Medicine, as any discipline, or technology, evolves. In any evolution, important elements are gained, yet equally important and unique elements are lost.
I see that a special component: the house call, is becoming fast extinct, at least in my neck of the woods.
During my training, house calls were a required part of the curriculum of ambulatory (non-hospital) rotations. I remember, as a resident, how naked and unprepared I felt, walking up to my patient’s home, with only my stuffed black bag and brain, divested of the power and security of the hospital’s resources.
However, I also clearly remember the comfort our entire family derived from our own General Practitioner (Family Medicine wasn’t a specialty then), when I was age ten. No one in my family will ever forget the time he made a midnight emergency visit to our house. He gave my wheezing, purple-faced baby brother a shot of racemic-epinephrine and gifted my mother with his confident reassurance, when my brother was two and had croup. I also remember him opening his office up at 2 a.m., on another scary night, to suture my sister’s eyebrow, when she fell out of her bed and hit the metal frame of mine in our tiny, shared bedroom.
Most of the folks for whom I have made house calls have been frail, elderly, or in the throes of fatal illnesses, For these patients, trips to the clinic were problematic, either due to weakness, lack of transportation, fear, or pain.
On one of my first house calls, I visited a woman dying of metastatic colon cancer, who also had mild dementia. She lived alone in a run-down row home, which she said was “very comfortable”. I was appalled, entering her domicile, to see multiple live cigarettes scattered about, each sporting long gray ash and a red active center. Some were in ash trays, one was balanced upon on the arm of the sofa, two were on the kitchen counter, and another blazed cheerfully on the back of the toilet, where she had blithely, forgetfully, left them. There were multiple burn scars on every surface I could see. I had a horrible moment, envisioning my patient dying in a conflagration, instead of her primary disease. As I scanned the ceiling vainly for a smoke detector, I had a piercing vision of the two lively toddlers I had seen playing on the adjoining stoop next door. They were in danger too. This place would go up like a tinderbox.
After consulting my faculty advisor, we contacted the family, and then, the Fire Marshall. We clued him in to my patient’s dire straits. The Marshall’s stern visit to the home and the landlord’s office both motivated the landlord to install smoke detectors and inspired my patient’s family to hire “unskilled companions” who provided my patient much-needed company, and whose additional vital function was to douse the burning butts that my patient could not be convinced to eschew.
On another visit, to an elderly patient with many unexplained falls, I was both amazed and enlightened to see, standing like soldiers lined up on the window sill, four different bottles of Valium, written by four different physicians (thank God, my name didn’t appear!) all with the inscription “take two to three times per day for anxiety”. These powerful pills were accompanied by additional bottles of meds for diabetes and blood pressure. No wonder Mr. Peters was unsteady on his feet!
A carpenter, stricken with pancreatic cancer, told me he was “done with the hospital”. However, he had periodic debilitating episodes of vomiting and dehydration. When his attacks occurred, I visited before office hours. A dose of Phenergan (anti-nausea medicine) was of much assistance. After I started his IV, I would hang the bag full of rejuvenating fluid, (a sterile saline/sugar-water mixture) on the Tiffany lamp above the kitchen table. My patient smoked and smiled, as his wife scurried around the immaculate 1960’s-era kitchen, and prepared bacon, eggs, and biscuits for herself and me. I was embarrassed to realize that she did extra housework in anticipation of my visits. Her husband had no appetite, but as the nausea meds and the fluids eased his distress, we all chattered for a special 30 minutes, just people together, forgetting for a scant few moments his impending death.
On other calls, I brought asthma meds and other samples given by the drug companies to various shelters for battered women hidden in the heart of our city. I administered treatment to the children of blank-faced women with blackened eyes. I offered care and advice to the women as well. These torn families had fled, in the face of violence, without their essential medicines, their immunization records, any cash or insurance. Priests, nuns and layfolk obtained food, shelter, laundry access for these uprooted souls. All I could bring was “band-aid care”; a one-time exam and an assessment, a kindly manner, albuterol, and antibiotics. Yet this was still something of value.
I’ve made house calls to check on a neighbor child who jumped off his bed and landed on his head. I’ve removed sutures from a toddler’s face (dog bite) while he was rolled up in a towel upon his mom’s kitchen table. (His parents couldn’t afford the return ER visit.) I’ve helped to remove chewing gum from hair and eyelashes, diagnosed lice in a Ford F-150. I’ve stitched up cuts in the kitchen, and on a boat. I once did a pelvic exam on top of an old baby grand piano! I have been called upon to be the unofficial gynecologic telephone advisor for a number of the young women in my daughter’s college dorm. (I blame my daughter here. She is as enthusiastic as an ad agency!) People often need medicine and medical advice in diverse locales apart from “the office” and I feel it is part of my role to provide what I can, as long as it can be done safely for the patient and the doc. If house call care, (or telephone advice) is not appropriate or is insufficient, I refer the patient on to the relevant facility.
At times, although it is no longer expected, normative, popular, or reimbursed, I still go to a patient’s home, if they desire me to do so. I learn more about my patients in these encounters than can be obtained in multiple office visits. There is nothing like seeing how people live to inform the treating doc of what the patient and his/her family might most want or need.
Likewise, once I have sat at a patient’s kitchen table, and sipped tea, coffee, coke, or even a beer, I think my patient knows me better as a clinician and a person than they would ever have been able to do, had I stayed in my relatively sterile office, clad in a white coat.
Paula Lyons, MD
November 14, 2009