The Hotel Doctor

The last post on this blog - but I'm continuing on another

2021-02-01T06:44:00.004-08:00

For mysterious reasons, Google has stopped indexing this blog, so you few loyal readers are among only a dozen or two that can still find me. I've tried and appealed to many support groups, but no one has helped.

Finally I decided to continue this in a new blog with a new name and a different E-mail hoping Google would lift the ban. I changed the name to "The Housecall Doctor." At this point it doesn't look good because if you Google "The Housecall Doctor" the new blog doesn't turn up. But you can reach it by entering the link "thehousecalldoctor.blogspot.com.

A Dog-Eat-Dog Business, Part 11

2021-02-01T06:21:00.003-08:00

“This is Doctor Oppenheim,” I repeated several times before hanging up. Caller ID identified the Doubletree in Santa Monica, so I phoned to ask if someone had requested a doctor. Someone had.

“You answered, but you couldn’t hear me,” said the guest. “So I called the front desk again, and they gave me a different number. Another doctor is coming.”

That was upsetting because the Doubletree is a regular. When asked, the guest gave me the 800 number of Hotel Doctors International, a service based in Miami.

“How much are they charging?” I asked.

“I don’t know. They just asked if I had insurance.”

That was a red flag. Many hotel doctor agencies charge spectacular fees and then assure guests that travel insurance will reimburse them. Forewarned of our rapacious medical system, foreign travelers rarely make a fuss – and foreign travel insurance generally pays outrageous fees. But American insurance doesn’t.

I told the guest, an American, that my fee was $300 and that he should call the agency and ask what it charged. It turned out to be $650 (far from the largest I’ve heard), so I made the housecall.

Afterward, standing on tiptoes to peer over the front desk, I saw the colorful business card of Hotel Doctors International stuck on the counter. The clerk, who had insisted that mine was the only number she knew, expressed surprise when I pointed it out.

All In a Day's Work

2021-01-28T07:14:00.005-08:00

“She speaks Spanish. I’m not sure what’s going on, but she needs a doctor.”

The caller was the night manager at the Torrance Marriott. The hotel rarely calls, but I go regularly for crew of LAN, Chilean Airlines. An LAN crewperson who falls ill is supposed to call her supervisor who calls the central office who calls Federal Assist, a travel insurer, who calls Inn House Doctor, a national housecall agency who calls its answering service who then calls me. The guest hadn’t followed the procedure. If I made a housecall at her request, getting paid would be a major hassle.

I phoned the answering service which had no idea what do. I phoned Federal Assist who insisted it wasn’t responsible for arranging visits. I phoned the director of Inn House Doctor to alert him to the problem. Then I waited.

It was 5 a.m. It’s dangerous to make these housecalls before official approval because it may never arrive. But the rush hour was about to begin, and I couldn’t resist. I jumped in my car and drove the twenty miles to the Marriott. The freeway moved smoothly, but two blocks before the hotel, barriers and police cars blocked traffic. A dead body had been found on the street. That I was a doctor making a housecall did not persuade the guard.

I parked and walked toward the hotel. A policeman hurried over as I passed the barrier, but he accepted my explanation and escorted me past the tent concealing the body.

The visit was easy, and official approval arrived while I was in the room. When I finished at 7:00, my sigalert revealed a solid red line of jammed freeway for my return. So I returned to my car, tilted the seat back, and went to sleep.

The European Plague

2021-01-24T07:53:00.000-08:00

“I have the European plague. I need a doctor.”

“Excuse me?...”

“I have the European plague. I need a doctor for the American plague.”

“I’m not sure what you mean.”

“My child is in the bathroom with the European plague. Can you bring the doctor?”

What was he talking about?.... The exchange continued for some time until the light dawned. This was the fourth occasion this has happened in over thirty years and 30,000 phone calls. The guest had phoned the front desk because his electrical devices used European outlets which are different from ours. He needed an “adapter.” The clerk, not listening carefully, had heard “a doctor” and forwarded his call to me.

But I was also not listening carefully. It’s human nature to hear what you expect to hear, so I assumed that the caller had a medical problem.

I had heard “European plague” when he had said “European plug.” He had not said “my child is in the bathroom” but “my shaver is in the bathroom….”

