House Calls

Renate G Justin, MD

Spring 2005 - Volume 4 Number 4

 

Patients enter my space when they come to my
office; I enter their space when I go to their home. I
am invited into my patients’ kitchens, living rooms,
and lives when I make house calls. Patients learn
about me by observing the ambience of my waiting
room; I learn about them by observing the colors,
furnishings, art, and books in their dwellings. Once
in their home, I may perceive, within minutes, what
eludes me in the examination room. When I pick my
way carefully to an elderly man’s bedroom, along a
narrow path bordered on both sides with walls of
piled-up newspapers, I at once understand the se-
verity of his neurosis, which escapes me when I
concentrate on his coronary artery disease in the of-
fice. A glance into the refrigerator, while getting a
cold drink of water, tells me more about my patient’s
diet than I will find out by exhaustive questioning.
When we stop making house calls, we lose the inti-
macy of the relationship in which doctors and patients
alternate being hosts. Displaying family pictures on
the desk is not exclusively the doctor’s privilege; pa-
tients also can share photographs when the physician
visits in their home. The balance of power in the doc-
tor-patient relationship shifts by changing the locale
of the encounter from office to home.
House calls can be surprising, frightening, sad, and,
at times, inspiring. House calls make me feel humble
because they teach me under what adverse condi-
tions the human spirit can survive and even thrive. I
also learn things about my patients of which I stay
ignorant if I only see them in the office. A grand
piano in the home of a lady who has hypertension
and is no longer allowed to drive because of epi-
lepsy leads me to ask her if she would play for me. I
am deeply moved by the beauty of the music and
her expertise. Both of us momentarily forget the rea-
son for my visit and revel in the joyous sound.
House calls can also arouse pity. A childless couple,
Mr and Mrs Peters, have been patients for several
years. Both hold jobs in spite of Mr Peters’
excess use of alcohol. One sunny day, a neighbor of the
Peters’ calls to say that she is concerned about them.
Their car is in the driveway, and she has not seen
either Mr or Mrs Peters leave for work. During my
lunch hour, I check on my patients. Their house looks
disheveled, beer cans scattered among the weeds in
the yard, the door ajar. The unkempt appearance of
the yard, however, does not prepare me for the scene
that confronts me as I enter. Two human forms, on
iron bedsprings, covered completely with worn
sheets, rats scuttling across the floor, beer bottles and
empty cans piled high, enmeshed in spider webs. I
gently pull back the sheet from the head of one of
the prone figures, expecting a corpse. Under the sheet
lies Mrs Peters; the other sheet covers Mr Peters. Both
are breathing air that reeks of alcohol, both passed
out. Carefully I replace the sheets, as pity and pessi-
mism overcome me. I realize that my ability to help
this couple is minimal, the scope of their problems
overwhelming. I am surprised, because, prior to this
visit, I did not know that Mrs Peters, as well as her
husband, has severe difficulties with alcohol; know-
ing this makes it clear to me why controlling Mrs
Peters’ blood sugar has been unusually difficult. When
I bill Mr Peters for the house call, he objects. He is
unaware that I had been to his house; only my accu-
rate description of the scenery convinces him that my
bill is justified. During this discussion, my offer to sup-
port him and his wife in any and all efforts to overcome
their addiction is firmly and politely rejected.
The element of surprise is ubiquitous in house calls.
Sixty-eight-year-old Mrs Gerad has been in chronic
mild heart failure for months. She leaves a message
with the office nurse that her shortness of breath is
getting worse and is told to expect me after office
hours. When I arrive, Mrs Gerad is lying in bed, ob-
viously dyspneic, with distended neck veins. I suggest
she sit up to ease her breathing and therefore put a
sofa pillow under her back. While fluffing up her
bed pillow I feel something hard, a loaded revolver.
I am scared and taken aback, but on further reflec-
tion, I realize that this weapon is meant to protect
my helpless patient against unwelcome intruders. It
might well have discharged while I rearranged the
pillows, but I leave it where I found it, and resolve
to be more careful in the future.
Usually I do not make house calls to a stranger.
However, a concerned neighbor is desperate and
insistent; therefore, I tell her I will come. From the
appearance of the small, ramshackle house, I con-
clude that the owner has been sick for some time.
The portly, white-haired lady who called me greets
me on her doorstep. She reports that her neighbor
has been moaning loudly all night and adamantly
refuses to go to the emergency room.
My knocks go unanswered. When I open the door
slowly so as not to startle anyone, a strong smell of
vomit assails me. I leave the door open to let in some
fresh air; it is too early in the year to worry about
flies following me in. The curtains are drawn, but a
weak bulb sheds enough light to reveal a man, about
sixty-four, in bed with a shotgun leaning against the
bedframe. He greets me loudly:
"Who the h... are you?"
From the tenor of his voice, I conclude that he
is deaf and therefore respond equally loudly that I
am a doctor who has come at his neighbor’s request."
"D... meddler," he comments. After my eyes adjust
