The grimy pickup truck raises dust as it pulls into the driveway of a solitary house in the Antelope Valley desert, hauling an ancient trailer about the size and color of an elephant.
The driver emerges from a tattered interior strewn with clothes, paper cups and other debris. He wears jeans, a soiled shirt and wraparound sunglasses with a pink frame. He carries a black toolbox containing medical supplies.
Meet Lawrence F. Smith MD, the wandering doctor of the desert. He only makes house calls.
Smith lives wherever he parks his trailer in the barren expanse of the Antelope Valley, 70 miles north of downtown Los Angeles. His nomadic brand of medicine makes him one of a handful of doctors in Los Angeles County who treat patients exclusively in their homes, according to the county medical association.
Smith does not have malpractice insurance and professes little interest in money. He claims to have rejected what he sees as the cold avarice of the medical establishment in order to provide compassionate health care to people in isolated and low-income areas.
"I'm the maverick, I'm the loner," said Smith, 44. "I'm not at the garden parties."
For good reason, according to doctors and others in the local medical community. They describe Smith as a misfit whose unkempt appearance and dilapidated vehicle indicate a lack of professionalism. They are disturbed by the rambling, angry letters he fires off regularly to authority figures and the verbal confrontations he has had with other medical professionals.
Most significant, Smith's lack of affiliation with a hospital allows him to evade scrutiny by peers, said his critics, who asked not to be identified.
"The concept of what he says he's doing is wonderful," said one Lancaster doctor. "But I wish it was somebody else doing it. There's no way for organized medicine to review what he's doing and he refuses to submit to that review. I have a real uncomfortable feeling about him."
None of those interviewed knew of any incidents of medical misconduct by Smith. Vern Leeper, director of enforcement for the Medical Board of California, said Smith's license is in good standing and he has not been the target of disciplinary action.
One medical worker familiar with Smith's practice said she would never let him treat her. But she said he serves a unique population, many of them "desert rats" living meager existences. They probably would not get medical care otherwise, she said.
"I think it's good that he goes out to those rural areas," she said. "He does go out to people who cannot get another doctor."
One such patient is Geneva Coughenour, 70, whom Smith treated recently for skinned elbows and emphysema at her house in the harsh landscape that is part of Lancaster but resembles Death Valley.
"I hate going into town," rasped Coughenour, a stick-thin chain-smoker. "You go in and sit with a dozen people in the waiting room. If you're not sick when you go in, you're sick when you come out."
Nancy Garcia of Palmdale, whose 88-year-old grandmother is Smith's patient, said: "My impression was that he was very thorough. I said here's one doctor who really cares about his job."
Garcia's grandmother, Mercedes, said Smith spent several hours on each visit treating her arthritis and a calcium deficiency.
"He told me he was a doctor without money," she said in Spanish. "I felt that he was very considerate."
Although Smith eschews the aspects of establishment medicine that he finds bureaucratic and mercenary, he said he follows the same general treatment procedures as most other doctors.
Though he is not much on fancy offices and fax machines, Smith does have a beeper, a cellular phone and an answering service so his patients can reach him.
At the Lancaster doughnut shop where he takes care of his paper work, Smith described a career during which he has practiced at various hospitals and clinics around the country before adopting his more unstructured work schedule.
He said he has alienated administrators and peers with obsessive criticism of problems he sees in the system, such as what he calls the "assembly-line medicine" of doctors who cram as many patients as possible into their schedules.
"They wanted me to be a businessman," he said. "It makes you compromise. I could be seeing 40 patients a day, making money. . . . What I would have to do is throw out the window what I'm doing now, taking the extra hour to get into a line of questioning you (other doctors) should have gotten into. The kind of thing most physicians have pushed into their subconscious."
Smith was born in Northern California and raised in San Bernardino County. He spent two years as an Army medic and got an undergraduate degree from Brigham Young University in 1972.
Practicing medicine was his ambition ever since he read the book "Dr. Dan the Bandage Man" as a boy, he said. He got his medical degree in 1975 at the University of Guadalajara in Mexico, according to American Medical Assn. records.
Smith did yearlong internships in Canada and Michigan and started--then abruptly quit--a residency in family practice at a hospital in Austin, Tex.
In 1981, he started a practice in the dusty climes of Boron near Edwards Air Force Base. He says business foundered after he alleged that local doctors were unethical; a medical worker in Boron said Smith's antagonistic personality alienated doctors and patients alike.
The end result: "I took my last bucks and I bought this trailer. I was going to be free of all this politics."
For the past six years, Smith has been mobile. He said he earns $15,000 to $20,000 a year serving mainly Medi-Cal and Medicare clients. He charges $35 for the first visit and $25 for succeeding visits.
Smith hopes to move his practice one day to greener country, perhaps Alaska. Such dreams require money, which is particularly scarce because the budget impasse in Sacramento has delayed his receipt of Medi-Cal payments for the past month.
"I don't care that much about money, but I need it like everybody else," he said.
Smith insists he is on an altruistic mission that highlights the failings of the profession he had always idealized. But his critics argue that doctoring in the desert is the only kind of work he can get.
Wherever the truth lies, the maverick medic fits into the back-roads culture he serves.
"I used to be like, 'Jesus, this is desolate, this is like the moon,' " he said as his truck clattered past stark rows of Joshua trees. "It has grown on me."