Good Luck

2021-01-20T06:23:00.002-08:00

A national housecall service connected me with a guest at the Montage in Beverly Hills. She was suffering the flu; I told her I’d arrive in half an hour.

As soon as I hung up, I realized, to my dismay, that I had quoted my usual fee, forgetting that the housecall service takes a 40 percent cut. The Montage is a super-luxury hotel, and the guest was probably rich, but I couldn’t change the fee.

I was in luck. Not one but three guests in the room had the flu, so it worked out.

Vomiters Hate Waiting

2021-01-16T07:53:00.001-08:00

A hotel guest phoned to ask when I’d arrive.

“In about fifteen minutes.”

On her initial call, I had told her I would arrive in an hour, and I was on schedule, so the call meant that she was still vomiting. Vomiters are impatient.

My database shows 2,328 entries for “gastroenteritis” (the common stomach flu). It’s my second leading diagnosis and far more satisfying than “upper respiratory infection” (4,584). Both are almost always incurable, but gastroenteritis rarely lasts more than a day; patients give me credit when it goes away.

The guest greeted me at the door, a good sign. A guest in bed is OK, sprawled on the bathroom floor is not good.

I asked the usual questions and did not interrupt as she delivered a precise, item by item, account of dinner. Everyone blames an upset stomach on their last meal, a belief as correct as most popular health beliefs. I gave the usual advice which included telling her to stop what she was doing (putting fluid into her stomach as fast as it came out) and to suck on ice and wait.

I gave the usual antivomiting injection and two packets of pills which I had pocketed before leaving so I wouldn’t have to remember to restock my bag.

When I phoned later, she told me that she had recovered and thanked me for curing her.

Christmas Day

2021-01-12T06:00:00.008-08:00

A travel insurer reported a sick child at the Anaheim Holiday Inn, near Disneyland forty miles away. Freeway traffic was tolerable, but when I arrived and knocked no one answered.

I walked around the lobby. With my suit, beard, and black bag, I look like a doctor in an old Hollywood movie, but no one responded. A waitress in the hotel restaurant asked at everyone’s table, but no one admitted calling a doctor.

I drove away in a good mood. When hotel guests call and then disappear, I’m out of luck, but travel insurers pay for no-show visits.

I was a mile from home when the insurer called. The mother was on the line, claiming she had been waiting in the hotel. So I drove back to Anaheim. To my everlasting credit, I was entirely pleasant to the mother, waving off her excuses. The child had a cold.

Another Easy Visit

2021-01-08T06:54:00.002-08:00

I drove to Glendale to care for an elderly Argentine lady who had been vomiting. That can be a tricky problem in an old person, but she was recovering, so I felt comfortable leaving her with advice and medication.

During the visit, I had the experience of listening to someone with a thick Spanish accent denounce Mexicans. She had eaten in a Mexican restaurant and was certain the spicy food made her ill. Argentina is a country with extensive cattle ranches and a largely meat and potatoes diet.

Another Failure of Communication

2021-01-04T07:19:00.002-08:00

“My son with pain in ear. Maybe he need a doctor.”

“I can come to the hotel.”

“Not today. I give medicine. Maybe if he has pain tomorrow.”

“So you’ll call me tomorrow?”

“Yes. Can you come in the morning?”

“Yes.”

“When.”

“I can be there between 10 and 1.” Strictly speaking, I can come at any time, but I like to avoid driving during the rush hour.

“Three hours is too long. We want to visit the city.”

“You said you’d call tomorrow. When you call, I’ll tell you exactly when I’ll be there.”

“OK.”

Most guests who promise to call never call, so I put the matter out of my mind. After noon the following day, the phone rang. It was the concierge at that hotel. “I’m afraid we’ve had a complaint, Doctor Oppenheim,” she said. “Mr. Desai in 403 says he and his family have been waiting over three hours. Are you going to come?....”

Good Insurance

2020-12-31T06:23:00.001-08:00

The caller spoke with a Hispanic accent, so I assumed he was a travel insurer, and I was right. It was StandbyMD, one of the good insurers. It phones; I make the visit; I fax an invoice; it sends a check. Latin Americans make up most of its clients, but anyone can sign up.

A guest at the Sheraton Four Points had been awake all night with an earache. The call arrived at 4:30 a.m., but that’s almost my time of rising, so I was not unhappy. Freeway traffic was light. I was at his room in half an hour.

