by Peter Palmieri
This was the Grand Prize winning entry at the 2015 Dallas Medicine+Literature writing contest.
The highest praise I received as a doctor came from a steely-eyed, reticent cowboy near the start of my career. He sat in the mommy chair of my exam room, his three-year old daughter squirming on his steady legs, and had up to now issued only yes-sirs and no-sirs in response to my queries. It was while I was washing my hands before examining the little girl that he uttered it.
“When I tell my friends what you did that night, none of ‘em can quite believe it.”
It caught me off-guard, and luckily I could think of nothing to say in response. So for once, I respected the solemnity of the moment with the silence it deserved. I glanced at him as I dried my hands with a paper towel and nodded to acknowledge the compliment. His eyes were fixed on me as if he were still trying to size me up, a look of astonishment as much as of regard stamped on his features. “Honest to God,” he added, as if to drive the point home, and never brought the subject up again.
I had just moved to Texas with my wife and two young children and settled into my new practice with the earnestness of a freshly-minted pediatrician though this was not my first job. For three years I had worked in a community clinic in a gang-ravaged neighborhood on the South Side of Chicago to fulfill an obligation with the National Health Service Corps. Now, in my sleek office half-way between Houston and Galveston, in a building unscathed by the stray bullets of countless drive-by shootings, I was overwhelmed with gratitude: I was thankful for the daily sunshine, for the vastness of the sky, for smoked brisket and juicy watermelons, for the civility of my new neighbors, the collegiality of my partners, and, most of all, for the trust of the families of my new patients.
So when I was paged shortly after dinner that night, you might say I was primed for the choice I was about to make. The woman on the other end of the line explained that her daughter had become feverish that afternoon, refused to eat or drink and was acting downright ornery. I asked a half-dozen questions to which the mom gave curt answers before she finally said, “I just don’t like the way she looks. I’ve never seen her this way.”
From early in my career, when wrestling with choices of patient management, I’ve often engaged in a form of mental consultation with my former professors. I call them the peanut gallery. I ask myself a question and immediately they start murmuring their opinions, their admonitions, their barbed critiques. Standing with the phone pressed to my ear, I began to hear the echoes of the voices of my mentors. As the mother’s words sunk in, one professor reminded me that you can’t see what a kid looks like over the phone. “It doesn’t matter what you know,” another one warned me. “The best doctor is the one that gets out of bed in the middle of the night to check on his patient.”
“What hospital do y’all go to anyway, Texas City or Clear Lake?” the mom asked.
I hesitated in answering. The truth was that, being new to town, I had yet to be granted hospital privileges. If a trip to the hospital were required, I’d have to endure the embarrassment of having to call one of my partners.
That’s when I recalled the words of Dr. G., the eldest of my mentors – a man with experience so deep and broad one could forgive his propensity to nod off in nearly every conference. “You can learn more about a family in a single house call than in five years of office visits,” he would say in his baritone drawl. “The Italians make the best coffee,” he added with a droll smile, no doubt forgetting that he had used the line repeatedly with the same group of pediatric residents.
“Where do you live?” I asked the mom as I flipped open the laminated map I had been consulting almost every day since our move.
“Just outside of Alvin,” she said.
“Alvin,” I repeated as I traced a finger on the map. It didn’t seem too far away from my apartment complex in League City.
“Texas City or Clear Lake, it’s about the same for us,” she said.
“I was thinking… I can come out to you.”
“I can make a house call.”
There was a pause. “We’re out in the country.”
“Just outside of Alvin, you said.”
“You know where Alvin is?” she asked.
My cheeks got warm. At that point of my career, exhibiting ignorance of any kind to my patients was a predictable source of embarrassment. Already, I felt a tinge of regret for even suggesting something as eccentric as a house call, but there was no turning back now – not without sounding foolish. “I’ll need directions,” I said.
“You better talk to my husband.”
I barely made out a hushed exchange of words before a man’s voice came over the line. “Hello, doctor? Listen, we can take her to the hospital,” the husband said.
“Oh, no. I’ll be happy to come out to you,” I said trying to sound casual, as though I did this all the time. As though I had ever done a house call before in my life.
I jotted down the directions on the back of an envelope, not knowing that F.M. stood for Farm to Market road, not sure if I could spot a bayou in broad daylight not to mention after dusk. Once I hung up the phone, I realized I didn’t even own a real doctor’s bag. I stuffed my stethoscope, otoscope, a prescription pad and a few tongue depressors in a monogramed canvas briefcase I had received as a graduation gift at the end of residency. Debated whether I should wear a sports jacket but decided it was far too muggy for that. Besides, I didn’t even have a real doctor’s bag so who was I trying to impress? I kissed my children goodnight and told my wife not to worry, I’d be right back, and by the way, could I borrow her car? A silver Mazda looks more professional than an Aztec-Red Nissan Sentra, even if purchased second-hand.
