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House Calls with John

The patient liked my student so much that she wanted her to accompany me on future house calls, which, of course, was easily arranged. Over several months, the student developed a close relationship with the patient, which proved beneficial to both of them.

In addition to seeing patients in the clinic (and making house calls), I maintained contact with the preceptors who opened their practices to first-and second-year students. The students' time in their preceptors' offices helped them to correlate classroom teaching with real, live patients.

In January 1989, I was asked to take over the practice of one of our preceptors whose National Health Service funding had been revoked. That left the Mt. Moosilauke Clinic in Warren, N.H., without a physician. Because of the poverty of many of the patients, the program was unable to hire another physician and approached Dartmouth Medical School for help. I stepped in to serve this rural population. I often had medical students with me as I saw patients in the clinic and in their homes. In many ways, my years there were among the most satisfying of my career.

It was while I was at Mt. Moosilauke that I proposed a student elective focused on home visits. It was clear to me that students learned much by venturing onto patients' turf. Other family members, pets, the state of repair of the home—all of these elements placed an important framework around the center of attention, the patient. In addition, eliminating the artificial barriers of the white coat and the office or clinic or hospital—which can be threatening to patients—strengthened the true teaching, much of which comes from patients.

I was thus delighted when one of our students, Patricia Ruze (now Chapman), a 1990 Dartmouth Medical School graduate, wrote the dean about her experience making house calls. Here is her letter, slightly condensed:

"Dear Dean McCollum: I am writing to share my enthusiasm for a one-day elective I recently attended. The informal elective is the work of Dr. John Radebaugh, whom you know as a faculty member in the Department of Community and Family Medicine. For some time now,


Radebaugh spent the last few years of his career on the Dartmouth faculty. Above, he plays his ever-present harmonica to woo a wee patient.

Dr. Radebaugh has been exploring the idea of a single-day elective for medical students, which might be called 'Plain Doctoring' or 'House Calls with John.' The elective consists of a full day of visiting four or more families, several visits with health-care professionals in the community, and several readings in epidemiology and family medicine.

"Our day began in Bowler Auditorium for Pediatric Grand Rounds. Radiology was our next stop. The two of us reviewed films with the radiology staff for patients we would see later that day.

"We then proceeded to the depths of the Hospital to the autopsy suite, where a pathology resident presented his gross specimens and his findings for a recently deceased patient. Not unexpectedly, the partially fixed brain tissue revealed a peach-sized necrotic mass characteristic of glioblastoma multiforme. We were later to visit this patient's family in their home in Warren, N.H.

"Dr. Radebaugh and I, with a long list of patients' names and addresses, packed ourselves into his car. Our first stop was New England Industries in Lebanon, N.H., which produces machine parts. Dr. Radebaugh had met previously with the owner of the company, who this day welcomed us and presented us with ear plugs and safety glasses. We had come to see Mr. R.M., a patient of Dr. Radebaugh's who has persistent problems with nasal polyps. Weaving through the maze of giant metal monsters, noisily pounding frail strips of steel into a precise geometry, we found R.M. rolling a drum of industrial chemicals into the plant's back door.

"R.M. told me that his nasal polyps had

been treated surgically several times but continued to reappear and caused him difficulty breathing. The etiology of the recurrent polyps was unclear. R.M. felt that the chemicals he was working with at the plant contributed to the development of the polyps.

"He gave us a tour of the plant. We examined the labeling on many of the drums of chemicals that he was frequently exposed to. R.M. asked me to climb the stairs leading to the operator's station of a machine that chemically and mechanically washed some of the metals used in production. He turned on the machine so that I could experience the sharp odor and harsh racket of his daily working conditions. This was a new experience for this medical student from suburban Concord, Mass.

"We proceeded on to the home of Mr. and Mrs. D.C., a middle-aged, middle-class couple. They were expecting us, and we sat and chatted about his recent hospitalization for COPD [chronic obstructive pulmonary disease]. I examined his lungs and heart, and we gave him a report on the chest films we had reviewed earlier in the day in radiology.

"Our next stop was Mr. T.S., a frail but good-humored 92-year-old New Hampshire farmer whose wife died 10 years ago, leaving him to live alone with his horse team, advanced bilateral cataracts, osteomyelitis, and severe hearing loss. As we approached his tiny, run-down wooden shack nestled in the weeds just off a dirt road, I asked myself how it could be that I have had a full four years of medical school here at Dartmouth, yet have been so successfully sheltered from New Hampshire's poverty.

"My country doctor and I lunched for 50 at the Lebanon, N.H., Senior Citizens' Center. There, I met many septa-, octa-, and perhaps even nonagenarians—most of whom knew Dr. Radebaugh well and had many sores, aches, or pains to report, along with jokes and bits of gossip. It was valuable for me to get a sense of the services that are available in the community. I met a social worker and a community health worker and now feel I have a better sense of what can be available for the elderly in the Lebanon area.

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