One thing seemed strange. His name sounded American. This is not rare in Latin American countries, but he also spoke flawless English. He told me his pain began soon after he boarded a plane in Managua.

“So you live in Nicaragua?” I asked.

“No. Vancouver,” he said.

The light dawned.

“Of course,” I added. “You’re Canadian. No American would have such good insurance.”

American travelers buy American travel insurance. When they fall ill, they obtain care and then submit a claim to the insurer which pays as much as their fee schedule pays. Our insurers take a dim view of housecalls, so their reimbursement is not generous. I can’t remember caring for an American hotel guest and then billing one of the dozen travel insurers that use me.

More Evidence of America's Leadership

2020-12-27T02:53:00.004-08:00

Opening an envelope from an international travel insurer, I expected a check but found only a form letter containing a dozen boxes, each listing a reason why payment was denied. An “X” through one box revealed that I had not submitted my invoice on an HCFA-1500.

That’s the claim form American doctors send to American health insurers. It’s complex, full of codes, questions, boxes, and charges – far longer than my simple invoice. Despite this, it’s badly organized. One must enter today’s date three times.

I found an HCFA form and filled it out, leaving many cryptic questions blank, guessing answers where I wasn’t certain, and including a fictional breakdown of services because I charge a flat fee. An American insurance clerk would post it on the office bulletin board for general amusement.

Two weeks later, a check arrived. Foreign insurers are not up to speed, but they’re trying.

Ultimatums Are Risky

2020-12-23T05:42:00.006-08:00

Could I see a gentleman at the Omni with an upset stomach?

The dispatcher for International Assistance was delighted to learn that I could. In most cities, dispatchers work hard to find a doctor willing to make a housecall but not in Los Angeles.

I copied the guest’s name, age, room, and insurance I.D. I quoted a fee. That was acceptable. I said I would arrive within an hour. He was pleased to hear that. Then I dropped the bomb. I would need a credit card number.

I could hear the air go out of his balloon.

“We always send a guarantee of payment.”

“You do. But then you don’t pay.”

Many travel insurers pay promptly. Others require repeated phone calls. Pestering a billing department relentlessly usually works, but sometimes I run out of patience, and many visits for International Assistance remained unpaid after six months.

“I’m not sure we have a credit card.”

“Yes, you do. Ask your supervisor.”

All travel insurers have company credit cards but they vary greatly in their willingness to give them out. Some do it routinely. Others require an ultimatum. I hated hearing from Universal Assistance until they coughed up a credit card number. Now I love it when they phone.

But ultimatums are risky. The dispatcher agreed to consult his supervisor and call me back, but I never heard from him.

A Rash During the Rush Hour

2020-12-19T05:57:00.002-08:00

A guest in Long Beach had broken out in red spots.

This looked like a terrific visit; skin problems are easy. A sudden rash is frightening but hardly ever indicates something serious. I have no objection to making a diagnosis over the phone, but guests are terrible at describing a rash’s appearance. In any case, most want the doctor to look at it.

My only problem was that the call arrived at 5 p.m. on a Friday, and Long Beach is thirty miles away. I avoid long drives during the rush hour, so I told him I could come around 9.

That wouldn’t work, he replied. He had a long business engagement that evening. But he’d be happy to see me the following morning.

Saturday morning drives are easy, but a rash that arrives quickly often departs quickly. I wanted this visit, so I told him I would be there in an hour. Or two.

Hitting the Jackpot

2020-12-15T06:41:00.005-08:00

A call arrived during breakfast. Half an hour later the phone rang again. I was pleased because it was an ideal time for multiple housecalls.

I exercise before noon because later the gym becomes crowded. Two morning housecalls makes arriving before noon impossible. This doesn’t happen often, so I reward myself by skipping the gym without feeling the usual guilt. An hour of exercise is as exciting as an hour brushing your teeth, and I’m deeply suspicious of anyone who claims to enjoy it.

Even better, the second patient was at the same hotel, a rare treat! A downside was that both seemed to be suffering my least favorite illness: a viral respiratory infection. You’ve heard plenty about my reluctance to give antibiotics when they won’t help.

My good luck held. The first guest had a cough and high fever, probably pneumonia because listening to her lungs revealed abnormal noises. In an otherwise healthy person, pneumonia is the only common chest infection that medical science can cure. So I cured her.

