Do You Accept My Insurance, Part 2

“I can’t afford that,” wailed the guest, an Australian newlywed at the Biltmore when she learned my fee. She had travel insurance, and I had told her it would undoubtedly pay when she submitted my invoice. But unsophisticated travelers who have never used insurance or asked for a housecall often panic.

I lowered the fee to $250. She consulted her husband who countered with $150.  

Since it was 11 p.m. the drive downtown was easy. When the husband ushered me in, I discovered they were staying in a large, two-room suite. The Biltmore charges well over $300 per night for suites.

But they were young, and I didn’t know their story. I did my duty and pocketed his $150. I was not disturbed and had material for a blog post.

Do You Accept My Insurance?

That’s the most stressful sentence a hotel doctor hears – more than “I’m having chest pain” or “my mother stopped breathing.”

American insurers look with deep suspicion on housecalls, and no hotel doctor wants to bill them. But almost no American has experience handing money directly to a doctor – and a housecall costs a good deal more than an office visit. Many of these guests agree to pay, but I often sense their discomfort. Other doctors are not so picky, but if they sound too reluctant I inform them of local walk-in clinics.

Foreign insurers are different. Many call me directly. Resigned to our rapacious medical system, they expect immense bills. I charge everyone the same, but I’ve been contacted by doctor-entrepreneurs who offer triple my usual fee to make their hotel calls in Los Angeles. They can afford this, they assure me, because they charge several thousand dollars for a housecall. This sounds creepy, but it apparently works because I’ve heard from these doctors more than once. 

Goodbye to the Shangri-La

“I’m not calling for a guest,” explained a desk clerk from the Shangri-La in Santa Monica. “I have a question…. In your arrangement with hotels, do you ever pay anything when we call?”

“That’s illegal,” I said. “I’m happy to give employees free medical care, but it’s against the law for a doctor to pay to get a patient.”

“Is that so? Are you sure?”

“Google it. It’s called a referral fee; it’s unethical and also against the law in California. If you use a doctor who’s breaking one law, what other laws might he break?....”  

“Oh, this is just for our own information. I appreciate your help, doctor. Thanks.”

Goodbye to the Shangri-La, I said to myself after she hung up. I’ve been going there since 1985, but the Shangri-La is not large. Since I give plenty of free phone advice, months may pass before I make an appearance, so most employees have never seen me. I don’t market myself, and most general managers leave the choice of a doctor up to the employee, so I regularly lose hotels when a competitor offers his services with the promise of a referral fee.

Sometimes, often years later, they return. Google “Doctor Jules M. Lusman.” He took a number of hotels away from me, but I regained them.    

Caring For a Physician

Having a doctor as a patient is stressful. They often suggest their diagnosis, and it’s awkward if I disagree. When I make a housecall, American doctors sometimes hint that I shouldn’t charge them.

This patient was an anesthesiologist, a good thing because he almost wasn’t a doctor at all – i.e. he’d long since forgotten how to deal with illnesses. He was foreign, another good thing. And he was Danish: the best sort of foreigner because Scandinavians speak good English. 

He had a headache and a 101 degree fever but no respiratory symptoms. I diagnosed a viral infection, perhaps even Dengue fever because he had flown in from the South Pacific. He did not object to taking pain medicine and waiting, and he recovered after a few days.

More Unsatisfied Guests

The son of two Viceroy guests was suffering a severe sore throat and fever.

I drove off in a good mood because it sounded like an easy visit. This combination often indicates “strep” which an antibiotic cures. Patients like that, so I like it, too.

In fact, sore throat and fever in a grown-up is usually a simple viral infection, my least favorite illness. Strep is overwhelmingly a disease of children and adolescents, but this patient was fourteen, so my hopes were high.

They were dashed when the boy admitted that he had a cough. Strep is strictly a throat infection; coughing is not part of the picture. Sure enough, his throat looked normal.

Rummaging thoughtfully in my bag, I pulled out a packet of acetaminophen (Tylenol), handed it to the parents, and explained that this would help his fever. I extracted a plastic bottle of Lidocaine, a gargle intended to relieve his throat pain. I gave them a cough medicine is similar to the popular Robitussin but in an immense eight-ounce bottle.