I headed west on 518 then hung a left on 528. Went several miles before passing the enormous Dodge dealership. So far so good. Soon, ever larger spaces separated the businesses on either side of the highway until there were no buildings at all and the sky turned a dark indigo, the darkness draping around the car’s beams on the road ahead.
I popped the Andrea Bocelli CD out of the car’s stereo and the loud buzz of static startled me. I dialed down the volume and began pressing each of the preset buttons on the radio in sequence, different tones of static whirring on each one. Apparently, my wife hadn’t had time to re-program the stereo since the move. I guess we hadn’t quite settled into our new routine.
I held the “seek” button on the receiver and sent the numbers on the green digital dial spinning until they settled on a Mexican station. A ballad was playing, runs of accordion filling the spaces between the harmonized vocals, a snare drum and the thumping of a tuba keeping time. It seemed as if they always played the same song when I stumbled on these stations, as though all the Mexican deejays had been given just one record and stern instructions to play nothing else. A tinny brass section jumped into the fray to complete the cliché.
I pushed the button again. A preacher was delivering his sermon over the strained chords of an organ that sounded like it might belong in someone’s living room – the kind of home decorated with porcelain clowns in mirrored cases and crocheted cushions on the sofa – the ever-present smell of cat dander and boiled cabbage wafting in the air. On the next try I landed on The House of the Rising Sun. It made me think how I could never get that strumming pattern quite right on the guitar. Maybe if I practiced it a little more…
Who was I trying to fool? I mean, really, what gave me the right to burst into someone’s home in the first place? And what exactly did I plan to do when I got there? With a stethoscope and a tongue depressor, for crying out loud!
Some lights appeared beyond a bend in the highway. I drove past a few brick homes and then some larger buildings: a muffler shop, a Dairy Queen, a fenced-in self-storage. In front of a high-school, a spot-light lit up a tidy wooden sign that proclaimed, “Home of Nolan Ryan”. The ball atop a water tower had “Alvin” painted across it in a decidedly reserved font.
I passed the center of town and turned west at the intersection past the Baptist church with the steeple that looked like a giant hypodermic needle sticking out of a megaphone. The highway gave rise to a two-lane country road. Five miles down, the road narrowed and shallow ditches appeared on either side. I lightened my thrust on the gas pedal and focused on the numbers stenciled on the mailboxes perched atop bare wooden posts by the side of the road.
The driveway to the home was packed dirt with patches of gravel filling mud-holes. A large diesel pick-up was parked under a car-port, a retractable aluminum ladder in its bed. The home was a bungalow in pale yellow aluminum siding, with a rocking chair and an Adirondack on the front porch.
The front door opened as I cut the engine. A man stepped out on the porch, thumbs hooked on his leather belt, wearing a plaid cowboy shirt with the sleeves rolled up over his thick forearms.
“Mr. Bowen?” I said as I walked towards the porch, ersatz doctor bag in hand.
He tipped his head. “Trouble finding the place?”
“Not at all.”
His gaze shifted from me to my wife’s car and back again. I should have worn that sports coat.
“Come on inside,” he said.
The entrance led into a narrow, dimly-lit living room. The patient was sitting in her mother’s lap, on a rolled-arm burgundy velvet sofa. The woman had a chiseled facial bone structure, with narrow lips offset by doe-like eyes. When I introduced myself, she clenched her child with both arms as though the toddler might spill out of her arms. When the child saw her father approaching, her arms came up, pudgy fingers spread open. Her father reached down and scooped her in his arms. The mother smoothed her jeans, got to her feet and rounded the sofa as her husband settled on the spot she had just occupied.
I reviewed the child’s medical history, the mother providing each answer with a shake of the head or a shrug of the shoulder as if to underline her perplexity, the father, gaze focused on the wall behind me, occasionally nodding in agreement. At first glance, the child didn’t look particularly miserable. In her father’s arms she beamed a coquettish irreverence. At one point, she squared her narrow shoulders, brushed a few strands of fine blonde hair from her face with repeated strokes of her flat palm then buried her face in her father’s chest when I smiled at her mannerism.
If you don’t know what your patient has by time you’re done gathering the history, one of my attendings used to say, by golly, you’re in trouble. My apprehension was growing. None of my questions provided any clue as to the source of the child’s fever.
“Have you noticed a rash?” I asked as I pulled my stethoscope out of my bag.
“A ra-ash?” the mom said. “Nah, no rash.”
Performing a physical exam in pediatrics is part fact-finding, part performance art. It is imperative that the pediatrician execute each act with deliberate calm under the parent’s ever-watchful eye and, whenever possible, a modicum of dexterity so as to assure all parties of the physician’s competence and skill. My movements were well-practiced and ordinarily smooth, but in this home, away from the aseptic security of an examining room, each motion acquired the heavy somberness one feels when walking through an ancient cathedral. Even when I conducted my review of the medical history, I sensed the slight drop in confidence an athlete might feel when not on his home turf.