On another floor, I examined a middle-aged man who explained that he had bronchiectasis. This is an uncommon condition in which a small area of the lung becomes obstructed, causing frequent infections. This was another, so I gave him antibiotics in good conscience.

These were satisfying encounters, but there was a downside. Because both were at the same hotel, I finished before 11 o’clock, too early to skip my workout.

Broken Glasses

2020-12-11T05:58:00.001-08:00

An elderly lady gestured me to come in. As I followed, she remained silent, a sign that she spoke no English. If someone doesn’t know “hello” comprehension is generally poor.

“Portuguese.” she said. “Speak Spanish?”

When I shook my head, she took up her cell phone. The first number didn’t answer. The second, after a short conversation in Portuguese, proved unfruitful. She continued dialing. She was Brazilian, and most South American travelers have travel insurance. If I phone the insurance agency’s 800 number, someone will interpret. Unfortunately, my call hadn’t come from a travel insurer but a national housecall service, Expressdoc.

I could phone Expressdoc and ask for the agency’s number, but that makes them uncomfortable. Housecalls is a viciously competitive business.

The lady finally found a multilingual friend, and we proceeded with the consultation, passing the phone back and forth. As usual, delivering medical care was the easiest part. She had broken her glasses. She complained of a headache, but it was clear that she wanted a doctor’s note so insurance would pay for a replacement.

A Prominent Scam

2020-12-07T06:01:00.000-08:00

A guest at the Luxe explained that he was in town for six weeks and needed a disabled parking pass. I told him that was not something I handled. He added that he had the Department of Motor Vehicles form. All he needed was a signature.

I offered to come to the hotel, but – even at half my usual fee – he didn’t want to pay. I could have politely withdrawn, but he might then ask the hotel to recommend another doctor, never a good idea. As I do when it’s an easy service, I told him I would sign the form gratis if he came to my house.

After hanging up, I felt uneasy. Eleven percent of Los Angeles drivers have a disabled parking pass; it’s clearly a scam, and I didn’t want to add to it. What if I had to refuse him? When guests complain after I refuse narcotics, hotel management takes this with a grain of salt, but a parking pass….

You can imagine my relief when I answered his knock and saw that he had only one leg.

The Year of Viagra

2020-12-03T06:20:00.005-08:00

National FDAs in Europe and Asia approve new drugs after deciding that the benefits outweigh the risks. Aware that bad side-effects produce an avalanche of lawsuits, America’s FDA takes more care. No matter how many lives a new drug will save, it wants the risk to be minuscule. This is hard, so our FDA takes a long time to make up its mind.

As a result, other nations often have access to new treatments years before America. Doctors complain all the time, but no one expects the FDA to change.

There was a delightful exception: Viagra, discovered in Britain but first released in the US. It’s my impression that no foreign businessman in 1998 considered his US trip a success unless he returned home with a bottle. My records show forty hotel guests who summoned me with this in mind.

I love visiting guests who aren’t sick. While I have no objection to filling certain prescriptions over the phone, Viagra is a powerful drug with serious side-effects. Experts advise us to examine and educate everyone who wants it.

No one objected to paying for a visit, so I came and asked about the guest’s medical history, performed an exam, and delivered my Viagra education. It doesn’t enlarge the penis; it’s not an aphrodisiac, it won’t prolong intercourse or delay ejaculation. It only encourages an erection. No one failed my exam. One gentleman from Indonesia asked for 5,000 tablets. Suspecting these were for resale, I worried about the legality, but this was no problem insisted the happy pharmacist who called me to confirm.

Tricky Problems

2020-11-29T06:02:00.005-08:00

It upsets me to collect a fee and then send a patient to a clinic or emergency room for care I can’t provide in a housecall. I try to anticipate these.

Many guests phone after a painful accident, hoping I can do an exam and tell them whether or not they have a fracture. Sadly, unless it’s visible to the naked eye, I can’t. It turns out that medical science does little for broken toes, ribs, or noses, and most common fractures (arms, wrist, hand, finger, foot, ankle) are not emergencies. If a guest is willing to wait till office hours, I can make them an appointment with an orthopedist.

Upset stomachs make up the second most common ailment that I hear about. These usually don’t last long, and I carry medicines that help. Stoics often prefer to wait. This is not unreasonable, but the longer symptoms – usually vomiting – last, the less likely that medicine will help. After about a day of vomiting this becomes so unlikely that I send the guest to where they can receive IV fluids.

