Freshen your practice–make house calls

When you see a patient in his own surroundings, you getto connect in a way that office visits don't permit, the author says.

By Richard B. Williams, MD
Neurosurgeon / Woodland Hills, CA

The author (above) pays a return visit to William Klemphner (withKlemphner's daughter Heather).

House call. The phrase harks back to a bygone era. It conjures up animage of a stout, mustached physician, black bag in hand, trudging up adusty drive to a country home.

Integrating that image into most modern clinical practices might seemakin to pulling out on to a crowded freeway in a horse-drawn buggy. However,my experience in a large group HMO practice has convinced me that visitsin this most basic setting can be surprisingly useful, in a variety of ways.If approached correctly, house calls can even be a timely and cost-effectiveway to see patients.

So how did I arrive at this conclusion?

My first house call, as a neurosurgical intern in North Carolina, wastriggered by my own error. I had sent an elderly woman home with suturesin place—a mortal sin, according to the chief of neurosurgery. When I dutifullyreported the oversight, he became dangerously red-faced. After a momentof angry thought, he gave me the worst command he could think of: to drivethe 30 miles to her home, after work, and remove the stitches. The gravityof his sentence reverberated throughout the hospital. Nobody made housecalls—especially not after spending 40 of the past 48 hours in the hospital,with no rest.

The desire to keep my job being stronger than the urge to sleep, I droveto the patient's home after work. Though bleary-eyed, I found her ramshacklehouse in the late-evening dusk, at the end of a dirt road. Her family wassitting on the porch. "Were you waiting for me?" I asked.

"No, son," said her rough-looking husband. "We sit outhere every night and watch the pond. This is about when the beaver comesto chew on that big tree."

I watched for a moment. Just as he had said, a beaver came out of thewater and started chewing on a large tree that had fallen across the pond.

The husband took me inside the house, where my patient was delightedto see me. After a glass of sweetened iced tea and some friendly conversation,I took out her stitches and was on my way. Driving home, I realized I feltgreat—in less than 10 minutes, I had gotten to know this patient in a waythat 100 exam room visits wouldn't have allowed.

At 6 the next morning, I tried hard to appear contrite about my sin andthe assigned penalty. But the punishment turned out to be one of the mostpleasant things about my training. I never forgot how a simple home visitcould do so much for the morale of the patient and me.

As the years went by, I began my own practice and saw medicine changein many ways. In place of private practice, I found employment in a largegroup HMO, treating people who had contracted with the health plan for servicesbut who hadn't chosen me as their doctor. Visits sometimes seemed rushed,allowing precious few opportunities to develop a lasting relationship withpatients. Frequently, neither I nor my patients understood anything aboutthe other in a personal sense. Often, as well, patients seemed to view mealmost as an adversary.

Early in my second year of practice, I treated Antonio, a 77-year-oldItalian immigrant who had fallen off his roof while trimming a tree. Hehad sustained a skull fracture and cerebral contusion. His skull fractureextended to his temporal bone and vestibular apparatus, and he was troubledwith severe vertigo. While he was in the hospital, I made it as tactfullyclear as I could that a 77-year-old man had no business trimming trees fromhis roof. I also hinted that he shouldn't work in his yard anymore.

Two days after his discharge, I got a panicky call from his wife. Shesaid he was still vertiginous and terribly nauseated. She felt he shouldbe seen, but she didn't drive, and he couldn't. Her request for an ambulancehad been denied. Suddenly I recalled the house call I'd made during residency."Where do you live?" I asked. "I'll stop by on my
way home and examine your
husband."

After evening rounds, I picked up some antivertigo medicine from thepharmacy and drove over. Antonio actually looked a little better. I reassuredhim and left the medication. On my way out, his wife proudly showed me thelush gardens, trees, and shrubs that had become her husband's life in retirement.I realized that to stop him from gardening would rob him of his greatestjoy. Knowing this, I felt comfortable negotiating guidelines that wouldallow him to garden but keep him out of danger.

That experience, nine years ago, sold me on the benefit of an occasionalhouse call. I still look for opportunities to build relationships with patientsby visiting them where they live. I seek out people with poor mobility whoare difficult to transport, or those with whom I think I have a poor relationship,or those who seem to feel I don't care about them.

I make house calls as often as two or three times a week, sometimes asseldom as two or three times a month. It simply depends on my schedule andon who I think could use the extra attention. And it doesn't matter whetherthe patient is in a mansion, a mobile home, or a motel. A visit needn'tbe long; I find that a few minutes in the home are as effective as an hourin the office.

