DOC MELLHORN AND THE PEARLY GATES 'HE WAS JUST A GOOD DOCTOR AND HE KNEW US INSIDE OUT' Painted in 1938 on commission for the Upjohn company by Norman Rockwell 1894 - 1978
In the past year I have had the occasion to do house calls for 6 patients. These visits, performed in living rooms, bedrooms and outbuildings, have touched me in ways that no clinic visit or hospital bedside visit has. There is something about seeing a person in their home, in their own environment, that highlights their unique humanity and the reality in which any proposed intervention must occur. This sense of the whole person is somehow attenuated in the artificial construct of the doctor’s office. Seeing the patient as a unique individual is even harder in the busy hospital environment, where gowns replace clothing and people become patients who live in numbered rooms. In a home, rooms have names, not numbers, and patients are people, people who have lived their rich lives in those rooms. In their home, the doctor is a guest. It is a very different dynamic.
At this point, an admission, I am a house call rookie. I run a busy and growing Department of Medicine and I am a cardiologist; I don’t routinely do house calls. That said, in my house I have a medical bag full of all the tools for house calls: BP cuff, O2 sat meter, stethoscope, otoscope, ophthalmoscope, thermometer etc. Also, I still love the practice of Medicine and, while my practice has contracted as my administrative and research roles have grown, my patients remain very important to me. When house calls occur therefore, it is not the routine; rather, it reflects the patient living in close proximity to me or me knowing the family socially and increasingly reflects the patient lacking a family physician.
My first exposure to the house call occurred before I was in medical school, back in the 1970s. I was a teenager in Hampton, New Brunswick, uncertain of what I wanted to do with myself and wondering what university would be like (no one in my family had traveled this path before). In search of direction, I asked, Dr. Robb, my family physician, if I could go with him when he did a few house calls. This experience was formative and, in retrospect, was one of several reasons I decided that maybe I would try to become a doctor. I did not know much about Dr. Robb. I sensed he worked hard, I knew he had his clinic in his home, I was impressed that he understood how the body worked, and I knew he would sometimes see patients in their homes (which I personally experienced as his patient). I still remember (in a Ghost of Christmas past, disembodied way) one such house call, when I accompanied Dr. Robb as he visited an elderly patient in their modest, poorly lit, home. The smells and general disorder of that bungalow stuck in my mind. I sensed (for I had no medical knowledge) that any medical intervention for this person would be difficult. I didn’t know the term, social determinants of health; however, that first house call taught me that who the patient and their family are, where and how they lived and their employment/financial situation would be key, both to understanding them and to managing their disease. Dr. Robb was a terse teacher but an effective guide. He did not overtly state the impact of poverty and lack of a social support system on the care of this patient, he just led me to the stage and my eyes were opened to the scene. Dr. William Osler’s aphorism, “The good physician treats the disease. The great physician treats the patient who has the disease.” eloquently states that the more we know about a person the better able we are to treat them. Dr. Robb died prematurely in January, 1982.
What have I learned from my house calls:
You bring calm and order to chaos: A common reason for a house call is loss of consciousness. This usually is a result of a person fainting (vasovagal syncope in doctor speak). This is also the most common reason by far for calls for a physician called to render medical assistance during an airplane flight. I have done two house calls for this reason. While syncope is benign, the patient and their family don’t know this and often the call for help is often urgent. One episode began with a frantic phone call-someone has collapsed! Another involved someone coming to the house at night pounding on the door, a loved one was unresponsive. So, while both cases had happy endings, I was “concerned” at the beginning of both house calls. I did know a couple of things, prior to seeing either patient. The first bit of knowledge relates to my life as a cardiologist. I know that whether in the home or in an airplane at 30,000 feet, vasovagal syncope is the number one cause of losing consciousness. The loss of consciousness is fully reversible and reflects the activation of the vagus nerve which simultaneously relaxes all your arteries and slows your heart rate, which in tandem lowers blood pressure. This form of syncope onsets with a bit of warning (a sense of being about to pass out) and resolves gradually, over minutes. Unfortunately, while fainting does not usually lead to dire consequences and is the most prevalent cause of losing consciousness, the other causes (heart attack, strokes, and arrhythmias) are life threatening. So as the visiting doctor you have to quickly get the differential diagnosis narrowed down. I follow the dictum from Samuel Shem’s book, the House of God which advises that, when at a cardiac arrest, the first procedure is to take your own pulse. The same approach is important when arriving in a home for a house call! By arriving and bringing calm into the room, therapy has begun. For syncope you ensure the patient is breathing and has a pulse and blood pressure. Once so reassured, make sure they are lying on their back (supine) with legs elevated. Assuming the patient has a pulse and is conscious, diagnosis follows quickly, as you learn from the family how the episode occurred (a prodrome of impending collapse, it was preceded by abdominal pain, exposure to an emotional stress, by bleeding, or after suddenly standing etc.). From your bag you pull out your tools and examine the person (they are sweaty and pale, their BP is low but detectable, their pulse is slow). Nowadays, you may even measure their EKG using available home EKG devices. In the course of a few minutes, things improve (as they did in both these cases). BP and heart rate increase and the person recovers. You tell them to rehydrate (Gatorade works well), remind them about risk factors for fainting, instruct them on the first aid they can administer to themselves if they have a sense they are about to faint (lay down, with feet higher than head). You stay with them and chat, until they are confident. Then, armed with instructions to call you (or their GP) if this recurs, you leave. Obviously, not every collapse is benign and experience is required to identify the serious case of arrhythmia or infarction or stroke…but vasovagal syncope is very common (40% of people have fainted) and the house call is often the only intervention required. In my cases, both episodes of vasovagal syncope related to blood loss that were self-limited, in one case a massive hematoma, in another related to a chronic condition exacerbated by dehydration and abdominal pain. Neither case recurred.
