Are house calls by doctors on the way back? Long a staple of the family doctor’s working day, the practice of calling to see patients in their own homes has been in steady decline for years.
Personally I like doing house calls. Well maybe not at 4am on a winter’s morning, but a home visit to a patient as part of the working day has much to recommend it.
From the doctor’s perspective, the additional insights afforded by seeing someone in their own environment are legion. In the case of an older patient, you get to see how independent they are and what supports are in place to allow the person to continue to live at home.
And if you want a true insight into family dynamics, there is nothing to beat a house call to an ill child.
There is no doubt that patients value house calls too.
As one US physician put it, “the power and wizardry of modern medicine are impressive, but there is perhaps nothing that patients and families appreciate more than a house call.
“Almost everyone recognises that in making a house call, the physician is going the extra mile for the patient.”
Some of my best house call memories, perhaps counter-intuitively, involve the dying patient. Successfully facilitating someone who wants to die at home is, for me, close to the pinnacle of professional satisfaction.
Yes it can be sad and poignant, but some of the richest medical conversations I have been privileged to be part of have been with people with weeks to live. Unknown to me, one man recorded these reflections in a diary.
In a touching moment I will always treasure, his family presented me with the diary just after my patient passed on.
In a review of the topic in the current edition of the Journal of the Irish College of General Practitioners, Dr Alex Kelleher and Dr Liam Meagher note a decline in home-visiting rates worldwide.
“In 1930s America, home visits comprised 40 per cent of doctor-patient contact; by 1980 this had fallen precipitously to less than 1 per cent. More recently UK home visits have fallen from 22 per cent (of all consultations) in 1971 to 4 per cent in 2003,” they say.
Australian research confirms the pattern: in 1997 there were 158 house calls per 1,000 patients per year; by 2007, this had slumped to 77 home visits per 1,000 per year.
Why the decline?
Low physician compensation, the time-consuming nature of house calls and the disruption they may cause to a regular practice schedule are some of the contributory factors.
The introduction of practice appointment systems and the development of out-of-hours co-operatives are undoubtedly also part of the house call “evolution”.
Former minister for health James Reilly dealt a severe blow to the underlying economics of the rural house call when he abolished the distance element of payment to GPs. It's a decision that needs to be reversed by the next minister for health if older patients are not to continue to lose out.
But I started this column by speculating that house calls may be back in vogue.
Not in Ireland, unfortunately, but in the US, where a new breed of physician is emerging. These doctors do nothing but house calls and they are, by all accounts, flourishing.
Dr Shohreh Taavoni, who works for Doctors Making Housecalls in North Carolina, told the journal Medpage that, despite their complexity and multi-morbidity, her patients are healthier, go to the emergency room far less, and are admitted to the hospital less often than an average patient.
“We are able to spend more time with them and have a more comprehensive visit.
“As opposed to doctors who see patients every seven minutes, we can take care of the whole patient.”
Bring back the house call – you simply cannot beat time in patient care.
mhouston@irishtimes.com
@muirishouston