This was someone’s home. I was a guest. The furnishings, the framed photographs on the wall, the musket hanging over the mantelpiece of the fake fireplace all spoke of a family’s history, of their individuality. There were no medical record numbers here, no charts stuffed with letters and documents, no standard office procedures to befuddle the patient, no preconceived role-playing – just real human interaction.
When I raised the back of the pajama blouse to listen to the child’s chest, I noticed that her skin had a rough, bumpy texture. I asked the mother if she could turn on another light.
“I think she’s getting a rash,” I said. The father glanced at his wife and frowned. “I bet it’s more prominent in her private parts,” I half-stuttered, the pitch of my voice betraying my excitement. I couldn’t believe my luck. I had a diagnosis after all! Sure enough, her inguinal area had a pink blush peppered with red goose flesh. “You mentioned she hasn’t been eating. I bet her throat hurts.”
“She didn’t say so,” the mom said. “Chloe honey, does your throat hurt?”
The child pressed her lips together and shook her head.
I tore the paper wrapper off of a tongue depressor and asked the father to lay the child on the sofa. I wanted him to see this. I needed a witness.
With some effort I was able to pry the child’s mouth open and shone the light of my otoscope on the back of her throat. “Just look at that,” I said. The back part of the roof of the mouth was fire-engine red. The father nodded. “See her tongue? We call that a strawberry tongue.”
“What does she have?” the father asked me.
I removed the tongue depressor, rotated the otoscope switch to the off position. “This is scarlatina. Scarlet fever.”
“Scarlet fever?” the mom said. “Isn’t that…bad?”
“Easily treated,” I said. “Not to worry.” I tried to assuage her angst with my canned spiel on strep infections. At the time, I still subscribed to the belief that nothing was more reassuring to a patient’s family than a physician’s demonstration of his scholarship.
“I guess that explains it,” the father said.
“Her skin might peel in about a week, especially on the palms and soles,” I said, flaunting my forecasting aptitude in case my diagnostic sagacity had not impressed enough. All that was left to do was to call in a ten-day supply of Amoxicillin.
The mother brought me a refrigerator magnet in the shape of a giant Band-Aid with the phone number to a 24-hour pharmacy. With the father listening in, I had to spell my last name twice to the pharmacist who asked if I was new to the area, and would I mind reciting my DEA number so they could have me on file.
When I hung up the phone the father asked me, “So what do I owe you?”
“Oh nothing,” I said.
“What do you mean? You come all the way out here and done your job.”
“Really, it’s all right.”
“Not all right by me. I like to be squared away,” he said.
I hadn’t even thought of this part. “The thing is, I really can’t take any form of payment. I don’t have the billing codes or even a receipt book.”
The parents of the child exchanged a baffled look. “Don’t need a receipt,” the father said.
“Tell you what,” I said. “Bring her by the office to see me in a couple of days. I’ll just bill everything together.” I was rather proud of myself for making that up on the spot. I zipped my bag shut and got to my feet.
“Can I get you something at least?” the mother asked.
“Throw on a pot of coffee,” her husband said before I had a chance to reply.
I could almost see Dr. G. grinning at me through his bristly mustache, telling me to put the bag down and drink the damn coffee. Give them that satisfaction.
“A cup of coffee would be great,” I said.
The father and I sat on the front porch, me on the rocking chair – the Adirondack was clearly his seat. The smell of hay mixed with the aroma of the coffee to create a surprisingly agreeable effect.
“Nice place you have out here,” I said.
The man narrowed his eyes and shifted in his seat. “It’s a long stretch of highway,” he said.
I drove home with the window rolled down, feeling giddy. Swung my arm out of the car and let the wind push back on my cupped hand. A man with a grave voice introduced himself on the radio as the spokesman for an attorney, and repeated a phone number countless times, imploring me to call if I had unpaid medical bills due to injuries suffered in the work place. I scanned through several stations (that lawyer’s phone number now stuck in my head) until I heard John Denver singing about coming home again to his old farm. And it made me think there must be no better feeling than finding the place where you belong. I felt a twinge of envy and wondered if after all my schooling, after the endless nights on-call and grinding Emergency Room shifts, after travelling half-way across the country, had I finally found a place where I belonged? I told myself not to think about it so much and just enjoy the moment. Tonight, I was the doctor I had always wanted to be.
I’ve made a few more house calls since that night, each rewarding in their own way. I’ve learned that from a patient’s perspective, respect and sincere concern trump diagnostic acumen every time. That the practice of medicine is first and foremost a personal interaction despite all the high-tech wonders doctors have at their disposal.
And I’ve also gotten bogged down, from time to time, in the drudgery of medicine: the interminable documentation on electronic health records, the reams of pre-approval forms to fill out, the fickle regulations to comply with in an ever-expanding bureaucracy. It is in these moments that I think back to that night on that long stretch of highway, and I wonder if a soft-spoken cowboy from Alvin still tells his unbelieving friends about the young doctor who made a house call late one summer night.