“Doctor, why are you staring at my breast? Is something wrong?” Darlene spoke free of embarrassment or admonishment.
Her questions interrupted my concentration as I listened intently to her heart murmur. As a fledgling doctor for the first time away from the protective network of a teaching hospital, it was difficult to quell my excitement. I was so thrilled to be diagnosing rheumatic heart disease that I gave no thought to the person or the body that lay before me. Let me put the event in context to allay any doubts the reader may be entertaining.
During my final year of internal medicine training in Boston, my wife and I were living on a tight budget. Having trouble making ends meet, I responded to a request sent to all members of the Massachusetts Medical Society for volunteers to make house calls on indigent residents of Boston. Actually “volunteer” wasn’t quite the correct word for each patient would be required to pay the sum of seven dollars. Nominal or not, the payment would feed us for two days. I signed up.
Actually I faced the potential new responsibility with trepidation. From the moment of my first involvement with a patient eight years before as a second-year medical student in 1946, I had always the security of a backup of a huge cadre of teachers and more highly placed residents, and indeed, the vast support system of one medical school or another. Now for the first time I would be out in the cold unforgiving world on my own. I and I alone would be prescribing for a patient with no one looking over my shoulder to monitor my decisions. It was scary.
Lo and behold on the following Saturday afternoon came a call from the dispatch center asking about my availability. Receiving a positive reply, they gave me the address and directions to a run-down section of Back Bay, Boston. I remember that my heart was pounding as I contemplated my mission.
Twenty minutes later I arrived at a two-story clapboard house. Four warped steps led to the front porch. Faded yellow paint was peeling around the door. The doorbell made no sound so I knocked. A six-year old girl answered and led me up one flight of stairs. The sparse furniture was shabby. The mother, who was obviously the patient, reclined listlessly in a cotton nightgown on a couch. I gestured to her not to get up; she appeared grateful. I shook her moist, flaccid hand. She forced a near-motionless smile.
My first dilemma was where to sit. I pulled a metal chair from the kitchen and sat opposite my patient, a comfortable and yet not unfriendly distance away and began my history taking. Her daughter sat at a nearby table with a coloring book.
The patient, Darlene, was an attractive twenty-three-year-old, a single parent. She worked in a laundry; her hands were red presumably from contact with strong soaps. She had called “the service” because of a severe sore throat and fever. Aspirin had done little for her. Inquiring further I learned that twelve years before, she had been hospitalized for rheumatic fever. She was unaware of any after effects and had no cardiac symptoms. I spent another quarter of an hour compulsively documenting a complete history. Her family had rejected her when she had become pregnant out of wedlock.
My next problem was where to examine her. I could have done so as she sat on the couch but this was in front of a bare window. Instead I helped her into a disheveled bedroom. She sat on a double bed and started to take off her nightgown; I indicated that this wasn’t necessary. I placed my medical bag next to her and started the physical examination. The first abnormal finding was an inflamed throat with patches of pus on her tonsils, an obvious “strep” throat. So far so good. My training was paying off. As I took out my stethoscope, again she started to raise her nightgown. “Oh my!” I thought. “This is far different from a hospital setting with a nurse in attendance or at least nearby.” I began listening to her heart sounds. Within a couple of minutes Darlene interrupted my routine with the question that started her story.
If I was embarrassed, this was not the explanation of my excitement for I had heard a loud heart murmur indicative of rheumatic mitral insufficiency, in lay terms, a leaking valve. Such a great teaching case! I wanted only to demonstrate my findings to the medical students working in the ward but, of course, this wasn’t a ward and there was no one around to teach.
I compulsively performed a fairly complete physical examination, but certainly no pelvic exam. I couldn’t help wondering if Darlene pondered what a breast exam had to do with a sore throat or even a heart murmur. I was relieved to return to the living room.
“You have a strep throat,” I said. I doubt if I weighed the impact of my medical jargon as I continued, “You have rheumatic heart disease. We have to treat your streptococcal infection especially so to prevent the streptococci from spreading to your heart valves. You must take penicillin pills four times a day for ten full days in order to do that. Don’t interrupt the medicine even though you ought to be feeling normal within thirty-six hours.” I was in high gear as though I were confidently completing the last question of a medical school exam. I wrote out a prescription for forty penicillin tablets, which she could obtain for a minimal fee.
As I rose to leave, Darlene went to the kitchen where she took a cookie jar from a closet. She reached in and extracted its contents, seven, crumpled dollar bills. So many thoughts flashed through my mind. “Was this all the money she had?” “Could I take three? Would that humiliate her?” And finally, “Had I already not been amply rewarded by the validation of my years of training? Wouldn’t taking money from her tarnish our relationship”? Never before having received a fee from a patient, I was at a loss for an answer.
I put the seven dollars in my pocket, and after an approving glance at the stick-figure drawings by the little girl, I departed.
I’ll never know if Darlene followed my instructions or whether in later years she had her valve successfully replaced or whether her daughter went on to become a famous artist.
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