Abdominal pain is usually benign in a young person but less so as the years pass, and it’s tricky. Entire books have been written on it. I recommend the shortest: Early Diagnosis of the Acute Abdomen by Zachary Cope, a British surgeon. He wrote it in 1921, and revised it every few years till he died in 1971.

You can download it free. He’s a droll and witty writer, easy for laymen to understand.

When the Doctor Needs Your Help

2020-11-25T06:58:00.006-08:00

Almost every hotel guest that I see is working or taking an expensive vacation, so illness is more inconvenient than usual. Everyone agrees that doctors have no magical powers…. except… maybe… if you really need magic…..

What if you’re scheduled to deliver an important speech or attend a wedding or visit Disneyland, and you absolutely can’t be sick? In that urgent situation, a smart doctor might come up with a cure that he or she keeps in reserve for such situations.

Doctors love to help you, but they also want you to feel helped. If we do our best, but you’re unhappy, that hurts more than you realize.

So if you want the doctor to prescribe a placebo make it absolutely clear that you will be disappointed unless you get “something.” This happens so often that many doctors assume every patient yearns for magic. That’s why, for example, giving useless antibiotics for respiratory infections is not a sign of incompetence. Even good doctors do it.

Really, I don’t hold anything back for especially deserving patients. It sounds odd, but if you don’t want a placebo, let the doctor know. Say something like “I just want to know what’s going on. If a prescription won’t help, that’s fine with me.”

That sounds like you’re telling the doctor how to do his job, but many need your help.

Not Again! Again.

2020-11-21T06:11:00.006-08:00

I was minding my own business on a plane returning to Los Angeles when I heard the elderly man in the adjacent middle-seat say: “Victoria... Victoria?.... Victoria?... VICTORIA!!...” Turning, I saw that he was shaking his wife who had passed out.

I informed the flight attendants who produced the traditional oxygen bottle plus a stethoscope and blood pressure cuff and made the usual request for any doctor on the plane. The wife began responding, if groggily. Her blood pressure was undetectable, but engine noise made listening difficult.

By this time, another doctor arrived. She was about forty years younger than I and anxious to be involved. She suspected it might be necessary to land the plane. This is not a decision airlines make lightly. Headphones and a long cord appeared, and, after some delay, she spoke to a doctor on the ground who advised taking the wife to the rear of the plane, laying her on the floor, starting an intravenous line, and observing. With the other doctor leading the way, everyone trundled up the aisle. I wasn’t required.

The couple returned to their seats when the plane began its approach two hours later. The wife seemed all right although she had no memory of what had happened. Paramedics came on board at the gate and led the couple away.

I waved off the flight attendants’ thanks, but they insisted on giving me five thousand frequent flier miles.

What Makes Travelers Sick

2020-11-17T06:02:00.006-08:00

American water.

Travelers worry that our fierce advocacy of the free market includes opposition to government meddling in the water supply. I regularly assure them that all American tap water is drinkable.

American food.

No one believes that Taco Bell or McDonald’s sell healthy food, but foreigners worry that these exotic, colorful substances are toxic. We Americans are warned about eating in nations with poor sanitation; about one in three American tourists in these areas get sick. If we’re careful, our sickness rate drops to… Actually, it doesn’t drop. No one knows how to prevent traveler’s diarrhea. The Swiss get sick when they come to the US.

Air conditioning

Americans accept air conditioning with even more enthusiasm than personal firearms, but most of the world has never caught on. They tolerate it as an odd American custom but believe that air from a machine is unhealthy whether it’s automobile exhaust or a box in a window. When someone gets sick, they turn it off. I wear a suit, so caring for foreign tourists during the summer is a painful experience.

Air Travel

Travelers blame the airline for any illness that occurs within a week of flying. This is not so for aches and pains and unlikely for an upset stomach but true for respiratory infections.

Stress

Vacations are stressful, particularly if children are involved. They miss their friends; they hate the food; they prefer watching TV to sight-seeing; they refuse to adjust their sleeping hours. It turns out that stress makes everything worse, but it doesn’t cause anything, so there’s no reason for the parents to get sick. When they do, it’s a respiratory infection, usually the children’s fault.

