I used to make house calls. Making house calls was an integretal part of general practice. It would have been unthinkable to tell a mother of a baby with a high temperature to take her kid to the emergency department at two in the morning in the prairie subzero temperatures, or any other time for that matter, other than for a genuine emergency. Doctors knew their patients and assessed the information over the phone and had to make the decision whether to make a house call or to turn over and go back to sleep. It was often a difficult decision to make. If the patient sounded ill it was easier to get up and go and assess him, than to leave it until office hours the next day. Just sloughing off the patient with a "go to emergency " didn't help much when there were no full time physicians in the emergency room and the doc was just going to get another phone call from the ER nurse. Quite apart from that, physicians had a sense of obligation to their patients that caused them to respond to their distress and to try to solve the patients' problem rather than the physician's. Of course, this all pre-dated the 'Health Care Industry'. I know all this sounds pretty corny, but that's the way it really was.
House calls achieved a rapport that social workers, psychologists and psychiatrists are unable to replicate (at great expense). Something, much more important than a prescription for a respiratory infection or tonsillitis , took place during those visits. A glance around the home was often more informative than half an hours history taking. It was easy to understand why some kids were recurrently arriving in the office with infected eyes, ears, noses and throats. It became easier to understand why certain patients were showing up repeatedly, week after week, the so-called frequent flyers. It gave insight into some of the problems financial and otherwise that some had to deal with. Most important, it gave an insight into the family dynamics, healthy or otherwise that family physicians deem to be so important. It focused on the environment in which disease and disorder, mental and physical, so commonly originates.It also tended to create a bond between patient and physician that few other contacts apart from obstetrical delivery did. (In those days most of the obstetrics were carried out by family docs).
So why was this important aspect of the doctor - patient allowed to wither away?
There are three main reasons:
1. Time. Doctors practices almost always were based in the neighbourhood where their patients lived, so it was possible for a doctor to make a house call, often on the way to work or the way home without it taking an inordinate amount of time. The demographics of family practice have changed.
2. Money. Despite the time and effort required to make house calls the administridiots who plan the budgets decided on a fee schedule that was grossly inadequate. The last time I looked, it was more expensive to have a consultation with a plumber. That therefore, was a de facto decision to discourage home visits by physicians. This decision, far from saving money, generated huge costs, because many patients particularly the elderly, opted to be looked after at home when they knew the physician would visit as frequently as nece4ssary and monitor their needs..
3.Technology. As we have become more reliant on laboratory investigations to make our diagnosis physicians are often afraid to make a diagnosis without a batch of (sometimes unnecessary) investigations, lest they be accused of not exercising due diligence. This results in the defensive mode of practice and the tendency to over-investigate almost everything.. Thus, it became increasingly acceptable, with a grain of truth, to respond to requests for a house-call with "we're going to need some tests so go down to emerg". Now, with full time ER physicians, the family doctor is off the hook!
All of the above are remediable if the right people were in charge.
Come back next week you want to read an account of a real live house call of yesteryear!
House calls achieved a rapport that social workers, psychologists and psychiatrists are unable to replicate (at great expense). Something, much more important than a prescription for a respiratory infection or tonsillitis , took place during those visits. A glance around the home was often more informative than half an hours history taking. It was easy to understand why some kids were recurrently arriving in the office with infected eyes, ears, noses and throats. It became easier to understand why certain patients were showing up repeatedly, week after week, the so-called frequent flyers. It gave insight into some of the problems financial and otherwise that some had to deal with. Most important, it gave an insight into the family dynamics, healthy or otherwise that family physicians deem to be so important. It focused on the environment in which disease and disorder, mental and physical, so commonly originates.It also tended to create a bond between patient and physician that few other contacts apart from obstetrical delivery did. (In those days most of the obstetrics were carried out by family docs).
So why was this important aspect of the doctor - patient allowed to wither away?
There are three main reasons:
1. Time. Doctors practices almost always were based in the neighbourhood where their patients lived, so it was possible for a doctor to make a house call, often on the way to work or the way home without it taking an inordinate amount of time. The demographics of family practice have changed.
2. Money. Despite the time and effort required to make house calls the administridiots who plan the budgets decided on a fee schedule that was grossly inadequate. The last time I looked, it was more expensive to have a consultation with a plumber. That therefore, was a de facto decision to discourage home visits by physicians. This decision, far from saving money, generated huge costs, because many patients particularly the elderly, opted to be looked after at home when they knew the physician would visit as frequently as nece4ssary and monitor their needs..
3.Technology. As we have become more reliant on laboratory investigations to make our diagnosis physicians are often afraid to make a diagnosis without a batch of (sometimes unnecessary) investigations, lest they be accused of not exercising due diligence. This results in the defensive mode of practice and the tendency to over-investigate almost everything.. Thus, it became increasingly acceptable, with a grain of truth, to respond to requests for a house-call with "we're going to need some tests so go down to emerg". Now, with full time ER physicians, the family doctor is off the hook!
All of the above are remediable if the right people were in charge.
Come back next week you want to read an account of a real live house call of yesteryear!
Ah yes, how well I remember those days when Dr. McKay used to come see me at home when I was sick! He would come every day at first, then as I started to recover less frequently. When he finally told my parents to bring me to see him in the office next week for a final checkup I knew I was better!
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