I assured them that bed rest would not help, so he should try to enjoy himself. He could eat whatever he wanted. But it was likely that he’d feel under the weather for a few days before recovering.

The parents seemed happy to receive the medicine. They expressed gratitude for my service, and thanked me effusively as I left, but I knew that this was mostly good manners.  They were on vacation. The doctor had come, given some not-very-powerful medicine, and told them the child would continue to be sick. Did the doctor realize how important this trip was to them? Maybe if he had tried harder…. Or if they’d called a better one…. 

Not a Bad Job

Awakened at night, most hotel doctors prefer to give advice, and, if that fails, they discover that the guest requires the paramedics.

I don’t mind wee-hour calls. Traffic is light, parking is easy, and since I have no office, I can sleep late. With TIVO, I can leave whatever television show I’m watching. I don’t mind calls during meals, even restaurant meals, because finishing doesn’t take much time. Calls during a movie are problematic although I’m happy to leave at least half the time. If the call arrives soon after the credits, I ask for a refund, and no one has yet refused. I credit much of my success as a hotel doctor to the rarity of occasions where I’m reluctant to make a visit.

Mostly, I dislike driving during the rush hour. Hotels between Beverly Hills and the ocean are close enough to be tolerable, but traveling downtown or further is tedious. Mostly, guests are willing to wait a few hours provided they are not vomiting or hurting.

Two For the Price of Two

An insurance service informed me that two sick children awaited in Orange. It’s a rule that if one child is sick, there’s a small chance it’s serious; for two children, never. They almost always have a simple virus.

The major difficulty was the distance, nearly fifty miles, and the fact that my wife was preparing dinner. To my delight she offered to delay it and accompany me on the visit, something she rarely does. We had a pleasant hour’s drive to Orange where I cared for two children with a simple virus, and we ate dinner at the hotel.

Lost in Translation, Part 3

“I am constipated.”

“’Constipation’ means different things to different people. What exactly bothers you?”

Silence…. When a caller doesn’t answer, it usually means he doesn’t understand.

“Do you have pain?”

Silence.  I knew the word for pain in French is ‘douleur.’

“Pain….douleur?”

“Yes.”

“So you have pain in the abdomen.”

“Yes,” he answered without conviction. He made it clear he wanted a visit, so I quoted my fee (“yes”) and made the trip.

Half of my hotel guests are foreign, but usually one person in the group speaks enough English to get along. Men do better than women. Guests from Asia cause the most trouble. South Americans are the easiest because every hotel has Hispanic workers. I can’t remember the last time I drew a blank from a European male.

“When was your last bowel movement?”

Incomprehension. The wife handed me an Ipad with a translation app. I typed “bowel movement” and the screen obligingly displayed “movement de l’intestine.” Even I knew that this meant “movement of the intestine” in French. He looked blank.

He had no fever, and my examination of his abdomen was normal. His urinalysis was unremarkable. He wasn’t old enough to be at risk for the many abdominal catastrophes that affect the elderly. I concluded that it wasn’t an urgent problem. He seemed to understand that he should go to the hospital if he weren’t better in a few hours. The hotel promised to keep an eye on him. Everything worked out.

A Stoic Patient

This patient lived on the edge of Beverly Hills, far up Topanga Canyon Road. Turning into a side street, I stopped at a guard house. It was not impressive – a tiny shack next to a commercial port-a-potty, but a genuine uniformed guard asked my business. According to Google, the street beyond held only a dozen houses, but they were big. Really big.

Following the lady who greeted me at the door, I walked and walked, passing through room after room with polished wooden floors, high ceilings, exquisite furnishings, bookshelves and paintings lining the walls. Movie stars and Arab princes live in such places. Visit Hearst’s Castle to share the experience.

But sick people are just sick. A lady was suffering excruciating right eye pain. She hadn’t injured it. My diagnosis was acute glaucoma, an emergency.

