Why medical residents should do house calls

During my ambulatory care rotation, I got the opportunity to tag along with my attending on a house call to a geriatric couple. The husband, “Joe,” had recently been in the hospital for severe respiratory illness. His wife, “Sally,” had recently fallen and broken her hip and was recovering from a hip replacement.

While my attending checked on Sally, he advised me to talk to Joe. We chatted a while about the Red Sox and the Patriots. His main concern about his health was when he could get off oxygen. He hated being tied to the oxygen cylinder all day. I looked through his file, and it seemed he had very severe lung disease. His pulmonary function tests looked horrible. He went on to tell me how frustrated he felt because he didn’t know the time frame and prognosis of his disease. He was fairly active before he was in the hospital. He drove, spent most of his time outdoors and was an active member of his community. He still got out and drove to get groceries sometimes, but the visiting nurse constantly reprimanded him for this because he could get light-headed. I looked into the eyes of an independent 80-plus-year-old who was feeling claustrophobic and helpless. I skimmed through his chart again, and it looked like his lungs were irreversibly damaged. I told him that I would examine him first, review his chart carefully and then we could have a discussion about the prognosis in front of the attending, who knew Joe’s background better than I did.

After the attending finished examining Sally, he came into the room. I gave him a brief summary of my history and exam findings and conveyed Joe’s concerns. The attending asked me what I felt the prognosis would be in his case. I looked at Joe and told him that from his chart and our brief encounter, I felt that the chances of his getting weaned off the oxygen were slim. The attending then told Joe why we thought that was the case. Then we talked about options to improve his mobility. Joe told us that his insurance only covered a particular type of oxygen cylinder. The oxygen lasted anywhere from 6-8 hours. We then tried to figure out ways he could go to Cape Cod with his family on weekends, an activity he really enjoyed. The best options allowed him a half a day trip based on logistics of his insurance and oxygen requirements. Joe looked deflated and sad, but he thanked us for letting him know about the likely progression of the disease.

As we went into the living room, Sally asked about Joe. They both expressed concerns about each other’s health. I could see how much they cared about each other. Throughout the house, we saw many carpets, and physical therapy had expressed concerns about falls. So we advised Sally to get rid of the carpets. Joe said he would call someone to have the carpets removed.  We then fixed Sally’s walker so she wouldn’t trip over the carpets in the meantime. Joe took me aside and proudly showed me his war medals. A World War II veteran, he had recently been recognized for his service during a formal event which his children and grandchildren had attended.

I left the house feeling deeply connected to the couple. As I described to my attending the satisfaction of the visit, he said that was the reason he brought residents on house calls. When we are in the hospital, the elderly are oftentimes not their usual selves. We address the acute condition and discharge them. We never see their own struggles to stay healthy and independent. In the primary care office, we have limited time to interact with patients. For such a brief time in a very controlled setting, we don’t get to see the human and social aspects of their struggles to maintain independence. In the clinic, would I have seen Joe’s war medals and learned about the life he had led? Would I have known about the potential fall hazards in the house? Or how important it is for Joe to get better so he can see his family in Cape Cod?

I’m thankful that my residency still has a house call program and makes sure residents and fellows participate. Every time I see a patient in the clinic I think of Joe and Sally. I am reminded that every patient has a story that helps explain the barriers or the stepping stones to their optimum health. What is this patient’s story? I think every resident and med student should be required to make a house call. As clinic interactions are increasingly constrained by time, technology and compensation, we sometimes forget that we are not treating an amalgam of diseases. We are treating a human being.

Aftab Iqbal is an internal medicine resident who blogs at Primary Care Progress.

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