk, and poured out her distress. The doctor they recommended wouldn’t take her credit card; she had no money, and she needed help. I cringed at this terrible P.R. She wasn’t complaining about me, but it’s never good for a hotel to hear a guest having problems with the doctor. Luxury hotels will advance money and add it to the bill, but the Royal Palace, while comfortable, was not in that class. The desk clerk suggested she find an ATM.

Long ago, I drove a guest in search of an ATM, and I’ll never do it again. Begging my forgiveness, she swore that when she returned to Mexico City she would phone with the number of an acceptable credit card. I had no other suggestion, so I brushed off her apologies, and we parted on good terms.

That was several weeks ago; I don’t expect to hear from her.

My practice where almost no one see me a second time and everyone lives far away is a supreme test of integrity, and it’s discouraging how few measure up. Guests have already agreed on the fee before I arrive, so it’s rare that I leave unpaid. When this happens, guests are invariably upset and embarrassed. Once home and aware that there will be no unpleasant consequences if they don’t pay, only about twenty percent come across.

A No-lunch Day

The Langham called 11 a.m., a perfect time. I was finishing at the gym; I could shower, make the visit, and return home for lunch.

The gym is near the 405 freeway, a few miles from my home. It’s not my usual route for the 25 mile drive to Pasadena, being slightly further, but I decided to experiment. A mile after I set out, traffic stopped cold as far as the eye could see.

That’s when I remembered we are adding a single northbound lane to the 405 through Sepulveda Pass. There’s no room, so workers must rebuild every overpass, carve out and reinforce cliffs, and heap up dirt to widen the roadway. This six-mile addition will cost a billion dollars. I cannot think how much mass transportation a billion dollars would buy if there were any political support.

After fifteen minutes of creeping, I reached an exit and took old Sepulveda Boulevard past the construction. While driving, I answered a call from an insurance service and agreed to see a Brazilian boy with a fever in Huntington Beach. Huntington Beach is in Orange County, forty-five miles from my house. It could have been worse; it’s the same distance from Pasadena.

The Langham guest was a Washington Post reporter with a respiratory infection. He was covering a local convention, so the paper was paying for his room at the very posh Langham, but it wasn’t paying his medical expenses, so he had phoned several times before deciding on a visit. I delivered advice and medication before proceeding on my way.

The knowledge that I’ll miss a meal stimulates my appetite, so I suck on hard candy from a supply I carry. I never grab a bite at a hotel because I love eating and prefer to remain hungry and take care of obligations, so I can relax and enjoy it.

After shaking my hand, the Brazilian father reminded me that I had visited him a month earlier. Over most of the US, travel insurers send clients to clinics or emergency rooms. Having a doctor appear at their door is more pleasant, so Los Angeles travelers lose their inhibitions about asking for help, and I see many repeat customers. After examining his son, I explained this it wasn’t necessary to give him a cold shower for his 101 temperature. He would feel bad for a few days and then recover; I handed out four packets of Tylenol.

It was after 3 when I pulled into my garage and answered a call from the Westin at the airport. This was one of those what-might-have-been calls because I’d passed the freeway exit only blocks from the Westin half an hour earlier. I retraced the route to care for a lady with a painful eye, returning in time for supper.

The American Way

“This is AXA insurance about the patient you saw last month, Mrs. Diaz. We are asking you to accept a lower payment. In exchange, we list you as a preferred provider.” The offer was for less than half what I billed. I declined. AXA would eventually pay my regular rate although a few months would pass.

AXA sells travel insurance to Latin Americans. Its US agency and a dozen others phone me to make housecalls. Afterward, I fax my invoice, and (here American doctors will recoil in amazement) the carrier sends a check for the full amount. I’ve made thousands of such visits.

Working alone, I can’t accept American medical insurance with its complex requirements and unreliable reimbursement. The universal American claim form (called the HICF 1500) is cryptic and ambiguous, requiring mysterious codes and far, far more writing than the form I use. Thus, mine has a single space for today’s date; a HICF form requires today’s date in four or five places. Under “place of service” there is no box to check for “housecall.”

Not accepting American insurance is no problem for me, but I’m a special case. As soon as the average doctor opens an office, every American carrier makes an offer he can’t refuse. If he agrees to become a “preferred provider” and accept a reduced fee, the insurer will send patients. If not….

While foreigners look with horror on our medical care system, foreign insurance carriers have long admired their American counterpart’s techniques for saving money. Inevitably, the temptation has grown irresistible. I’ve long since stopped explaining that, including travel, a housecall may take ten times as long as a clinic visit. These callers are not negotiating; they want a “yes” or “no” answer. They lump all doctor visits together, so housecalls get no special treatment.

American doctors have not taken this lying down. One advantage of the Byzantine American billing system is that a resourceful doctor can tack on charges for tests, injections, medication, dressings, complexity-of-visit, length-of-visit, etc. so that he ends up collecting what he thinks he deserves. After decades of dueling with insurers, the typical American medical bill has become a purely fictional creation.

I quote my fee on the initial phone call. It’s larger if the call gets me out of bed or requires a long drive but never changes once I set off. I’ve made 700 housecalls for AXA over twenty-five years but only four during 2011. This is less tragic than it seems.

Confronted by my refusal to become a preferred provider, AXA and a few other travel insurers transfer their business to one of the national housecall services with names like Expressdoc, Hoteldocs, Travel-Med, AM-PM Doc. All boast that they can send a doctor on a housecall in any US city. Since none employ doctors, when a request arrives, their dispatchers consult a list of moonlighters and begin phoning. Tracking down a doctor willing to make a housecall can be a tedious business except in Los Angeles where calling me always succeeds. I’ve made thousands of visits for these services.

I quote my usual fee. To make a profit these services must bill AXA et al several hundred dollars more. If this seems illogical, you should realize that every insurance carrier knows that the “preferred provider” policy saves money, so no one questions it.