House Calls with John
The students were pleased to have an opportunity to work with live patients and soaked up information like sponges. Among many other lessons—such as the importance of caring, of learning to listen to patients, and of not being hasty with advice—I tried to teach them (including by example) the value of home visits.
Occasionally, a house call would uncover a problem that could only be solved outside the parameters of medicine. The visiting nurses once asked me to see a family that lived in a rural area south of San Jose. In a small house, surrounded by high raspberry bushes, I met a middle-aged woman who had just received a notice saying that her welfare benefits were being canceled and that she had to find full-time work immediately. She was distraught, for she was the only support for three retarded children, all in their twenties, who were ambulatory but could not support or care for themselves. They would have to be moved into an institution! She said she'd take her life before she would allow that to happen.
I said I would try to persuade the welfare department not to drop her from its rolls. Hoping this was not an idle promise, I met with the visiting nurses to plan our action. We calculated that putting three retarded children in an institution would cost the county far more than the present welfare benefits, which allowed the mother to care for her children. After a few more house calls, we got a date for a court appearance. The mother, her three children, a visiting nurse, a social worker, several welfare department representatives, and I were present for the hearing. Our arguments persuaded the judge to order continuation of support for the mother. I was pleased with the outcome of this unusual situation. To my mind, it is important not to overlook social problems that can often complicate medical care.
A new challenge soon arose for our family practice clinic. It became a refuge for AIDS patients from San Francisco who felt unwelcome elsewhere. Word spread that ours was a caring program. I recall one such patient, a Mexican-American, who was referred to me by the visiting nurses. Though he was in the final stages of his illness, he wanted to continue home care. He was in no pain but was emaciated and depressed.
"Our house calls made us aware of environmental problems. Frequently I saw patients who had developed sudden asthmatic attacks when planes spraying pesticides flew too close to their homes. One patient died of toxin exposure."
On my second visit, he voiced a desire to visit his brother in Hawaii; would we allow him to do so? I discussed the idea with his family and the home-care nurse, and we agreed that he should go. He made the trip and returned two weeks later, obviously much happier after a very satisfying visit with his brother.
Soon he was on a hospice regimen, and within two weeks of his return he was in a terminal state—semicomatose and unable to eat. I was called to his bedside late one night, found him close to death, and stayed there for the next few hours. When he died, the family called the undertaker, who upon arrival realized this was an AIDS patient and refused to accept the body. "If you refuse, your name will be publicized all over the San Jose papers," I threatened. "There are no risks to you as long as you wear gloves and are careful with needles." It did not take long for the undertaker to decide to cooperate. I visited the family twice in the succeeding weeks to support their grieving.
Meanwhile, Stanford had decided that the
Division of Community and Family Medicine would be placed under the Department of Medicine. I was concerned because the Department of Medicine valued research publications more than the service and educational aims that were a priority for me; I had published only five papers during my entire career.
While exploring other opportunities in medical journals, I saw an ad for a family physician at Dartmouth Medical School. My career had started in New England, and both Dotty and I had family back East. More important, I liked the sound of the program. I applied and was invited to come for a visit. We were well received by the faculty, which ran a primary-care clinic and a preceptor program for medical students. Once again, I did not relish the thought of leaving my patients in San Jose, but I was eager about the chance to promote teaching and service opportunities at Dartmouth.
It was a chilly 10-degree day in January 1986 when we moved to Hanover. My colleagues in the clinic included a seasoned family physician, a family physician who had a half-time research project, and a former dean of the Medical School who was an internist.
One of my first students was an African-American woman from New York City who was in cultural shock from the transition to the mostly white community of Hanover. She seemed uncertain of herself in the clinic, and I tried to take extra teaching time with her. She accompanied me on some house calls, one of which was to the home of a former nurse who had rheumatoid arthritis and was housebound in a second-floor apartment.