Knock knock, it’s the doc

Issue: BCMJ, vol. 60, No. 9, November 2018, Page 426 Editorials

“Knock knock.”

“Who’s there?”

“Your doc.”

“Your doc who?”

“Your family doctor.”

“What?! No way!”

The door swings open and there she stands, Mrs S., with a genuine smile on her beautifully wrinkled face. Her smile widens even more when she sees that I have my 3-year-old daughter in tow. She opens her arms for a hug and welcomes us into her home. It is a very tidy and organized space full of knickknacks and pictures of her loved ones.

We walk through the living room, which looks untouched, and then to the kitchen, which has nothing on the counters. It is immaculate. Then we enter the family room, where we see Mr S. He is lying on a hospital bed tucked in with lots of blankets and facing an amazing view. He is pale and unresponsive and remains that way throughout the visit.

Mrs and Mr S. are both my patients. His health declined rapidly over the past few years to a point where his Parkinson disease and dementia made it difficult for Mrs S. to bring him into the office. She hired a private caregiver to help her as she didn’t want a different home care worker looking after her husband every day. He was a very private person, and she wanted him to maintain his dignity. For the past few years I have been visiting him at home to ease the burden on Mrs S.

Mrs S. offers us a fruity drink and I see that her fridge is well stocked with food. During the visit, my daughter has to use the bathroom and I see that the raised toilet seat and bath bars are in place and there are no dangers of tripping on any risky rugs.

A house call is an eye-opener. It usually takes about 30 minutes and it is not structured. We talk about everything and anything, not just medicine. Usually it ends up being more about assessing the health of the caregiver, and it lets me see and understand so much more than I ever would if the patients came to the clinic.

MSP pays a family physician $114.29 per house call between 8 a.m. and 11 p.m. and $71.06 between 11 p.m. and 8 a.m. It usually takes me an hour to do one house call, including drive time. Many doctors don’t do house calls because the financial incentive is poor. They will rely on home care nursing or caregiver history to make medical decisions regarding a patient’s health over the phone.

Telehealth and virtual house calls are becoming the new fad. Telemedicine limits the doctor’s ability to actually see the patient and to assess the patient’s real environment. We also forget that many patients do not have the technological savvy or the appropriate device required to conduct a virtual house call.

There have been a few survey studies done to assess physicians’ thoughts about house calls. A study cited in the Canadian Family Physician, January 2013, had a 29.2% survey return (unacceptable by Dr Richardson’s standards) and concluded that physicians lacked time and remuneration for doing house calls.

Toronto has a house-calls program in which four physicians each see eight patients per day. The program provides an at-home care service for seniors in Toronto who are unable to get a doctor. Financial constraints limit this program.

Uber for doctor house calls is becoming popular in the US. The patient downloads an app on their smartphone and enters their symptoms, address, and other personal information and, poof, there is a bona fide doctor at the patient’s front door in 20 to 60 minutes. Amazing, right?! What’s the catch? It costs money—privately $50 to $200 per visit, depending on the company used and the reason for the visit.

Despite all this new technology, I still think that a hands-on approach should apply to most patient care. When and if possible, see your patient in the flesh. Listen to their concerns while looking them in the eye. I realize that this is not always possible with the current lack of family physicians and the growing patient population. But for those patients who can’t make it into our offices—like our seniors and those who are physically or mentally challenged—the house call is priceless.    

Jeevyn K. Chahal, MD. Knock knock, it’s the doc. BCMJ, Vol. 60, No. 9, November, 2018, Page(s) 426 - Editorials.

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Dr Robert Henderson says: reply

This is interesting because another family doctor and I are planning to provide a house call service out of the Black Creek area on Vancouver Island probably starting in the late spring and hoping for support from our colleagues and residents in the area. I should be an excellent resource for people lacking mobility and perhaps allowing earlier discharges from hospitals.

Dr. Robert Holmes says: reply

Thank you, Dr. Chahal, for this warm and informative insight into what was once a most important part of general practice. One could learn so much about a patient and his/her family, and what kind of support that your patient received at home. Sadly, the computer screen has replaced the in situ findings which where obtained at the home or in the office, and technology has overcome reasoning and empathy.

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