House Calls and Home Care

In medical school, the importance of monitoring vital signs, labs, and disease markers was drilled into our brains. When these numbers were sub-par, we were told to advise folks to “eat less processed food,” “get more exercise,” “take your meds as prescribed,” etc. It becomes easy to fall into the trap of treating the humans sitting across from us in the exam room as the total of their labs and vitals. But for many patients, other factors are just as important. Some cannot easily eat well or bathe themselves, so they ask their PCP to find home health care to assist them with food shopping, meal preparation, laundry, and basic housework.

“Doctor, he cannot be moved. Could you arrange to see him at home?” Admittedly, a request like that is almost never exactly welcome at first blush. Sometimes, you know such an appointment can be managed from a distance (if the patient’s problem isn’t serious). More often, you worry about practical difficulties (how to find the home—now much easier since the advent of GPS; whether there will be a convenient parking space; how much can you do without your usual office facilities; and, most importantly, how you’re going to carve out the necessary time—several multiples of a routine office visit—from your already busy workday).

In practice however, you rarely regret a home visit. Once you overcome your hesitation, and the practical obstacles, you get to know your patients in a different light when you see them in their own daily environment, which certainly impacts on their health and quality of life in many ways.

The loneliest existence I have ever encountered was a hospital room that briefly held an elderly man.

At report, there were no significant signs suggesting his inevitable outcome. I began my first rounds as I had done thousands of nights before. I checked on him and introduced myself. His response was lackadaisical, perhaps even whimsical. Nothing stood out. No red flags caught my attention.

I’ve been working for over five years in home-based primary care division of geriatrics. As a physician assistant (PA), I don’t have to stay in one specialty for my whole career. Many PA friends from graduate school have transitioned between fields: cardiology, bone marrow transplant, neuro ICU, critical care, OB-GYN, dermatology, oncology, and so on. Why haven’t I switched to something more glamorous or exciting? The answer is almost impossible to capture in words, but I’ll give it a try…

Maan was born on my daughter’s sixth birthday, after an uncomplicated pregnancy. Husband, both grandmothers (sisters to each other), all from Southern India, were present and supportive. The birth was greeted with great joy, but within an hour, that joy was marred by a sudden seizure. I called in my pediatric colleagues, and we transferred the infant to the tertiary care center an hour up the road.

When most people hear the term “house call,” I’m sure the picture in their mind is of a black-bag-toting physician tending to a patient in the patient’s own home.

But when I hear the term “house call,” the picture in my mind is of a time, 49 years ago, when my family physician tended to me at his home.

I used to tell myself that my work in health communications was about more than earning a paycheck or typing words on a page. Yes, I didn’t provide clinical care, but didn’t I make a small contribution, too?

When I left home for medical training, I knew distance would be hard, but I didn’t understand how distance could change time itself. As a medical student, my schedule is packed tight, and traveling home has become a kind of emotional arithmetic: three visits a year, maybe four if I’m lucky, each only a handful of days. Somewhere along the way, my time with my mother stopped being measured in years and became measured in holidays, long weekends and whatever small windows my training allows.

Years ago, two of my patients were retired nurses and close friends. They were so inseparable that they saw me together for their office visits.

Gladys always wore a sour face and complained about her aches and overwhelming fatigue. I never could get her to talk about the hysterectomy she had at a young age that left her childless, but it clearly was the reason she swore off any surgery, even the minor procedure I was convinced would eliminate most of her symptoms.

Just as one never forgets a first kiss, one also never forgets a first house call. And specializing as I did in geriatrics included becoming a specialist in house calls.

At the university where I did my fellowship, the university contracted with a hospice company, which provided me with my first exposure to house calls, as well as to interdisciplinary teams—including social workers, chaplains, and volunteers. The hospice case manager was Nurse R, a seasoned 30-year veteran. She invited me to ride with her, zipping through Chicago’s narrow streets in her station wagon and parking in impossibly tight spots.

Twice Dr. Eddy made a house call because of me.

The first time was on a hot July day in 1953 when I, age seven, ran a fever during a polio outbreak. I didn’t have the poliovirus—but a year later I got the vaccine before my big sisters did.

The other time was when I was nine and had the mumps. I asked Mommy to take down “the hanging thing in the hall”—which nobody else saw. She tried to take my temperature, and I bit off the thermometer, fortunately above the mercury bulb. I spit it out on her order.

Daddy called Dr. Eddy, who used his thermometer: 103. He asked me to bring my pointer finger to my nose. I poked myself in the eye.

Even when the sun shone, our apartment was enveloped in darkness. A look of confusion or pain replaced Dad’s usual smile; I frowned all the time, caught up in a period of pre-grief as I prepared for the inevitable passing of my beloved father. Dad was tired of trying to live, and I was exhausted of trying to help him maintain some quality of life. Then, a miracle occurred. A diagnosis of pancreatic cancer made Dad eligible for hospice at home. The light returned to our lives.