You may know about glaucoma, a disease where fluid drainage from the eye is blocked, increasing pressure, eventually causing blindness. Experts advise you to have a yearly check, but this is for common, chronic glaucoma where pressure rises slowly, so doctors can make an early diagnosis and treat it with eye drops. It’s painless. Acute glaucoma, where drainage stops abruptly, is rare and very painful.

This was not news to the patient who explained that many family members were blind from the disease. She agreed to go to UCLA’s emergency room but asked for something to help her vomiting; severe pain often causes vomiting. I gave an injection and took my leave.

Phoning the next day, I was flabbergasted to learn she had stayed home. She didn’t want to travel because of the vomiting, she explained. By evening it had diminished, but so had the pain. She decided to wait. She had an appointment at the ophthalmologist for the afternoon.

Twilight of the Hotel Doctor

Uber is driving taxi companies out of business. Air Bnb is putting stress on hotels. A stream of retail chains are declaring bankruptcy in the face of online competition. No one doubts that this trend will continue. Online services are cheaper if sometimes inferior. Uber drivers earn less than traditional cabbies – not a notably prosperous profession. But customers aren’t complaining. They like cheap.

It’s absolutely certain that housecall doctors like me are doomed. We’re expensive and often – at least in my case – the quality of our service is too good.

Los Angeles residents already have a choice of two phone apps. Tap either one, enter your credit card information, and a doctor will arrive within hours. The fee will be less than mine – and I charge less than the typical hotel doctor.

One consequence of a low fee is that they pay doctors less than the going rate. As a result, they attract residents in training or just beginning practice, but these seem adequate.

As you know I work for everyone, and I worked for both. I didn’t care for the low pay, but I’d still be working if it weren’t that I had no control over the patients I saw.

When hotel guests phone, I always talk to them. If the problem is minor, I give advice and suggest that a housecall isn’t necessary. If it requires a simple service such as a prescription, I take care of it over the phone. If it requires a test, x-ray, or emergency room visit, I can usually determine that.

If the guest has unrealistic expectations, I can avoid an unsatisfying encounter. I can warn a hoarse singer that she probably won’t be better by evening.

Many callers request treatments that they don’t need. You might think of narcotics, but mostly it’s an antibiotic for their respiratory illness. I only prescribe an antibiotic if it will help which puts me at odds with most of the medical profession, so many patients will be disappointed and a few upset if I don’t treat their “bronchitis” or “sinus infection” as their doctors do. When this seems likely I direct them to a local clinic where they’ll get their antibiotic or (if they stumble on a competent doctor) express their disappointment to someone else.

When hotels phone, I make a housecall less than half the time. Guests love the free service. Even better, when I drive off, I know that I’ll be able to help, and – no less important – the guest will feel helped.

Working for these Uber services, I had to make every visit they assigned. All I learned was a symptom (“cough” “allergy”). The result is that I walked into situations where a housecall was not appropriate (“granny hasn’t seen a doctor in thirty years; would you check her out?...”). Many had problems I could have handled over the phone; others required more than a housecall could provide. And there were the usual unreasonable requests.

My faithful readers know that hotel visits don’t always work out. I’d estimate that five percent are less than satisfactory. Working for housecall services, the percentage was much higher. I didn’t like the stress of wondering what I would encounter.

But I see the writing on the wall. Hotels that emphasize superior service (i.e. expensive ones) will continue to refer guests to a specific doctor. Otherwise, ironically, the old days will return. When I began in 1983, motels and chains (Holiday Inn, Ramada, Hilton, Best Western…) had no interest in a hotel doctor. At least in Los Angeles, I was the first to approach them. By the 1990s, they were calling me and an increasing number of competitors, but managers of these hotels still pay little attention, so employees are on their own when guests ask for help.

Although my faithful clients continue to call, I’ve noticed a decline from the great mass of hotels that never called regularly. But I already collect Social Security, and I’ll be fine when I retire.

Easy Money, Part 2

“I need an eye doctor,” said the caller. “A big red spot came out this morning!”

The guest added that the eye felt fine. The spot didn’t affect his vision but looked terrible.

