The article in the July/August 2018 issue of the journal about assessments by pit appointment [2018;60:304-313] reminded me of the dom appointments I took part in, in UK general practice. No, not that kind of dom, but the domiciliary visit. A specialist consultant and the family doctor would meet at a patient’s house. The fields covered included internal medicine and especially psychiatry. These visits were very popular with all concerned, especially with the specialist, who was extremely well paid for this service. Some of the lessons from these visits have stuck with me all my long professional life. An illustrative case follows.
A late-middle-aged accountant suddenly changes his behavior. Previously his routine was immutable. He took the same train in from his small village to his firm in the city of Birmingham every day for years. Suddenly, changes occurred. He began stealing women’s underwear from washing lines and planning grandiose holidays and world tours. Naturally, his wife was worried and, as was the fashion then, called the village constable, who, instead of locking him up, called the doctor.
As a junior in the practice I was delegated to meet the psychiatrist on a domiciliary visit. We found a gregarious, garrulous, excitable but very happy chap. A short history disclosed the sudden and dramatic change in behavior in a man who had never been mentally ill in his life and had no family history of mental illness. “What was your impression?” the psychiatrist asked me. “Hypomania,” I replied. “True,” he said, “but look at his fingers.” They were heavily nicotine stained and gave the suggestion of clubbing. Several months later he died from lung cancer. The possibility of paraneoplastic syndromes presenting as mental illness has been a lifelong lesson. “Look at and learn from the patient” was promoted by Osler and remains as true today as it was over 100 years ago.
Having a specialist and the family doctor meet the patient had obvious advantages. Perhaps as our health system evolves we could revive some of these ancient practices?
—Ralph Jones, MD
This letter was submitted in response to “Assessment by pit appointment as an alternative to full psychiatric consultation.”
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