The curly-haired man, his husky 6 feet, 4 inches clothed in a brown sport coat, white shirt and plaid slacks, knocked on the ranch house door. "May I come in?" he yelled. "I can't hear your feeble voice."
Hefting a large black bag, he entered a small, cluttered living room where a tiny, white-haired woman in a blue pants suit sat in a corner easy chair. Her nearby cane and television channel selector indicated she rarely left the spot.
The man chided her: "Your lungs are all shot and yet you keep this house so cold--it's cold right now!"
"Well," said the old woman, obviously used to this repartee, "you left the front door open."
It could have been nothing more than a spirited visit between old friends, except that the man was a doctor and he was making, of all things, a house call.
This was not Marcus Welby, the television character often jokingly referred to as the last American doctor to make house calls, but Dr. Marcus Gartner, one of a number of real-life West Coast physicians who are part of a startling comeback for what most doctors consider a relic.
When the nation was younger, towns smaller and transportation more primitive, doctors often went to their patients' homes for the sort of jocular visit enjoyed by Gartner, 45, and his patient, Jane Gagnon, 80. But the automobile made it easier for patients to travel, and the population boom deluged the limited numbers of doctors, who soon found that spending an hour to reach and treat just one patient was wasteful and expensive.
Now, medical schools have done so well catching up to the population boom that some cities have a glut of doctors. As a result, small companies are springing up that specialize in arranging home visits by licensed physicians.
The trend is more advanced on the West Coast, where the attractions of western life have brought an abundance of doctors, reduced the crowds in waiting rooms and left free time in some doctors' schedules. Dr. Leonard D. Fenninger, vice president of medical education and scientific policy for the American Medical Association, said many of those doctors "are beginning to realize that there are observations that can be made in the home that cannot be made in the hospital."
In some cases, however, the impetus for house calls is more financial than professional. Physicians in the most doctor-saturated areas find they have to make them simply to earn a living. In Portland, Ore.; Orange County, Calif.; Los Angeles and San Diego, house-call services have had some problems getting established, but finding enough doctors willing to do house calls has not been among them.
When Cele Jameson, formerly a business manager for an ambulance company, started a house-call service at Portland's Holladay Park Hospital in December, 1980, about 300 doctors inquired about what turned out to be 15 available positions. "I put an ad in the Portland Physician, and, good heavens, we were swamped," she said.
According to AMA figures, the number of physicians in the United States grew from 334,028 in 1970 to 467,679 in 1980, a 40 percent increase, far exceeding the 8 percent growth of the general population. Even the numbers of "primary care" doctors--the general practitioners, internists, pediatricians and obstetricians who handle most common ailments--increased after a slight drop in the 1960s. They numbered 186,227 in 1980, a 36 percent increase from 1970.
Noel Lehr, 45, and her son Craig, 27, began their Doctors' Housecalling Service in Fullerton to serve Orange County last year after Craig, a chemical engineer, could not get a doctor to visit him as he lay sick and dizzy in a Louisiana hotel room. The Lehrs were also annoyed that Noel's mother, for whom they had arranged a special room in their home, had to move to a convalescent home because they could not find a doctor willing to make regular home visits.
Their service is making money now, Craig Lehr said. They arrange five or six calls a day for about 20 doctors on their list, including Gartner.
Gartner, with 20 years of experience as a general practitioner in Orange County, said that when he began to make calls regularly for the service "there were complaints from other doctors. They think it doesn't fit into the scheme of things. They think patients should go to the local emergency rooms. Well, I'm a director of a local emergency room, and I can tell you that is an expensive way to practice medicine."
House-call services charge about $50 to $70 per visit, roughly splitting the fee with the doctor. Gartner, who also has his own office specializing in care for the elderly, calls regularly on some of his own patients and usually charges them about $30, the amount Medicare would pay for an ordinary call.
The Center City Hospital in San Diego set up a house-call service in January in response to intense competition for patients among private hospitals in the area, according to the service's director, Dawn Ainsworth. A house-call service made sense, she said, because "we have a lot of elderly people who have relocated to San Diego and cannot get around well, and we have a lot of tourists here who don't know their way around."
Indeed, many callers to the southern California services are hotels and motels with guests who suddenly need a doctor.
Local residents, who assume no one does house calls anymore, have taken longer to discover the service, but their portion of the business is growing. The services have spent little on advertising so far, many relying instead on publicity by local newspapers and television stations intrigued by the novelty of a house-call service.
House-call services are being set up in some other U.S. cities with an abundance of doctors, health administrators here say. But Washington apparently isn't one of them yet. Franc Ferraraccio, executive vice president of the Medical Society of Washington, said an unsuccessful house-call service in the city folded several years ago. However, local medical society officials say they will refer patients to doctors on their lists who occasionally do house calls.
Dr. John Nasou, a Silver Spring internist who is treasurer of the Montgomery County Medical Society, makes an occasional house call but said, "The public is better educated that a house call usually doesn't have any value." If a person is seriously ill "they end up in the emergency room anyway," he said. "If they are not sick enough for that, often you find that the complaints of illness are exaggerated," or that they could easily get to a doctor's office.
Gartner and other doctors here argue, however, that physicians can gain valuable information going to the home. "The big thing is seeing how they live," Gartner said, recalling his surprise at how low the heat was at the Gagnon house.
His most recent visit was to check on her ankles, which had swollen severely because of poor circulation caused by a heart ailment. "You haven't got them wrapped up at all," Gartner said, and before leaving he instructed Gagnon's 34-year-old grandson on how to wrap them firmly to make it easier for her to move.
As for the patient, Jane Gagnon remembers when doctors would come to her home in New York City, "but that was a long time back." What do friends say when she tells them a doctor visits her now? "They don't believe it," she said