I’ve encountered several dozen subconjunctival hemorrhages, a fancy name for a bloody patch on the eyeball. Googling turns up a dozen causes from injuries to coughing, leukemia, high blood pressure, and clotting disorders. In reality, if there are no symptoms and the person is in good health, the blood appears for no reason and disappears in a few weeks. That’s happened in every case I’ve seen, including my own.

The guest was staying at the Mondrian, a luxury hotel. He was in room 500 which I knew was a suite. If he’d been at a cheap motel, I might have been more reassuring, but I confined myself to suggesting he might have a subconjunctival hemorrhage and that this was probably not as serious has he thought. He wanted a visit.

It was, of course, entirely satisfying. I examined the eye, paused thoughtfully, and then assured him that it was a subconjunctival hemorrhage and that he had nothing to worry about. He was thrilled. I collected my fee. Everyone was happy.

When the General Manager Consults the Lawyer

The concierge expressed relief when I answered. A lady’s 11 year-old son was seriously ill, but the mother had refused to take him to an emergency room. She had been pestering the hotel staff all day.

“What’s the problem?” I asked. “You only had to phone me.”

I’d made over 300 visits to that hotel since the 1990s. But even as I spoke, I remembered that it hadn’t called in six months. As I feared, the concierge explained that a new general manager had decreed that, for liability reasons, sick guests would be directed to the local emergency room unless calling 911 was appropriate. Doctor referrals were forbidden.

At any given time, about twenty percent of Los Angeles hotels have this policy, but it’s never the same twenty percent. Hotels adopt and then discard this rule because it causes public relations problems. Most guests don’t require 911 and don’t want to go to an emergency room, so they stay in the hotel, sick and resentful. A few persistent guests make so much trouble that, as in this case, a desperate employee disobeys her boss. I’ve made a dozen such visits.

Calling me would have saved everyone trouble. The child had a fever and a bad cough, a routine viral infection. It was an easy visit.

Afterward, as I was commiserating with the concierge, my phone rang with an example of how things are done right. A man at the Langham in Pasadena wanted a doctor to check out his cold. I told him I’d arrive in 45 minutes.

A Rule of Medicine That Didn't Apply

I give out medicines gratis. Mostly, they’re cheap, but exceptions exist. For unclear reasons my supplier charges $17 for antibiotic ear drops but $1.50 for antibiotic eye drops. Experts agree that it’s OK to use antibiotic eye drops in the ear, so that’s what I do.

I felt pleased handing over a bottle to a lady with swimmer’s ear. Ear infections are easy visits, and guests appreciate that they do not have to hunt for a pharmacy.

My heart sank when the guest’s insurer called the following day. She wanted another visit. I phoned the guest who admitted that her ear was no worse, but now she had a fever, headache, and sore throat. That was disturbing. Had I missed something?

I returned to the hotel. She had a 102 temperature with swollen tonsils and swollen neck glands. Since she was barely out of her teens, Strep throat was a reasonable diagnosis.

It’s a rule of medicine that a doctor who makes two separate diagnoses is not thinking clearly. Patients have one thing, but this woman definitely had swimmer’s ear and Strep throat. 

Relentless Time

Melrose Avenue is hip and upscale as it passes through West Hollywood. Further east, toward downtown, businesses tend toward pawnbrokers, bodegas, and Kentucky Fried Chicken. At least that’s how I remembered it.

If you live long enough, everything familiar vanishes, and I parked among a chic collection of freshly painted boutiques, restaurants, and fashionable clothing shops. Plus a beautiful new hotel that I’d never heard of.    

It was the Hollywood Historic Hotel, converted from a 1920s apartment a few years ago, I learned from the desk clerk. He insisted that I was the first doctor that had appeared, and he seemed happy accept my card.

Even better, there was no answer when I knocked. Since I’d come at the request of a travel insurer, I’d be paid. I tell the insurer that if the guest wants to drive to my home, I’ll take care of him at no charge. No one has taken me up on it.

Goose Chases

I knocked at room 777 of the Hyatt Regency, downtown. The guest who answered denied calling a doctor.

Did I get the room number wrong? It’s happened, but this seemed unlikely. Did I get the hotel wrong? There is only one Hyatt Regency in Los Angeles but many Hyatts. The only one that calls regularly is at the airport. I phoned. Sure enough, room 777 at the Airport Hyatt wanted a doctor.

