House Call.

From the time of antiquity,  healers, physicians, medicine men have treated their patients in the home.  In the United States, up until a century ago, a visit to the home was the standard way of delivering medical care.  Today, things are much different.  A study published in the New England Journal of Medicine in 1997 looked at the frequency of house calls to the elderly.  Shockingly, less than 1% of Medicare patients received house calls from physicians.  I suspect that this remains the case.

And let me be clear, what I am addressing here are the home visits by a patient’s primary care physician, not the walk-in clinic doctor opening up a house call business.

 

The days of your family doctor coming to your home instead of you going to their office, are largely over, I think.   Although my colleagues still make house calls, mostly for their elderly and housebound patients, as well as those dying at home, it’s not very often, and I can usually hear them grumbling about it. “Ugh, I have to make a house call.”

I am proud to say that I have made a few house calls, albeit not many, but when I feel it would benefit my patient, I make the effort.  Granted, I have a much younger patient population than my colleagues, so the opportunities for home visits are few and far between.  I expect this to change as my patients age.  I was interested to find out what the state of house calls is in this country, so I looked it up.

In 2010, family physicians in British Columbia were surveyed about house calls. The sample size of physicians who completed the survey was small.  After all, who has time in their busy practice to fill out a survey among all the other paperwork?  In this study, 73 surveys were completed (250 were sent out).  Of those completed, 87.7% stated they had done at least 1 house call in the past year; 31.5% did house calls at least once a month and 16.4% did them at least once a week. What I found interesting was that when the study authors looked at the physicians in two groups – those who graduated from medical school before 1990 and compared responses to those who graduated in 1990 and after, they found:

The 49 physicians (67.1%) who graduated from medical school before 1990 were no more or less likely to have done at least 1 housecall [sic] in the past year than the 24 physicians (32.9%) who graduated in 1990 or later (n = 42, 85.7% vs n = 22, 91.7%; χ2 = 0.53, P = .47). However, 11 (22.4%) physicians who trained before 1990 did housecalls at least once a week compared with only 1 (4.2%) physician who trained in 1990 or later (χ2 = 3.92, P = .048).

Younger physicians are doing about half the house calls their older counterparts are doing and even less are doing them once a week.  The tide is turning, indeed.  Even more interesting, is the report from the National Physician Survey:

The National Physician Survey reported that, in 2010, only 47.8% of British Columbia (BC) family physicians offered their patients housecalls and 0.9% described housecalls as a specific area of focus in their practices.2

Family doctors seem to prefer to see their patients in the office, not in their patients’ homes.  I can understand why – it’s more convenient to stay in the office, travel time in the city can be a nightmare, and remuneration may leave something to be desired.  After all, in the time it would take to travel to visit one patient, a physician could see 5 – 10 patients in the office.

A lot can be learned from visiting a patient at home.  For example, an 85-year-old woman who has had multiple falls in recent months;  she can’t come to the office because she’s in a cast after having broken her ankle.  You, as her physician, decide to take the visit to her home.  Upon walking in the door, it’s quite evident why she’s falling a lot – the floors are lined with ratty carpets, even you almost trip on your way in!!  The patient’s daughter is also present for the visit and instead of discussing the fracture, the visit is spent discussing removal of the carpets!

I made a home visit this week to a patient who is dying of cancer.  I called her husband last week and asked if she was well enough to come into the office.  She has a team of doctors looking after her, one of whom is a palliative care physician who makes home visits every few weeks.  A visit with me at this point is purely supportive in nature as her palliation is being tended to by the specialists.  Her husband said that, while they do make it to chemotherapy appointments, and other specialist appointments, it takes a tremendous toll on his wife and he didn’t think she’d be up for an office visit in addition to their weekly outings.  I knew he wouldn’t suggest a home visit – most of the time the last thing a patient wants is to impose on their physician.  So, I gently asked if she wouldn’t mind a house call.  The pause on the phone was telling.  “That would be wonderful for her,” he said.  “She would enjoy that so much.” He sounded a little bit surprised that I would offer.

Seeing a patient in their home environment is one privilege of family medicine I didn’t expect.  Once you step foot into their home, they cease to be “just a patient”.  You bear witness to their real life, to the home they have made, to their hopes and dreams, to their sorrow and sadness.  My patient and her husband welcomed me into their home, offered me a delicious cup of coffee and we talked.  We talked about her cancer and her pain; we talked about how chemotherapy was going;  we talked about the cat I saw roaming in the backyard; they told me how they met in Spain thirty-five years ago; and we talked about their four children. I saw the hope flicker in her eyes when she talked about the chemotherapy that helped her pain and maybe, just maybe, is shrinking the tumors. I saw the courage in her husband’s eyes as he tended to her needs and fluffed the pillow she had behind her back.  I saw the profound sadness in her eyes as she struggled to find the words to describe what it’s like to plan her own funeral.

Most family physicians don’t do house calls anymore.

I am not one of them.

 

4 thoughts on “House Call.

  1. Got to say, I love house calls. I mean, I’m just a student, but when we do family medicine we have to do house calls for all our portfolio patients, and it’s always one of my favorite experiences of Fam Med.

    We had a talk about house calls in third year, and the lecturer asked how many of us had ever had a house call by our primary care physician. There were SO FEW, I was shocked. My family has had the same physician for nearly twenty years, and he doesn’t “advertise” that he does house calls, but he does them every once in a while. Like after my mom had my little brother and had such bad postdural headaches that she told us she was going to go out of her mind, he made a house call. And my dad his legally blind, so the one or two instances where he’s been too ill to walk to the office, our doctor came to see him at home.

    Then there was the time my aunt was murdered, and our doctor came to our house to check that everyone (especially my gran) was doing okay after the news. He didn’t bill us for that one.

    I found your post insightful – and I look forward to being the kind of physician who does house calls.

    • Thank you so much for the comment! My family physician never visited me at home when I was growing up, but she did come to visit my mom after her breast cancer diagnosis. I know how much it meant to my mom.

      Good luck with the rest of your training! I have enjoyed following you.

  2. I think there are so many things that physicians can do to show their patients that they care about them as a person and not just an appointment in their day. It is nice to see when physicians embrace those opportunities when they present themselves. This job is not just about making money… It’s about changing people’s lives. If a house call will make a difference… Well, there should be no excuse not to do it.

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