Bird Cage

Tomorrow morning I will make a run out to the suburbs to fetch a bird cage. A veterinarian friend of my sister will be waiting at her clinic to hand it over. The cage is for one of my patients, a lovely woman of 75 named Kate with a history of bleeding brain aneurysms who keeps a large bird in a small cage. The cage sits in her parlor window right beside the front door, so I see it every day when I walk in. There is barely enough room for it to open its wings. It has one narrow perch and stoops like an old man waiting for a bus. Whereas I have a bleeding heart for anything that draws breath, Kate has little empathy for caged things. I thought about asking her to part with it, but she loves it in her way. The bird is her company. From the piles of mail and personal papers in the parlor, she spends most of her time in there. The bird watches the window and she watches the bird. So rather than trying to find it a more hospitable home, I decided to make her home a bit more hospitable. Hopefully, Kate will accept my offering.

This brings to the fore how housecalls are different than typical doctor visits. I am privileged to so much more information about my patients than if we were meeting in a clinic or a hospital. I walk right into their world. I learn a tremendous amount in two minutes, very little of it medical. How organized is the environment? Are there great-grandchildren running around? How many cigarette butts are in the ashtray? Do they own a treadmill or exercise bike and is it doubling as a coat rack? Is the outer door of their apartment building bashed in? Can I walk right up to their inner apartment door? In one case, could I walk right into her apartment and then her bedroom when she failed to answer the bell? Are there family members drinking beer at 10am and watching The Price is Right? Is all the food in the refrigerator bad? Are there stacks and stacks of unopened incontinence supplies? The good news is that I can view my patients from a closer vantage and interact with them on a much more personal level. The bad news is that what I ought to do with this information, where my role starts and stops is easily blurred.

The bird cage is one example of the blurring of professional boundaries. Another is when I started visiting an accomplished photographer with emphysema who is now living in a warehouse, a real SoHo living space as he called it, that he is slowly converting to a proper living environment. It was drafty and dusty and cluttered with books, prints, developing equipment, and all manner of odds and ends, a very bad set-up for someone with very bad lungs. I started coming in on weekends to help drywall his bedroom. We became friends. But his expectations on my time kept escalating and eventually I had to back off. Now during visits, things can be a bit awkward. Early on in my practice, I took on a lot of responsibility for referring my patients into community support services, specialty care; I made a lot more phone calls to family members. I wrote a lot more letters. Now I find myself doing less. The Company supplies a modicum of support for extending the focus of care beyond the visit itself. There are coordinators who each carry about three physicians, but they are overwhelmed with handling very basic duties, like dealing with pharmacies and handling patient calls. Asking them to serve as social workers and community liaisons is unfair. I have brought my concerns to the founder and CEO. I petitioned for an employee who could serve as an expert on community support services, making sure vision impaired patients are hooked into Lighthouse For the Blind, or that families of patients with dementia are linked up with day programs that offer sliding scale fees. But he was uninterested.

For a recovering alcoholic and addict, accountability is extremely important. Many of us lived with very little of it for a long time. We have to unlearn the tendency to put our own convenience first and foremost and become accustomed to keeping our promises. A big part of that is realizing that we should not promise too much. As much as we may want to be heroes and save everyone, nothing is accomplished when we fail to show up. While others figure out that they still cannot count on us, we internalize the same message about ourselves, and the downward cycle continues. The key to success is starting small and slowly building. As much as I may want to fix all of my patients' problems, my time and ability are limited. I can find a bird cage. I can make a few calls. But I must be sure not to take on more than is reasonable.

Also important is that I try to bear in mind why I am choosing to do something. By bringing her a new bird cage, am I really helping Kate? Perhaps I am helping the bird, though I cannot know for certain what the bird wants. Mostly, I am addressing my own feeling of discomfort when I walk Kate's parlor. I should bear this in mind when I offer her my "gift."