“Take care John,” I said as I left his home. It was 9:30 pm. Before leaving, John and I had shared a piece of cake. One of my mentors told me never to refuse such an offer from a patient. John was one of my favorite patients. He was always upbeat. Whenever I entered the exam room, he would boisterously say “greetings and salutations.” John was a retired schoolteacher and lived with his son. Recently, he developed end-stage kidney disease and had gotten too weak to come to the office. The reason for the house call was to discuss his decision to forego dialysis. John’s living room was filled with mementos of his life — photos of his late wife, his family, and letters from students.
Over the years, I have occasionally made house calls. I would do them at the end of the day because it did not make economic sense to do them during regular office hours, and the timing would guarantee that I would not be rushed. The house calls were a potpourri. There was the mother of a good friend who was dying. There was an irritable old man who, when I saw him in the office, always reeked of cigarette smoke. When I made home visits, I would need to wash my clothes afterward. In the office, I didn’t particularly like him, but I gained a new perspective when I saw the medals he received for his service with the Polish Resistance Army during World War II hanging in his home.
Then there was Henry. He always came to the office accompanied by his wife, who rarely spoke. When his spinal cord disease eventually prevented him from getting to the office, I made house calls. At the first house call, I learned that Henry spent three years in the Second World War on the USS Ghemung. This ship was used to refuel battleships. It was slow-moving, large, and defenseless, an easy target for the enemy. That had to be harrowing. I also learned about his wife, who was not a patient of mine. She had been an award-winning marathon runner. Numerous medals hung in the den.
One of my most memorable house calls came early in my career. We received a call that a patient who was agoraphobic and would not come to the office was having shortness of breath. Upon entering the home, I found 4-inch shag rugs, lamp shades, and assorted knick-knacks. There were also nine cats. Within minutes, I excused myself due to my own cat allergy. At least I knew what was causing her wheezing.
Various people have attempted to establish a business around house calls, but it remains, at best, a niche endeavor. Larger organizations have built-in post-hospitalization home visits or home care programs, which make a lot of sense, but cannot replace the primary care physician.
I can think of four reasons to do house calls. The first is to preserve continuity. As patients become more frail, many find even greater value in their relationship with their primary care physician. Often, their relationship with their PCP is intertwined with relationships with other family members, many of whom receive care from the same doctor.
The second reason is that the visits add specificity to the doctor’s understanding of the patient. This specificity helps to answer pragmatic questions. Is the patient safe at home? What about fall hazards? Is the patient taking the proper medications and taking them safely? Is she receiving adequate nutrition? When might we need to discuss moving to assisted living? Who else is important in his life? Is she isolated, lonely?
The third reason is that it reduces the total cost of care
The fourth reason is memories and meaningful encounters. When we look back at our careers, we might reflect on accomplishments such as publications and leadership positions, or the impact we have had on colleagues and students. I have experienced all of those, but for me, the most relevant measure of my professional career is the meaningful encounters I have with patients. I can scarcely remember who I saw in the office yesterday, but I do not think I have ever forgotten a house call.
Leaving John’s house that night, I knew it would be the last time I would see him. Although I was physically tired, I felt energized by my visit.
Robert Eidus, MD is a Family Physician in Walnut Creek, California
Photo Credit: The Doctor by Samuel Luke Fildes
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You sound like a gem Dr. Eidus.
Here's my favorite house call story: This was from the mid 90's. The patient and her husband were about 90, with 72 years of marriage. The patient was bed bound due to a paralyzing stroke. So I was there to check on her and renew prescriptions. She passed a couple of years later.
Their small home, probably their first and only one, was vintage 1920's. It felt like I entered a time warp, taking me back to 1925. The house interior and furnishings were dated, but well maintained. The patient's bed dominated the living room. I fancy there was a 1930 era wooden Philco radio and Victor Victrola phonograph in the corner, but probably just my imagination.
in an office setting, you'll never have this sort of memorable experience.