Pietro Longhi painting called Fainting (1744). This illustrates the wrong way to deal with syncope. The patient needs to be placed with their head down and feet elevated. They then require reassurance and oral hydration.
Sometimes the problem becomes obvious as you walk through the door
I once did a house call where the problem was leg swelling in a patient with known cardiovascular disease. The family’s question was whether this was heart failure. I entered the house and saw the patient. They were in a chair, swollen feet dangling on the floor. He was immobilized by a recent orthopedic injury and had been sleeping in the chair for two weeks. The exam showed a normal BP and heart rate. The patient also had normal jugular venous pressure (meaning the filling pressures in their heart were not increased) and there were no murmurs, gallops, extra heart sounds or other signs of heart failure. Reassured by their normal cardiac examination, I was able to determine that the problem was largely a case of dependent edema from having their legs chronically hanging down and by poor venous return, all exacerbated by sleeping in a chair. I found a fix for the patient’s orthopedic problem, which allowed him to become mobile again. As a result, he was able to sleep in their bed and within a week the leg swelling disappeared. Cause of problem: “bloody obvious”, just like in the Herman cartoons by Unger (below).
You’re not always being called because you’re a medical expert: showing up is half the battle
One house call involved clarifying how a family could access Ontario’s complex home care services. The South East Community Care Access Centre (CCAC) provides advice and services related to care in the home and access to long term care facilities. In this case, a family was floundering, after the death of a spouse during the holidays, to access these services for the surviving partner. I’m not an expert in accessing CCAC; however, in the absence of a connector my role was to figure it out. I found the folks at CCAC, including a very helpful Marilyn James, busily working on a holiday evening and as was most impressed by their willingness to arrange an occupational therapy consultation and a clinical care coordinator home assessment for my patient. In this case I was probably little more than a lay person, but, services provided during a house call, though often not heroic or high tech, can nonetheless be very impactful. The 2 hours connecting with CCAC and communicating with the two sides of the far flung family helped them deal with a situation which might otherwise have led to the Emergency Department.
House calls make you vulnerable:
I have attended to people at or near the end of their life at home. These visits often serve to keep people at home and avoid both the logistical challenges of going to the hospital and the attendant risks of futile investigation. This is the type of visit that my colleagues in Palliative Care do all the time. It is also the bread and butter of the family physician’s practice (traditionally-see below). My point, as a novice in this field, is that these visits are powerful. They remind you of the fragility of life, the importance of family and they render you vulnerable. There is no white coat to shield you, no computer to hide behind. It is you and the family, talking, sharing a reality that none can alter. Tears may be shed, hugs may be given, it can be simultaneously draining and rewarding. I have great respect for my colleagues who do this regularly. It is an art that elevates the practice of Medicine and makes whatever span of life the patient has left more meaningful and better in quality.
Our system is not working optimally in part because of a lack of family physicians
Clearly, doctors like me who dabble and do 6 or 7 house calls/year are not an important part of the solution to enhance care in the home. Equally clear to me, in my role of Department Head and Program Medical Director for Kingston Health Sciences Centre (KHSC) , the physician aspects of Ontario’s system of home care is not working optimally. Too many patients wind up in our Emergency Departments and hospitals because they lack adequate home care support and/or lack a family physician. Kingston is currently experiencing a tremendous shortage of family physicians. When I checked recently I found that over 6% of all patients who receive care from a specialist in my Department (125 doctors in the Department of Medicine) lack a GP. However, the number feels larger. In the past 2 years, each of my half-day weekly clinics seems to have a patient with no family doctor. Even the new faculty I hire (who are themselves physicians) struggle to find a family doctor. The story of these orphaned patients have some common threads. First, they do not lack a family doctor for want of trying. They have tried! They have asked family and friends. They have used websites the Ontario government provides, like Health Care Connect to find a GP; however, most report these sites don’t work in a timely manner and many of my patients have been listed for 1-2 years without success. I now have started listing “Lack of GP” as a problem at the problem list which begins each of my clinic notes! The reasons my patients have no family doctor fall into 3 categories: Their GP has reduced their practice to part time work or has retired, the person seeking a GP is new to Kingston, or the patient is deemed difficult and has been (for want of a better term) “fired”. So they are seeing me in a hybrid role as cardiologist and general internist. I don’t purport to be able to offer them all the care and continuity a family doctor could-I’m just the best of their bad options.
In conclusion, the house call is a fundamental medical service; not an anachronistic artform. These visits are no less necessary in 2020 than they were when Norman Rockwell painted old Doc Mellhorn. The importance of these home visits to patients, particularly the elderly and frail and those in the final stages of life, cannot be overstated. A well done house call offers diagnosis, therapy, reassurance and prevents visits to Emergency Departments. While nurses, occupational therapists, and some palliative care doctors and GPs perform much of this service, I worry about our supply of general practitioners who are willing to perform this vital service. For house calls to continue we need adequate numbers of doctors who acknowledge it as their role to serve in this capacity and these doctors must be broadly enough trained so they are comfortable and competent outside the confines of a clinic or hospital.
I know I am a better doctor for having gone on a few house calls.
I look forward to hearing your thoughts on the matter.