When a patient refuses help

"My husband just opened up a new office up the road," my wife told the shopkeeper. "He does home visits and I'm sure he won't mind doing a 'business visit' to come see you. Here's his card."

"Oh, God," I thought. Sure, I needed new patients, and I appreciated my wife's enthusiasm, but this guy was not who I needed in my budding practice. His XXXL shirt could not hide the fact that he was morbidly obese. He could hardly stand and smelled of diabetes.

"Nice to meet you," I said.

"Oh, God," I thought again.

"By the way, I don't have insurance, but I pay all my debts. Don't worry."

"Oh, God," I thought one more time.

After we left the store, my wife told me what a nice person he seemed to be. I was secretly hoping he might lose my card.

A few months later, my nurse told me that Mr. Smith was scheduled for a home visit. I packed up my black bag and drove to his store. There I met a friend of his, who escorted me to his apartment. When the friend opened the door, the smell of methane in the vestibule hit me like a wave. I felt the protective wall of depersonalization, which I had not experienced in years, rise up in me. As I stabilized myself emotionally, I was able to become more analytical and began to evaluate my surroundings.

The apartment consisted of a large, dimly lit living room, an efficiency kitchen, and a small bathroom. There was a floor lamp, a TV, and a pull-out sleeper sofa. On the sofa mattress lay Mr. Smith.

"Hello!" he said cordially. "Thanks so much for coming. You know, I kind of tripped on the curb and fell down and couldn't get up. It took nine paramedics to get me here, and I've been lying here, unable to get up, for the past five days. Sorry about the smell, but I can't get to the bathroom, so I've been peeing into paper towels and throwing them onto the carpet. I have someone who comes by and cleans them up every day or so."

"No problem," I lied. "What about food? How are you getting nutrition?"

"Oh, I give friends money and they bring me stuff to eat, so don't worry about that."

I asked about his medical history, and he told me he suffered from diabetes, hypertension, hypothyroidism, congestive heart failure, and chronic skin problems related to his obesity. He showed me his medication bottles, many of which were empty, and I tried to prioritize which issues we should tackle first.

"Do you have any family?"

"Yes, but my son and daughter don't talk to me since I divorced their mother."

"And you don't have insurance?"

"No. I had great insurance, but after my heart attack, I realized I hated my life as a company executive. I decided to follow my dream and open my business. I've never been happier, but no insurance company would even give me a quote due to my pre-existing conditions."