Monday, October 20, 2014

Running Out of Medication


A Doubletree guest had run out of insulin. I could have made a housecall, written a prescription, and a pharmacist would have filled it. Instead I explained that insulin doesn’t require a prescription. She should go to the pharmacy and ask for it. The same is true for the morning-after pill, another request that arrives now and then.

An Italian guest at the Four Seasons brought a migraine prescription from her doctor. Pharmacies wouldn’t accept it. Could I come and write an American prescription? I told her to have the pharmacist phone, and I would approve it.

When housecall services (Expressdoc, Medicast, AMPM Doctors) send me to see guests who need a prescription, I write it, collect money, and leave. Those are easy visits, but guests are never grateful. Americans look sullen; foreigners understand that American doctors require immense fees for any service. When guests call directly, I take care of it over the phone, gratis. It’s no great sacrifice and good public relations.

It may even be good business. Long ago, when I returned from a day off, the doctor who covered told me a guest at the Casa Del Mar had phoned. That was exciting news; this was an upscale Santa Monica beach hotel which had never called. The guest obviously had a bladder infection, so the doctor phoned a prescription to a pharmacy. I nodded. Treating an infection over the phone is not a good idea, but simple bladder infections are considered an exception. He added that he had charged the guest $30 for the service. I mention this only because it happened during the 1990s, and I haven’t heard from the Casa del Mar since.

Thursday, October 16, 2014

When Everything Works Out Brilliantly


A call arrived as I was eating dinner at the home of friends. A gentleman at the Biltmore felt that his blood pressure was high. The meal was ending, so I took my leave.

Driving the twelve miles downtown, I parked and opened the trunk to retrieve my black bag. It wasn’t there. Dismayed, I realized I had left it at home.

I keep the bag in my car. My driveway is outside, and during hot weather I take it into the house to keep the heat from melting my pills. Getting a housecall jogs my memory, but I had driven to friends without giving it a thought.

I phoned the guest to explain that I’d have to return home. Before I could apologize, the guest apologized, explaining that he was running out of blood pressure pills and only needed a refill. He knew his travel insurance would not pay for this, so he claimed to feel ill. He wasn’t ill. I wrote him a prescription and went home.

This blog is full of incidents whose entertainment value is based on things going wrong. But sometimes everything works out.

Sunday, October 12, 2014

"Un Momento..."


I was out late one night and prepared for bed after eleven. As I was brushing my teeth, the phone rang for a housecall in Torrance, twenty miles distant.

Traffic was no problem, and Google maps deposited me at the correct address which turned out to be a massive apartment complex behind high walls. Now and then I drove past a gate with no guard and no evidence that it was the correct entrance. I phoned.

The patient’s husband answered. He was Italian and spoke rudimentary English, and his efforts to direct me were incomprehensible.

“Un momento…” There followed several minutes of silence. Just before I decided he had hung up, he came on the line and resumed his unintelligible instructions. Then my headlights illuminated a distant figure in the middle of the deserted street waving a flashlight.

He guided me to a gate, punched the code to open it, and directed me to visitor’s parking. I followed him through a maze of sidewalks to the correct building. After I cared for his wife, he guided me back to my car.

Wednesday, October 8, 2014

Housecalls Are Not Cheap


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

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

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

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

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

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



Saturday, October 4, 2014

Customers Come and Customers Go


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

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

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

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

Tuesday, September 30, 2014

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


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

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

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

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

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

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

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

Friday, September 26, 2014

Hotel Visits I Don't Make


I don’t make housecalls for certain symptoms: shortness of breath, chest pain, loss of consciousness, and severe abdominal pain.

Treating asthma, the leading cause of breathlessness in the young, takes hours. Giving a shot and then leaving before the guest improves is risky.

Breathless in older people usually means heart or lung disease. No doctor in his right mind treats this with a prescription, but possessing a mind is not a legal requirement for practicing medicine.

No one ignores an elderly person who faints, but this doesn’t happen often. The young seem to faint regularly. They collapse, wake up, and call me, frightened. I’m happy to make a housecall, check blood pressure, do an exam, and ask questions. By this time he or she has recovered, and I’ve never discovered something alarming in otherwise healthy young people. “Everyone is entitled to one faint,” a wise old doctor told me. If it keeps happening, a doctor should investigate.

Chest pain is a serious sign, but serious chest pain is not subtle. Niggling discomfort does not qualify. Textbooks warn that heart attacks can occur with no symptoms although these are usually in people with other problems, especially diabetes. Since a doctor cannot diagnose a heart attack by listening with a stethoscope, a housecall isn’t helpful. If you phone because you’re worried, it’s unlikely the doctor will tell you not to worry because if he’s wrong, you’ll sue him.

As I’ve written before, when a guest suffers abdominal pain, I feel reassured when there’s diarrhea or vomiting. That usually indicates a stomach virus, miserable but short-lived, and I get the credit when he guest recovers. Pain alone can also be a stomach virus but plenty of serious conditions (gallstones, kidney stones, blood clots) come to mind.  

Medical science has no cure for drunkenness, but hope springs eternal, so hotel staff continue to call.