“You’re at the Hyatt,” I said. “Why did you say you were at the Hyatt Regency?”

“Aren’t they the same?”

They aren’t. I drove the fifteen miles to the airport and took care of him.

A Medicolegal Visit

A guest was eating lunch in the hotel restaurant when the chair collapsed. Unfortunately, her hand was resting underneath. The desk clerk asked if I could come immediately.

During my early years, I would hurry over, take care of the problem, and present my bill only to have the guest insist that the hotel was responsible. Management sometimes disagreed, so I learned to settle matters over the phone.

“I need to know who’s paying,” I said.

The clerk she put me on hold, returning to announce that the hotel would take care of it. This would be my 146^th  medicolegal visit, my name for a housecall when the hotel offers to pay. Most involve minor injuries that occur on the premises. There were also thirteen upset stomachs, purportedly from hotel food, and nine insect bites, always bedbugs according to the guest.

I arrived to greet a young Englishwoman, her hand in a bowl of ice. Two fingers were exquisitely painful. She needed an x-ray. I found a local orthopedic group on the internet and phoned.

“An initial visit is $500,” said the receptionist. “She needs to pay when she comes in.”

“Wow!” said the guest when I passed this on. This was probably not a comment on the size of the fee (which the hotel would cover) but the traditional European amazement-cum-horror at American doctors’ preoccupation with money.

Both fingers were fractured. Fortunately, her visit was ending, and she flew home the next day.

I Just Need a Shot

A woman under treatment for infertility needed a progesterone shot every month. She had the vial. Could I send a nurse?...

Why do doctors cheerfully give patients medicine and send them off on their travels? It guarantees a hassle.

I don’t have a nurse, but I quoted $50, drove to the hotel and gave the shot. It was not a short drive, but she wouldn’t have paid my regular fee, and I wasn’t doing anything at the time.

This lady was lucky. In any other city, she would be in for a rude, expensive shock. I do hotel doctoring fulltime. My colleagues have other jobs, and they're not likely to drop what they're doing and make a visit at a discount.

Some guests think they can call a nursing service. Nurses earn less than doctors, but a visit from a nursing service is not cheap. It also won’t happen. A nurse won’t give medicine without a doctor’s order.

Going to a clinic or doctor’s office is not likely to work. In today’s malpractice climate, few doctors will give an injection on a patient’s say-so. Carrying a note is also a crapshoot. As I have recounted more than once, doctors look with deep suspicion on patients who arrive with notes. See my post from April 20.

I Encounter a Rare Disease

A man suffered a headache on his flight. After arriving at the hotel, his left ear began hurting and soon became excruciating.

When he opened the door, I noticed that the left side of his face drooped.

Nothing pointed to the usual ear infection. He had no cold symptoms. The plane’s descent did not aggravate symptoms. He didn’t swim or use q-tips. He did not have a fever.

When I looked inside the ear canal, I saw blisters.

Painful blisters in the canal and a droopy face….  In forty years of practice, I have never seen a case of Ramsay-Hunt syndrome, but there it was. The poor man had shingles inside his ear.

Shingles is a viral infection of skin nerves. It’s fairly common and usually appears as a patch of blisters on the chest, abdomen, or back, sometimes the face. But there is skin in your ear canal. An additional complication occurs because the nerve supplying the ear canal also feeds muscles of the face, so victims suffer facial weakness on that side.

Treatment is an antiviral drug and a course of cortisone which is modestly but not dramatically effective. Chances are he would recover completely, but he would have an uncomfortable few weeks.

Blood Clots

Jogging on Santa Monica’s beach, a traveler twisted his ankle. He went to a clinic where an X-ray revealed no fracture.

That was two days ago, he informed me, and the ankle was healing. He was to fly home tomorrow, and his doctor in Switzerland had suggested he get an injection to prevent a blood clot. I receive a sprinkling of these requests, all from foreign travelers. They began a few years ago when the media began reporting clots in travelers after long plane flights. The risk in healthy people is tiny but not zero and concentrated among those who fly more than four hours.