to the dim light, I see the outline of the man’s greatly
distended abdomen under the sheet. He is undoubt-
edly obstructed, given the pain, distention, and
vomiting. "Do you want me to examine your stom-
ach?" I query. He pulls down the sheet. He is fully
dressed but has unzipped his pants to allow for the
distention. I do not have a chance to lay a hand on
him because he starts to retch and moan. When, ex-
hausted, he lies back, he looks at me as if he has
forgotten our previous exchange. In a hoarse but
loud voice, he says: "What do you think you are
doing here? Get the h... out."At which point, he
starts to reach for his gun. I hasten to tell him again
who I am and that I have come to help ease his pain.
"None of your d... business!" In my bag are a few
demerol and codeine tablets, which I leave on his
nightstand next to a glass of murky water.
"You may take these if the pain gets too bad; your neighbor
has my telephone number if you want me to return."
He responds: "I told you to get the h... out of here."
I do just that.
I never heard from the neighbor nor from the old
man with the gun again. That he could not accept the
help I offered, but insisted on suffering alone in his
smelly, semi-dark room made me sad, but also I was
frightened by his gun, his anger. Driving away from
that scene, I wondered about this man’s life, his job,
his family. What experiences made it impossible for
him to accept help, or even to acknowledge that help
was being offered in good faith? Also I mulled over
my own actions. Would a different approach have
been more successful? If I had moved the gun out of
his reach when I entered, I would have been less
threatened by him; and perhaps if I had stayed longer,
he would have relaxed more in my presence? Should
I go back and try again, or was it now too dangerous?
Years ago, a young woman called me to the home
of her grandmother, who was in pain. The old lady
lived in a one-room, wooden cabin. When I entered,
she was stretched out on a narrow bed, softly moan-
ing, but she greeted me in a warm, welcoming manner.
The source of her pain was a large, creeping cancer,
that had eaten away part of her face. She was small,
frail, and her thin body left enough room for me to sit
down on the edge of her mattress and hold her hand
while I explained how to use the medicines I left for
her. Her granddaughter took notes, and when I was
finished, we three women held hands silently for a
few minutes in that small cabin. I left after a gentle
hug with both the young and the old woman, and
with a renewed respect for, and joy in the human
spirit. The dignity and quietude with which death was
expected by this woman was inspiring; she had lived
her life and left no major tasks unfinished.
It was different for Helen, the young mother who
was dying of breast cancer. She struggled to stay alive;
she wanted to celebrate her son’s third birthday. She
cried, inconsolable, in my arms, unable to accept her
fate. Before she died, she asked me to see her son,
Thomas, regularly, whether or not he was sick. I prom-
ised. About four years after Helen’s death, I once again
visited Thomas, now six years old. He knew me well
and, on this occasion, introduced me to his
"new mom." He showed me the house into which he
had recently moved with his dad and his stepmother.
Once in his room, he sat down on a bean-bag and told me
to sit in the rocking chair. Soon he inched closer and closer
to the rocking chair, and then, taking a photograph of
his mother off the shelf, he sat in my lap.
"Tell me about Mom."
I had known her for longer than he had
and could talk to him about how pretty she was as a
teenager, and how smart.
"She used to come to my office even before she knew your dad.
After college,your mom got a good job and then met your dad.
She was a happy, lovely bride, and Thomas, your grand-
parents loved your dad."
I told Thomas about the breast
cancer and how sick his mother had been during the
chemotherapy treatment, but that she and dad really
wanted him to become part of their family. He was
born when his mom felt better.
"Your mom and dad had two wonderful, happy years with
you until mom got sick again and died."
Thomas was now snuggled
in my arms, and we rocked silently for a while; then
he jumped down and went out to play. I sat there
alone, thinking about his lovely young mother who
did not want to die. Then I left the house, content that
Thomas’ dad had found a new partner and a
"new mom" for his son. This family no longer needed to be
followed by me. Thomas and his father had recov-
ered after Helen’s death. The new family was well
established; the old, deep wounds had healed. After
this visit, I stopped mourning for Helen. The task she
had given me, to check on Thomas, was completed. I
could let go, say my final goodbye. Home visits can
be healing for physicians as well as for patients.
House calls are not part of today’s urban medical
practice; not cost- or time-effective, they have all but
disappeared from the daily routine of physicians.
There are occasional articles urging the revival of
house calls, and even a movement to create yet an-
other specialty, home-care doctors, but it is likely
that physicians will be dispensing medical care in
hospitals, emergency rooms, and offices rather than
in the home during the next few years. Having prac-
ticed during a time when house calls were part of
every day’s schedule, as well as more recently, when
I did not make any house calls, I feel strongly that I
dispensed better patient care when house calls
were part of my work.

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