Dr. Mark and friends
HOUSE CALLS: In an era where economics and patient backlogs mean speedy, less-personalized doctoring, one physician blazes a new way: old-fashioned conversation and caring where you can’t hear the clock tick
Dr. Mark Nowaczynski — hereafter referred to as Dr. Mark, which is what his patients call him — sees them before they die, and he wants us to see their “hidden world,” too. That’s why he takes photographs of his patients — beautiful, dignified, soulful portraits, in black and white.
And that’s why earlier this year he agreed to take me out on house calls with him for a day, to see what he sees. “As far as I know, I am the only physician in Ontario doing this (home visit) work full-time,” he says. “What I do is provide primary care for frail seniors.” FIRST STOP, John, a Korean War veteran in his 80s who came to Canada from Ireland and lives in an apartment near Yonge and Eglinton. “He’s a reclusive hermit. He has some cognitive impairment, probably related to lack of stimulation.” John showed up at St. Mike’s emergency with sore feet and was eventually referred to Dr. Mark. The doctor warns me: “John hoards. He’s set up a defensive trench to walk through all his stuff. Normally, our system deals with people like John by institutionalizing them. He’s challenging to help, but he still has his life. He’s very gentle, almost a lost soul, a delightful man.” We arrive at John’s building, together with Leslie Hogg, an occupational therapist with SPRINT (Senior Peoples’ Resources in North Toronto). John lets us in: it is a hot day, he is wearing two wool hats and layers of clothes, sweaters, a dressing gown, heavy boots. There are piles of stuff everywhere — a ratty curtain hangs askew, there is neither a phone nor a television set. His fridge is nearly empty.
The scene is astounding: the extreme eccentricity of the patient, the tenderness with which Dr. Mark and Hogg care for him. They are gentle, they accept him as he is; they help him.
Dr. Mark pulls out his laptop and makes notes as he takes John’s blood pressure and checks his heart. (The electronic records are shared by SPRINT’s health team, including Hogg, a social worker and a nurse.)
“John has an irregular heartbeat,” Dr. Mark says. “We started him on aspirin and a beta blocker.”
Hogg counts John’s pills, notes that he has taken the correct number, and tells him it’s time to sign post-dated rent cheques. (John was nearly evicted once when he fell behind on his rent.) He searches for his chequebook, and amazingly, extracts it from a pile on the table.
NEXT STOP: Clarence, 91, referred by Meals on Wheels; hadn’t seen a doctor for 30 years, has congestive heart failure, would have died in the fall of 2006 if Dr. Mark hadn’t seen him. “He’s frail, doesn’t get out much, refused a walker,” Dr. Mark says, parking in front of a run-down semi-detached house. Clarence is seated in a chair in the living room. He swims in an undershirt: he is skin and bone. “I creep around,” Clarence says. “I can no longer go out. I’m afraid of tripping and falling. But my stepson comes every Tuesday and takes me grocery shopping. That’s my one and only excursion into the outside world. My granddaughter comes once a week and brings me coffee. I am most fortunate to have them. Hogg writes out the cheques; John signs them. I think to myself: a country where this man is taken care of is a good country. They make living worthwhile.”
Dr. Mark takes Clarence’s blood pressure. “How’s your breathing? How’s the swelling of your legs? You sure you don’t want to try a walker?”
Enjoying the company, relaxing as Dr. Mark attends to him, Clarence talks about his life, “I was an accountant.”
“You were the CFO of an oil company,” Dr. Mark says.
“I find living rather tedious,” Clarence says. “I get Meals on Wheels. Not too tasty. The squirrels and raccoons get it.”
Cobwebs hang from the ceiling, dust piles on the floor. I ask Clarence if he’d like help cleaning the house: “I don’t see where the place is getting dirty,” he says.
As we leave, Dr. Mark says it’s not uncommon for patients to refuse a cleaner or other assistance. “They’re too proud to admit they need help. They don’t want to be seen using a walker. They think, ‘That’s for old people.’
“He’s nearly 92.” EMILY, 97, answers the door of a pristine midtown home. She holds onto her walker. This is a decidedly upper-class house, inhabited for many years by three siblings, all in their 90s. Dr. Mark has come to see Kathleen, 95, who is bed-bound upstairs.
Bienne, a personal support worker from SPRINT, is with Kathleen in the bathroom. Kathleen is as frail and bony as a baby bird, hunched with osteoporosis. She cannot stand up or walk on her own, and the curvature of her spine bends her neck, making it difficult for her to speak or eat. She wears diapers; her hair is in rollers.
“She likes to have her hair curled,” Emily says.
Bienne manoeuvres Kathleen onto a push chair and into the bedroom. Her spine and neck problems make it hard for her to speak or eat.
Under the rules of the province’s Community Care Access Centres, Kathleen would not receive enough care to keep her at home; she can afford to pay for what she needs.
Slumped in a chair beside her bed, Kathleen lets Dr. Mark take her blood pressure. “How is your breathing?” he asks. “Short,” she whispers. He asks about the pain in her back and encourages her to take more Tylenol.
