The Observer, October 12, 2007
Volume XL, Issue 7
Medicine Today: House calls provide insight on patients' day-to-day behavior
The family doctor picked up two fellow students and me at around 1:30 to head out for an afternoon of house calls. The relatively new University Hospitals house calls program is part of a new push by family medicine practitioners across the country to re-institute the very personal patient-physician relationship that can only be found, they argue, when a physician sits next to the patient on his or her own living room couch.
To qualify for the program, individuals must either have cognitive deficits to the point that leaving the house is dangerous or must have significant difficulty in making it from their house to the curb (where conventional transportation could pick them up). As such, most of the patients who do qualify are elderly and suffer from numerous chronic diseases, and are either bound to their houses or their beds.
Our first stop in East Cleveland brought us to the house of the first of three elderly women we would see that afternoon. Our patient, Mrs. B, had been unable to walk for nearly two years due to severe arthritis and a complete knee replacement. She suffers from type two diabetes, liver and kidney dysfunction, and elevated blood pressure, the last of which our physician was most worried by.
Mrs. B is taken care of by her son and adult granddaughter, who split the week at the house in order to provide around-the-clock assistance. They welcomed us into the house, which was neat, comfortable, and full of more medical supplies than I have ever seen outside of a hospital storage closet. Insulin syringes, glucometers, compression stockings, knee patches, and alcohol swabs were all within easy reach.
As we spoke to Mrs. B and her family, I was amazed by the knowledge they had gathered, especially by her granddaughter, about management of these chronic ailments and in particular, about the 14 prescription medications – and numerous over the counter remedies – that Mrs. B uses on a daily basis. Mrs. B's sense of humor was uplifting at the same time that her physical pain and understandable depression were devastating.
We bid farewell to Mrs. B – after a short detour back and forth to University Hospitals to pick up needles for the flu vaccines that never made it into the bag – and drove down the street and around the corner to visit Mrs. C.
Mrs. C, far more mobile than Mrs. B and able to move around her apartment, had aromatic salmon cooking on the stove when we arrived at her second-floor apartment. She likewise suffers from a variety of the ailments that plague more and more elderly Americans, and like Mrs. B, also takes over half a dozen medications for which she keeps a schedule pinned above her kitchen counter.
"I'm in bad shape aren't I, doc?" You're doing alright, we told her – far better than Mrs. B down the street, I wanted to say. While her high blood pressure had come down somewhat since the last visit, it still wasn't where it should have been. Have you been avoiding foods with salt? "Yes, I try." A quick glance at the counter revealed various seasoning salts, almost completely used up, that were no doubt contributing to her hypertension. When she smirked and contended that they were in fact "seasonings" and not "salts," the doctor pointed out that the very first ingredient on the nutrition label was indeed salt. Have you been reading the labels, Mrs. C? "I need to get glasses, I know that," she said, cracking a huge, guilty smile.
On the ride back to the hospital after one more stop, our doctor pointed out that if Mrs. C had come into the outpatient clinic, we would have gotten the impression that she was struggling with hypertension despite removing all salt from her diet; we only learned by sitting at her kitchen table and talking that she had dispatched the salt shaker but thought seasoning salts were quite alright. Though she may not alter her diet, the doctor said, we were able to provide her better care just by seeing her in her own home.
George L. Anesi is a first-year medical student and graduate student in the department of bioethics. He can be contacted at george.anesi@case.edu.