Why bother? With managed care, we're busier than ever. And that's whywe must take the time to show patients we care. Many times, patients confuseus with insurance companies, and we face suspicion and hostility. Visitinga patient's home is a way to restore trust and friendship. It also setsus apart from other professions. When was the last time you heard of a lawyermaking a house call?

Speaking of lawyers: House calls, when properly documented, can havemedicolegal value. I was once named in a lawsuit in which the patient claimeda delay in diagnosis. The referring doctors hadn't obtained studies showingthe problem until it was well advanced, requiring immediate surgery. Atdeposition, the plaintiffs' attorney quizzed me about my first contact withthe patient. My notes showed that her brother had called late on a busyday and asked me to see her right away. I told him she could be worked inthe next day or I could stop by that day on my way home. According to myrecords, the brother accepted the next-day appointment but was very appreciativeof my house-call offer.

"Do you often make house calls, Doctor?" the skeptical lawyerasked.

"Yes," I replied. "I've made many over the years. I keepa record of them."

His mouth gaped, producing a moment of blessed silence. Then he said,"That's all." I was later dropped from the suit. No amount ofmalpractice insurance could have protected me as well as that exchange.

House calls saved me from a possible lawsuit in another situation. Apatient was dying of a malignant, inoperable brain tumor. His wife transferredhis care to a university medical center, where he soon died. She complainedto our health plan about the care we'd given him, and the medical directorcalled me on the carpet. I mentioned that I had driven to the man's homein the hills during flooding rain to remove his biopsy sutures, since Ifelt he'd have trouble coming to our clinic.

"How many of the university neurosurgeons visited him at home?"I added. That stopped the questioning. Nobody was surprised when the womaneventually withdrew her complaint.

Another tangible benefit of house calls is financial. When a patientwould otherwise need an ambulance to bring her to the office, a home visitcan save several hundred dollars for the insurance plan. When an ambulanceisn't needed, a house call saves the patient and family the struggle oftransporting her. After your examination, you can order imaging and labstudies to be done at a later date, and the patient has to make only onetrip instead of two.

There are other situations when a personal visit is useful. If a patientis admitted to a long-term care facility such as a nursing home, a visitafter a week or two, followed by a call to the family, can mollify theirfear that you'd never care for her again. It's also invaluable to get toknow the staff at these facilities. And if they see that you care enoughto follow the patient, they may be more attentive and communicative withher and you.

Dying patients in hospice programs also appreciate home visits. Althoughthe hospice usually assigns its own doctors and other personnel, a visitfrom you, even if not required, shows the patient you still care. Some ofthe times I've felt closest to a dying patient and his family are when I'vevisited to show I haven't forgotten them. We may not even have spoken aboutmedical matters. These experiences have reminded me of the ideals that sentme into medicine. As appreciative as patients and families are, sometimesI think house calls give me a bigger boost than they get.

Even though a house call is informal, there are commonsense guidelinesfor conducting it. Don't visit a lone member of the opposite sex unaccompaniedif a question of impropriety could be raised. Never drop into a home unannounced;it adds to the stress of illness for the patient and family. Curiously,though, the opposite seems to be true for nursing home visits: Catchingthe patient in the ordinary circumstances of daily life can tell you a lotabout her adjustment and the quality of her care. And whatever the setting,and no matter how brief the visit, document it just as thoroughly as youwould an office call.

Finally, if you say you're coming, show up punctually. Once, I calledto check up on a patient with painfully immobilizing metastatic breast cancerand casually mentioned to her husband that I might stop by after work. Italmost slipped my mind as I left my office in the darkness and rain, butI recalled our conversation in time to drive there. When I arrived, he wasstanding in the downpour waiting for me, with umbrella and flashlight.

"How long have you been here?" I asked.

"About half an hour," he said. "I didn't want you to goto the wrong house." That was the last time I ever made such a commitmentlightly.

Other ways to show you care

House calls are only one way to climb out of a managed care rut, saysCalifornia neurosurgeon Richard B. Williams, author of the accompanyingarticle.

While reviewing inpatient charts, signing orders, or proofreading notes,for instance, he often calls patients at home to find out how they're doing.(The phone numbers are on the records, so picking up the phone is easy.)It's quicker than reviewing a chart, and the patients are always pleasantlysurprised.

"Many say they've never had a friendly call from their doctor, andmost become your friends for life," Williams says. "I've neverfound they call me more frequently, either. If anything, they call lessoften."

Special circumstances and events also call for contact outside the normalroutine. Keep a box of thank-you notes in your desk, Williams suggests:"Hand-write (don't dictate!) a quick note of appreciation for anythingthe patient has done for you, such as a gift, a poem, or food. Have notepaperhandy, too, for messages of condolence or congratulations."

Richard Williams. Freshen your practice--make house calls.

Medical Economics

1999;23:173.