“It’s a simple thing. If you undermedicate yourself, you’ll have more pain. You can take up to six Tylenol a day.” He says her heart is “in good shape.
“Your chest is clear. You’re better than you were one month ago. How’s your energy?”
“She doesn’t have any,” Emily says.
“I was asking Kathleen,” Dr. Mark says, firmly. “Keep trying to walk even if it’s only two steps a day. Two steps become four, four steps become eight steps. If you work at trying to get from the bedroom to the bathroom, then maybe you can go downstairs. Would you like to go downstairs?”
“Of course I would.” NEXT UP, DORA, 91. The widow of a surgeon, she lives in a big house in Forest Hill.
“How are you?” Dr. Mark touches her gently.
“Things could be better,” she croaks, cracking a grin. “I was dreaming, so vivid, now it’s gone. Sir, what are we going to do today?”
He checks her blood pressure, her heart, her breathing.
“I guess I’ve been lucky to get to 91. I’d like to be luckier. I sleep a lot. No energy. What future is there?” “Nobody knows,” Dr. Mark says. “Nobody cares,” Dora says. “You have three loving children,”
Dr. Mark says. “The end is near.” “WHATTHESYSTEMNEEDS is not necessarily more doctors but doctors who do a little of this work, making house calls,” Dr. Mark tells me in the car. “When I take residents (young doctors) out on rounds with me, they find it very satisfying. You learn so much about people, seeing them in their homes. The residents are amazed that old people can be so frail yet still living at home, until the end.” It may be a satisfying calling, but not financially so. “I’m paid twice as much for a house call as a family physician is for an office visit, but they see at least four patients in the time it takes me to do one house call.” WE DROP IN on Elizabeth, 80, who is at risk for developing diabetes, has shortness of breath and fluid retention. Dr. Mark tells her that as she starts walking around more, she could stave off diabetes. “I want to be independent,” Elizabeth says adamantly. “Nursing home? No way. You’ve got to have a purpose. If you don’t, you’re a vegetable.” Dr. Mark checks her blood pressure. “Beautiful. Good. You’re doing well.” He checks her heart. “Your heart rate is down, that’s good. The beta blockers are working. I’ll be back in two weeks to take blood and check your kidney function. I don’t anticipate problems.” “I thank God every night for Dr. Mark,” says Elizabeth. “Don’t let me upset him.” THORNCLIFFE PARK is next, to see a new patient. Theresa is 98, bedbound, hasn’t seen a doctor for two years. “Her daughter has been a heroic caregiver,” Dr. Mark says.
The patient sits mutely in an armchair in the living room, feet up, head dropped, chin to chest. Her daughter explains that Theresa had her first mini-stroke in 1987, followed by many more strokes, and stopped speaking 18 months ago. “It’s hard to believe this is my very active and social mother, sitting in the dark, head down. I wouldn’t wish this on anyone.”
They discuss medications. “I’ve been doing her meds for 11 years,” the daughter says, going over a long list of different drugs. She pays five different caregivers to look after her mother; she brings in a dental hygienist to clean her teeth, a podiatrist to do her feet. “She gets 14 hours of care from the CCAC, six days a week. That’s the maximum.”
Dr. Mark holds Theresa’s hand. He gets no response. “Theresa, I’m the doctor,” he says. “Can I check your blood pressure?”
The daughter is clearly overwhelmed. “I brought in the home care because of the loneliness. My mother sitting here all the time alone, I can’t bear it.
“When you’re in your 80s, friends don’t drop by. They can’t get out, or they’re dead. . . .
“She doesn’t want to be in a nursing home. She said last fall, ‘I would like to die.’ She has severe osteoporosis. She broke her hip. She’s been in diapers for a year. I can’t change her diapers. I’m sorry, I can’t do it. How much longer can this go on?”
“You’d be amazed,” says Dr. Mark.
LAST STOP. Vera, 97, has pneumonia. She is dying, and has refused treatment. She lives in a Toronto Community Housing building.
Dr. Mark knocks on her door. She is lying in bed, in the dark.
“Miss Vera,” he says. “It’s Dr. Mark.” He sits by her bed, holds her hand.
“I told you not to come,” she mutters. “It’s my job to keep an eye on you.” “I’m not up to it.” “Do you want me to go?” “No.” “Are you having trouble breathing?”
“It’s an awful day. Can you give me something to relax me?” “Do you want a patch?” He means a narcotic patch, given to those close to death to quell pain and anxiety. “It would help calm you down.”
She knows the meaning of the patch. “No! I don’t want the patch!”
He gives her a glass of water, a tranquillizer and sleeping pill. “Turn off the noise,” she says. “That’s you making the noise, you’re grunting and groaning when you breathe. The patch would help.”
“No.” FOR MOST of his patients, “If I didn’t go to them, they wouldn’t get any health care because they can’t come to me. They would fall through the cracks. These are hidden worlds: people who almost cease to exist, who have no voice.
“You’re not looking at an exotic species in another world,” he says. “You’re looking at your future.” Read the series so far and view video profiles, read additional stories and offer your comments at thestar.com/atkinson2008