Keeping a Child Safe

2020-11-13T06:13:00.002-08:00

On days I don’t go to the gym, I take a brisk one hour walk through my neighborhood.

One route passes an elementary school a mile away. Except for dog-walkers, the streets are deserted at this early hour, but a few blocks from the school the sidewalks gradually fill with children in their colorful outfits and backpacks accompanied by a parent. Passing the school I overtake the adults, often in chatty groups, as they head home.

Parents taking their children to school…. When did that start?...

I entered first grade in Cleveland, Ohio, in 1946. The school was three blocks away. My mother dressed me and showed me the door and, even in the dead of winter, I walked alone. I met friends along the way. I never saw an adult.

No big deal. But halfway through the year I took a test. Afterward my parents agreed that I could attend a special school for gifted children.

It required a six block walk and then a long streetcar ride. I made the trip alone every day. The school had a cafeteria, but, for reasons lost in history, I left the campus at noon and ate lunch, usually a hamburger, at a nearby diner. It cost a dime. Remember, I was six years old. I never regarded this as odd, and no adult I encountered gave me trouble except once on the streetcar when the conductor accused me of not paying the fare (I’m sure I did). When I burst into tears he did not pursue the matter.

It was not all smooth sailing. Years later in Los Angeles on the way to junior high, I encountered a bully my own age who cuffed me around painfully. But it was only one episode.

Another Spiked Drink

2020-11-09T05:43:00.007-08:00

It was one a.m. as I drove Santa Monica Boulevard, but crowds packed the sidewalks in West Hollywood, lining up to hear the latest band. A few blocks beyond, I parked at the Ramada.

A guest led me to the bathroom where her companion lay in the empty tub, clutching a towel and moaning. This was not the first time I cared for a patient in a bathtub or even the tenth.

“We’ve been out drinking,” explained the guest. “But not more than usual, and she didn’t have more than me. Do you think they put something in her drink?”

This was not the first time I heard that – or the tenth. I’m puzzled at how often guests suspect foul play when someone becomes violently ill after drinking.

I examined the patient as best I could without moving her because she insisted she could not move. Afterward I explained that alcohol is a toxin that messes up the brain, usually in pleasant ways but occasionally not. After delivering medication for vomiting, I told her to suck on ice chips and phone if she wasn’t better in a few hours. So far everyone has recovered.

An Exotic Travel Destination

2020-11-05T05:52:00.005-08:00

Tourists come to America expecting a strange foreign land. They usually leave satisfied, but encountering an American doctor is an unexpected bonus, so everyone on the tour gathers round, and I often go about my business in front of a large attentive audience.

My largest consisted of the entire company of the Chinese Peking Opera lined up along the wall of a ballroom in the Hollywood Roosevelt. One of its members had begun behaving bizarrely. I concluded he was suffering an anxiety attack which a tranquilizer might help.

This took place well before Chairman Mao’s influence became passé, so it was likely the Opera’s resident physician had no Western training. Etiquette demanded I treat him as a colleague, so I presented my advice as a suggestion.

After consulting other senior figures, he gave his approval. No one except the interpreter spoke English, so many subtleties were lost, but everyone seemed satisfied, and the entire troupe lined up to shake my hand.

Doctors Are Always Late

2020-11-01T06:22:00.004-08:00

At 6 p.m. on a Friday, I learned that a flight attendant in Costa Mesa had a cold. I prefer not to drive 46 miles during the rush hour, so I promised to be there between nine and ten. That was acceptable. Airline crew are not demanding.

Five minutes later a guest at the downtown Doubletree asked for a visit. This was a bad juxtaposition. Scheduling it for after Costa Mesa meant an arrival time near midnight.

Reluctantly I told her to expect me at around eight. I gave myself over an hour for a 25 minute drive, but traffic was not so bad, and I arrived early, but she was there. The freeway to Costa Mesa was also not so bad, and this time no one answered my knock at 8:30. The front desk was unhelpful.

Airlines have strict rules about sick crew, so this guest required a visit. If I waited an hour and then left, I might get a call on the way home. If she was out partying, I might get it several hours later. I did not acquire my peerless reputation by refusing calls, so I’d have to make the return trip.

As I fumed and paced, the guest returned. I expressed relief, but she did not apologize. She was present at the appointed time, and no one expects a doctor to be early.