The Law

A Finnish man with a fever was staying in a Hollywood Hotel. Treating flu symptoms is rarely satisfying, but I was pleased to learn that he was taking nothing for the fever. I handed over some Tylenol, and when I called back that evening he felt better. 

The following day was July 4. Hotel doctors look forward to holidays because freeway traffic is lighter. Sadly, no calls arrived. None arrived the day following or the day after that.

Deep down, no one believes in the law of averages. If you flip a coin heads ten times in a row, that’s not a fluke but as likely as any other combination. And the odds that the next flip will be heads remains fifty/fifty. It’s guaranteed that someone will win the lottery, but the winner always credits God. After several days with a silent phone, I conjure up images of a rival sweeping up my hotels with irresistible charm or fifty-dollar bills. But calls resumed

Against Medical Advice

A friend has had his gall bladder removed. He’s recovered, and you’ve agreed to drive him home. He is dressed and ready when you arrive. Hospital rules require the surgeon to examine him and approve the discharge, but after two hours the surgeon has not appeared. When asked, the nurse says he has been delayed. Asked an hour later, the nurse admits that no one knows where he is. They must wait.

An hour later, the exasperated friend announces that he will leave. You can’t do that says the nurse. If you do, you must sign this. She produces an impressive document that relieves the hospital of responsibility and lists terrible things that might happen when the signer leaves Against Medical Advice.

“Another thing,” adds the nurse. “If the doctor doesn’t sign the discharge, your insurance won’t pay.” Naturally, your friend decides to stay.

This happens all the time, but it’s nonsense.

First, you don’t have to sign an Against Medical Advice form. You can just leave.

Second, according to surveys, almost all doctors and nurses believe that medical insurance doesn’t pay if a patient leaves AMA, but it’s not true. Insurance pays.

Surveys also show that patients who leave AMA have a much higher rate of complication and readmission. Generally, it’s not a good idea. But, except for certain psychiatric cases, hospitals have no legal right to keep you.

A Risky Housecall

A lady at the Holiday Inn in North Hollywood reported that her husband was suffering diarrhea. She added that he had fainted during the last several episodes. I had never heard that before. Doubting that I could solve the problem, I told her we needed to call the paramedics. Sure enough, they took him to the hospital for a day of rehydration.

Warning! Make Sure You're Admitted!

This is strictly for American readers, but others will get a taste of the grotesqueries of our medical system.

Let’s say you’ve been vomiting for a few days and drag yourself to an emergency room. The doctor says you need IV fluids, so an aide wheels you to a room where you spend the night and most of the next day and then return home, feeling better.

Or you have chest pain. The ER doctor doubts that it’s a heart attack, but he wants to keep you for observation. After two days connected to a heart monitor and getting blood tests, you’re discharged, feeling better.

In both cases you’ll get a bill for at least $5,000, and YOUR HOSPITAL INSURANCE WON’T PAY!! 

Hospital insurance only pays if you’re admitted to the hospital, but remaining in a holding area for a few days or being kept “for observation” is not admission. You’re still an outpatient, so you’d better have good outpatient insurance.

If you’re over 65 and have Medicare Part A (which is free) but have decided to skip Part B (which costs $109 a month) you have no outpatient coverage. Part A only pays for the hospital. If you’re under 65 and have the usual Blue Cross or Blue Shield, you’re largely covered for hospital charges. Depending on the policy you’re willing to pay for, outpatient coverage varies. A lot. 

The solution, when the ER doctor announces that you need to stay for a while, is to ask: “am I admitted or not?”

Of course, you’re probably miserably sick or frightened (if not, maybe you shouldn’t be in an emergency room), so asking about insurance is not a priority. Woe unto you if you don’t.

The End of Narcotics

I once carried narcotics but gave it up. It’s too much hassle.

For garden-variety pain, codeine, Vicodin et al are sometimes but not always superior to over-the-counter pain medicines. I liked them because hotel guests have usually tried ibuprofen, Advil, Motrin, naproxen, etc. During the visit, I can hand over a few days of narcotics, and the guest knows he’s getting something different.

Nowadays, when I determine during the phone call that the guest only needs a pain medicine, I have nothing to offer, so I end up not making the visit. Many guests don’t want to pay the housecall fee in exchange for a prescription.

In an effort to fight the raging opioid epidemic, states have passed laws to keep track of narcotics. Pharmacists now send a report to the state for every narcotic prescription they fill. That’s easy because pharmacists already record everything on their computer, so they merely hit an extra button to send the report. 

If I hand out a few narcotics, I must sit down at my computer when I return home, find the reporting form, and fill it out. Some of the questions seemed cryptic, so I worried that I wasn’t doing it correctly. It seemed safer to stop handing them out.

