Where ignorance is bliss.

         The University of Manitoba recently had its commencements lecture to medical graduates presented by a journalist who specializes in health care.  His name is Andre Picard.   Picard is unfortunately a sanctimonious hack with little understanding of the health care system despite the thirty years he proudly informs us of reporting in that area.  He bemoans the poor communication between physicians and patients and presumes in the course of a brief presentation to teach these young graduates the right way to practice the art of medicine.   I have spent forty years teaching family medicine residents the art of medicine as well as the science.  I taught them the 'conversation' between physician and patient is vital, that house calls are an important tool, that there are limitations to investigation and treatment before the patient is harmed rather than helped.   Some learn quickly but time constraints are serious and limiting when it comes to applying what they have learnt.  The fee schedule doesn't help either.  The reward for freezing a plantar was more than for a half hour consultation for depression.  Picard doesn't understand that the unfortunate direction of medical care is the result of political decision making and the administridiots who serve them.  He has bought in to the theory that well paid administrators  perpetuate to protect their jobs, that they are the 'experts' in health care and how it should be delivered.   They only understand the 'Health Care Industry,' which has to do  with votes and finances.  Physicians have been manipulated, directed, bribed, threatened and penalized to make health care into what the politicians and their satraps want it to be and the experience and expertise of lifetime practitioners is cast aside. Unfortunately, it is the public who will pay the price for these ill-conceived notions.
        Many of the finest and most dedicated hardworking physicians I know have become so disillusioned with the direction in which medical practice is moving that they look forward to early retirement.
        Finally, our paymasters decided the value of house-calls, an important aspect of medical care, and a great convenience to the genuinely sick and elderly, when they decided they were worth about half the cost of a plumber's visit.

The Humble House Call.

       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!