Primary care training during internal medicine residency is draining. Physicians straight out of medical school are confronted with the most challenging patients, often in impoverished or under-resourced communities. These factors contribute to decreased levels of humanism and increased burnout. As a recent graduate of a general internal medicine residency, I experienced the positive impact of a home visit narrative program, developed by our behavioral sciences faculty.
The home visit team consists of house staff on ambulatory rotation, a clinical psychologist and a psychiatrist. The residents select one of their patients to visit, especially someone with multiple psychosocial or psychiatric issues or who had difficulty getting to appointments. After the visit, we write about our reactions and share them with the team. The two of us have analyzed themes and collected excerpts from 40 reflections over the past five years. These examples demonstrate how home visits, followed by narrative reflection, increase empathy and commitment to patients, and improves care.
The home visits allowed us valuable time and new perspectives required to understand our patients better. A visit to the apartment of a divorced woman with chronic pain and labeled “needy” by her providers revealed a history of sexual abuse by her stepfather, her role as the primary caregiver for two disabled adult sons and the abandonment of their family by her ex-husband. The family had run out of clean dishes and was using paper plates. The “lawn” contained scattered blades of grass and was covered with cigarette butts. We could hear a psychotic, cognitively impaired neighbor banging on the walls. “I am so tired,” the patient sighed, “but I have to take care of my sons.” Our view of this long-suffering woman changed from her being needy to one of respect and sadness for her situation.
The narrative self-reflection allowed us to observe sometimes intrusive and self-centered thoughts, struggling with our own reactions and judgments rather than being mindful of our patients. Some of us felt guilty about our inability to help or save patients and how we had failed them. One commented on the dread evoked when she saw certain patients on her schedule because she had nothing more to offer for their chronic concerns and was instead focused on how to move on to her next visit most efficiently. “The slowness of her speech and mannerisms confronts my fierce impatience. My drive for speed and my need for efficiency, at the cost of our fundamental human experience.” Another resident wondered why some patients kept returning despite a mutual feeling of paralysis and lack of progress.
By leaving the clinical setting and entering someone’s home, we could regain our empathy and confidence in our abilities as physicians. We left patient homes with an increased sense of trust and that our connections had grown. One resident wrote, “She immediately saw me and smiled, saying: ‘Dr. M!’ How simple her reaction was, yet so strong the feeling I had that I love what I do. I can’t believe how happy it made me feel to see her looking good.” These people became our patients, people who we could be proud of and care for. These relationship changes occurred in the setting of taking on different roles and disrupting normal doctor-patient routines.
The significance of family is another common theme mentioned in reflections. Often, spouses, children, and pets gathered around the patient and were witness to their life stories. Central to these stories were the relationships each family member had with the patient, evidenced not only through their verbal telling but also in the photos and paintings around the home. Young children were sometimes present, as one resident noted, “The youngest are curious about our home visit; they peer through the doorway, wave their hands, eager to attract attention. They are all elbows, knees, open faces, happy smiles.”
In a public housing unit, where we saw a depressed refugee from Sudan, we discovered, “She is the tree of her family. Her roots burrow deep into the earth, remembering the lives of her fallen brothers and sisters and gripping on to all that remains. Her memories like rings, growing wider and wider with love every year. She is the guardian, the supporter, and she pours out critiques, nutrition, and love. But in the process, she’s forgotten herself. We hope she can see she is surrounded by a new river that she’s created waiting to nourish her.”
The act of writing a narrative reflection requires the creation of a story about a patient. We reorient the natural history of disease to be patient-centered rather than disease-centered, enriching our understanding of the patient by inhabiting their worldview. Writing a narrative naturally generates questions as to how the patient’s story began, what we hope to learn as the journey continues, and how the story will end. These questions drive us to think critically about the behaviors and motivations of our patients and of ourselves as their doctors, allowing us to create a shared understanding of their health goals. The unknowns in the story motivate us to find out what happens next, to become more invested in our patients’ futures, and to work together toward resolution. “On this cool September morning, I’m left wondering what this fall will bring. Will she get some sleep, will her eldest son get to play football, will she stop feeling the need to cry at work, will her youngest like starting school?”
Thinking about the stories of patients makes us more empathic and better healers. We know how to learn medical facts and where to go to fill the gaps in our knowledge, but we have fewer tools that teach us how to maintain empathy, identify motivations, and remain committed when we have run out prescriptions to write or tests to perform. Home visits combined with narrative reflection help develop and retain these skills.
“There was some tangible power to being there open, vulnerable, and still welcoming us into her home and her life. The conquering of these obstacles seemed more achievable. Perhaps this is what is meant by meeting people where they are.”
David Levine is an internal medicine physician.
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