An Odd Anecdote

Long ago when I was a medical student, a woman came to our gynecology clinic to have an IUD removed.

Five years earlier, when abortions were still illegal, she had had an abortion. For some reason, the woman believed that IUDs were also illegal. The abortionist said that he would insert an IUD for an extra $180, and she agreed.

When the resident looked inside, he didn’t see a string hanging out of her cervix. All IUDs have this string, so they can be easily removed. He ordered an X-ray. It showed a bobby pin.

The resident removed it in the operating room, rusty but intact. It had served her well for five years.

Gratitude is All I Get

The Adventure is a large motel near the airport that caters to foreign tourists on a budget. It’s full of colorful, young Europeans and Asians. The owner-manager phoned to inform me that his girl friend was sick. Could I see her? He would pay.

That was the third time he had asked me to see the girl friend who had a tendency to get sick. I like calls from general managers because it gives me a chance to do public relations.

After my first visit, I waved off his money but suggested that I’d like to be the Adventure’s doctor. He expressed gratitude and promised to tell his employees that I was the man.

Six months later, after the second visit, I refused his money and reminded him of his promise. He expressed gratitude and swore he would give my name to everyone.

Doing favors for general managers has won me new hotels, but it’s remarkable how often it hasn’t. Most of the time, gratitude is all I get. On my third call from the Adventure’s manager, I accepted his money.

Frustration

I drove to care for a woman with a respiratory infection at the Georgian, a boutique beach hotel in Santa Monica. My phone rang as I pulled up at the entrance. The caller was JI, a Japanese travel insurance agency with a patient in a downtown hotel. Ten o’clock is perfect for driving downtown. Freeway traffic dips until noon when it begins a steady climb toward the evening rush.

“I can be there within the hour,” I said only to hear that the patient wanted someone between 4 and 6. I explained that people don’t realize how quickly I arrive. I could be there in 45 minutes. She checked but informed me that the guest wanted to go on a tour. Disappointed, I agreed to arrive at 4, a very inconvenient hour.

The phone rang soon after I returned home, a lady at the airport Westin whose husband was coughing. Did I accept Blue Cross? I didn’t. American insurance pays skimpily for a housecall, and billing requires skill and patience; foreign insurers do better. I gave directions to a walk-in clinic a mile away. Many Americans decide that paying for a housecall is preferable; she assured me she’d call back if she wanted a visit.

Night of the Concierge Doctors

Hotel doctoring has always been a dog-eat-dog business, but after 2010 another tiresome phenomenon appeared: concierge doctors.

These provide a personal service for a large fee in cash, no insurance -- American insurance -- accepted. Google “concierge practice” for the creepy details. When asked, these doctors insist that they’re not in it for the money which means that they’re in it for the money.

Building an office concierge practice from scratch takes a long time, but hotels are low-hanging fruit. Ambitious concierge doctors visit the general manager, something I never do. Even more effective is telling the staff that every call is worth $50. It’s illegal for a doctor to pay for a referral, and all deny doing this, but bellmen and concierges have begun hinting that, maybe, I’d forgotten something when I walked by on my way out.

I charge $300 to $350 for a housecall. Concierge doctors charge between $600 and $3000…. $3000?! Who pays $3000? The answer is: foreign travel insurers. Everyone in the world knows about America’s rapacious medical system so when an insurance clerk in Spain or Japan gets a bill for $3000, he probably assumes that that’s the going rate. This is no small market; insured foreigners make up a third of a hotel doctor's business.

At the lower end, American hotel guests will usually pay $600 to $1000, although they grumble. There is no free market in hotel doctoring as in all other areas of medicine. If guests want a housecall at a hotel served by a concierge doctor, that’s what they pay.

More Free Services

A guest from the Avalon phoned; her husband had been vomiting. Learning the fee, she decided to transmit my advice (stop drinking fluids; suck on ice) and wait a few hours. When I checked back later, he was feeling better.

An elderly man from the Beverly Hills Plaza lost his luggage and needed a supply of half a dozen medications. Rather than endure the lengthy process of learning the name, dose, and instructions of everything, I told him to sort things out with a pharmacist who would phone, and I would approve it.

A man at Le Petite Hermitage wanted a chiropractor. I could have told him to find one on the internet, but it’s better P.R. if I do it. I found one.

I was pleased at these contacts because the Avalon and Beverly Hills Plaza and Le Petite Hermitage never phone. They belong to my competitors who are not so easy to reach and unwilling to provide free services over the phone.

Doing stuff over the phone is easy, so I don’t object, and hotels that call now and then sometimes decide to call regularly.

The Get-Out-of-Jail-Free Card

“Our flight leaves at nine. My son was vomiting all afternoon but stopped a few hours ago. Is it OK to go?”