Drugs to thin the blood such as Coumadin and heparin have been around for decades but are too dangerous for healthy people. In 1993, the FDA approved Lovenox, a refined form of heparin, safe enough for use outside a hospital. My wife gave me six weeks of daily injections after I broke my leg in 2003. It was still under patent and wildly expensive, but generics have appeared, so it may soon become fashionable to get a shot before a long flight.

So far no Americans have mentioned the subject, and I give foreigners the traditional advice: walk around and drink plenty of fluids. Techniques that don’t work include compression stockings (unless fitted by a professional they may make things worse) and taking aspirin. Aspirin prevents clots in arteries, but clots from immobility occur in veins.

A Letter from His Doctor

A VIP had forgotten his medication. Would I prescribe it, asked the manager of a Sunset Strip hotel.

“He brought a letter from his doctor,” she added helpfully.

That was bad news. About twenty percent of guests with letters have complex medical problems that require an explanation. The rest are drug abusers under the impression that an official document will persuade us to prescribe something we ordinarily wouldn’t.

Sure enough, it was a popular narcotic. This guaranteed tedious consequences. The most critical was that, after my refusal, he might ask the manager to suggest another doctor, explaining that I had heartlessly rejected his appeal.

I listened as he described the complex pain disorder he and his doctor were wrestling with. Perhaps I could examine him, he added. While this sounds reasonable, such visits involve an unspoken agreement that if I came and took his money, I would give the prescription. That felt too much like selling drugs. I countered that I would call in a prescription for a good non-narcotic while he contacted his doctor who would phone me to discuss matters.

His doctor wouldn’t call, and I suspected the guest wouldn’t care for my prescription, so I could expect to hear from him in a day or two. But the clock was running. He might check out and return home or move to another hotel and bother another doctor.

A Mysterious Seizure

Airport security confiscated a tourist’s glaucoma eye drops, so he called his insurance who called me. 

The drops come in a tiny 2½ cc bottle, so the seizure seemed puzzling. On the other hand, ten years ago the examiner took my tweezers, a beautiful needle-nosed instrument perfect for removing slivers. It cost $20. Later, I checked the Transportation Security Authority web site and learned that tweezers are permitted. I’m still fuming.

Usually, I offer to phone a refill to a pharmacy when a traveler needs a legitimate prescription, but business has been slow, and the insurance had already told the guest I would come. Ironically, medical experts unanimously frown on giving prescriptions to an unfamiliar patient without an examination. They never explain how an examination in a hotel room can prove that a patient has, for example, glaucoma, osteoporosis, emphysema, acid reflux, or epilepsy. If he takes high blood pressure medication, and I find a normal pressure, must I refuse the refill?

"The Crab Tasted Funny...."

“No one but my wife had crab cakes in the hotel restaurant last night, and about 4 a.m……”

A miserable problem for the guest’s wife but also a difficulty for me. The caller had no doubt that his wife was suffering food poisoning although no one can make that diagnosis unless more than one person gets sick. In developed countries, viral infections cause most upset stomachs.

“She says the crab tasted funny…” That was not helpful because common food-borne toxins are tasteless.

I expressed sympathy, quizzed the husband for details, assured him that these illnesses were usually short-lived, and gave suggestions for relieving her symptoms. I would have made a housecall if asked, but on calls like this I hope the caller doesn’t ask.

If he asks, I mention the fee. My worry is that the guest, certain the restaurant poisoned his wife, will insist that the hotel pay. News that I am not a hotel employee never changes matters. Suggesting that the guest take this up with the manager never helps. Sometimes management refuses responsibility, so I’m confronted with an angry guest who suspects, despite my disclaimer, that I’m in cahoots with the hotel. I hate accepting money from a resentful guest, so I don’t.

Sometimes the manager tries to mollify the guest by agreeing to pay. A hotel manager is an exalted figure. I rarely meet one, and I want the first encounter to leave a good impression, so I wave off the money. They always appreciate it, but don’t assume I earn their undying gratitude. I did this in July of 2015 to the manager of the huge Doubletree in downtown Los Angeles. The hotel hasn’t called since.