If I came to the hotel and found nothing wrong, I couldn’t promise that the child wouldn’t resume vomiting. I’d be more confident after a day, but the family didn’t want to hear that.

“There’s six of us going to Australia. We can’t miss the flight.”

Long ago you went to the local airline office and exchanged your ticket. Today airline offices are a distant memory, and ticket exchange with its expensive penalties strikes fear into the heart of any traveler.

Some get on the plane and hope for the best. Others ask the airline for advice. No carrier wants a sick person on board, and every customer service agent knows what to say. 

“They want a doctor’s note,” explained the same caller later. “Can you come?”

Most “doctor’s note” visits are a snap because the guest has already recovered, so I’m simply handing over a piece of paper. This is never true while the illness hasn’t run its course. Guests yearn for me to clear them, but I almost never do. Failing that, they hope my note will persuade the airline to reschedule everyone gratis. This sometimes works, but the era when my note served as a get-out-of-jail-free card is long past.

In this case, they were lucky. The airline insisted that four proceed on to Australia, reticketed the mother and child for the next flight in four days with no penalty but also no reimbursement for the extra days in the hotel.

When Guests Drop Hints -Part 2

        Guest:  “I try not to.”

        This means “Yes” in answer to questions like:  “Do you cheat on your diet, stick Q-tips in your ears, consume too much food, alcohol, tranquilizers, salt,  or laxatives?.”

        Guest:  “I try.”

        This means “No” when I ask if someone has obeyed instructions that are almost impossible to obey (take a pill every four hours, stick to an exercise program, ignore a crying baby)...

        Guest:  “Everyone tells me what a great doctor you are….”

        My heart sinks when I hear this because it precedes a request that I’m not likely to fulfill.

When Guests Drop Hints - Part 1

Here are some phrases that I have to interpret.

Guest:  “You’re the doctor.”

This means “You’re wrong.”  Other hints that I’m off base include:

“I wonder if I need something stronger…”

“My regular doctor always gives me...”

“My husband had the same thing, and the doctor said it was...”

Guest:  “If I don’t get something it turns into (...bronchitis, strep, walking pneumonia, a sinus infection...).”

This guest is saying:  “I want an antibiotic.”

Patients often work hard to convince me that their cough, congestion, or sore throat has a special feature that requires an antibiotic.  They tell me that -

“I have an important meeting, and I can’t afford to be sick.”

“I have a tendency to strep.”

“It’s not a cold.  It’s bronchitis!”

“If I don’t catch it quick, it goes to my chest.”

Plus the old favorite:  “My regular doctor always gives me...”

Guest:  “Are you sure I need this?”

This means the guest won’t fill my prescription.

Similar hints include:

“I don’t take medicine unless it’s absolutely necessary.”

“My mother is allergic to this.”

“I have a sensitive stomach.”

Why We Get Old and Why We Die

People believe that bodies wear out as they age, but that's wrong except for teeth and joints. These are also two areas where medical science is perfecting good replacements, so it’s possible to get the wrong impression.

You can’t wear out your eyes by excessive reading any more than you can wear out your nose by excessive smelling. You can speed up matters through bad habits such as allowing the sun to shine on your skin, but aging is built into your genes.    

Evolution designed organisms to pass their genes on to future generations as efficiently as possible. After peak reproductive years – the 30s in humans -- evolution loses interest, and the performance of your incredibly complex metabolism declines. Efficient processes become less efficient. Things break. You don’t wear out; disease eventually kills you.

If you want encouraging news, it’s possible in theory to physically alter genes so that metabolism doesn’t peak at 30 but at 100 or 200 or never.

In fact, over the past decade biologists have developed ingenious techniques to manipulate DNA. I reviewed a good book on this called A Crack in Creation. Look it up on Amazon.

Nothing about vast life extension violates natural laws, so it’s probably inevitable, but you and I were born too soon.

When Stupidity Takes Over

In 2002 I had the satisfying experience of reading a front page story about my leading rival hotel doctor.  The California Medical Board had lifted his license, and he was in serious trouble for providing narcotics to more than one celebrity. You can google it.

Most drug abusers must take to the streets and run risks, but a few are rich enough to pay a doctor to make housecall to give a single shot of whatever they prefer.  A doctor for luxury hotels gets such request regularly (“My back went out, and I have a meeting I can’t miss...”).  If a doctor is quick with the needle, the word gets out.  Calls pour in.  Money pours in.  Most likely the doctor realizes he can charge a good deal more for this service and related services. Stupidity takes over.

Eventually, prescriptions labeled with this doctor’s name are sitting in medicine cabinets, purses, and glove compartments throughout the city. Their owners are fairly careless. This doctor is doomed.