Is there a doctor in my house?
By Tim Stoddard
In the old days, doctors who called on sick patients at home were usually lone rangers, working on their own and dispensing care from a weathered black bag. The School of Medicine physicians who perform house calls today, however, along with nurse specialists, a nutritionist, and a social worker, are part of an interdisciplinary team that brings a broad range of expertise into the home setting. The Home Care Program, a clinical service of the school's Geriatrics Section, has been an important part of the MED curriculum for over 125 years, and it continues to shape home medical services around the country.
The five MED physicians in the program pair up with nurse specialists, and each team covers a different section of the city, caring for about 550 homebound elderly in all. “It's the team that comes up with the care plan,” says Karen Bryant, a MED assistant professor of medicine and a geriatrician in the Home Care Program. “It's not a hierarchical system in this type of practice. Once patients know we're a team, they're comfortable talking to whomever they can get ahold of. It's not like there's only one person who can help them.”
Once the team has assessed the patient's medical, functional, and psychosocial needs, the nurse sets the care plan in motion, calling physical therapists and arranging home-delivered meals, laundry services, pharmacy delivery, and adult day-care programs. “Many caregivers don't know that those resources are out there,” says Catherine Fabrizi, a MED clinical associate and a Home Care Program nurse case manager. “So part of our job is matching these services to the needs of a patient or family. And it's different for every patient we meet. We don't look at just the medical care — we look at all the psychosocial issues as well, because those are going to affect how the blood pressure and diabetes are controlled. If the patients can't get their medicines because they don't have the money or there's no one to pick it up from the pharmacy, they're not going to take the pills and their blood pressure is going to go out of control.”
“It makes for a broad and meaningful care plan,” adds Clare Wolgemuth, a clinical associate in the MED department of medicine and director of nursing for the Geriatrics Section. “It's a very individualized approach to patient care.”
Power to the patient
Eric Hardt, a MED associate professor of medicine and medical director of the Home Care Program, says that on a house call, there's a subtle change in the doctor-patient relationship. “There's a shift in the power differential,” he says. “We knock on the door and ask to come in; we ask if it's okay to sit on a chair, to use the phone, to examine them, or to change their medications. The patients get the message very quickly that they are in control, that they have a major say in the management of their disease.”
For patients, this is a welcome change. “I love being home,” says Roxbury resident Beulah Blair, who turned 81 on Christmas Day. “I'm really blessed to have my doctor come all the way out here to see me so that I don't have to go into the hospital.”
House calls often open the door to diagnoses that doctors and nurses might not have made. “When there's power sharing in the doctor-patient relationship, there's more openness and honesty,” Hardt says. “The patient may feel it's safe to tell you the truth or to be candid about problems they're having.”
Sometimes the patient doesn't have to say anything. On a house call, physician-nurse teams gather critical information about their patients' living conditions that they wouldn't otherwise learn in the clinic. Signs of urinary incontinence or alcoholism, for instance, are often obvious in the home, but difficult to see in the clinic. The environmental assessment also gives the team a more accurate picture of their patient's functional abilities.
See one, do one, teach one
In 1875, the Trustees of Boston University felt that medical students ought to experience firsthand the influence of the family setting on disease. The School of Medicine created the Home Medical Service that year, sending fourth-year students into the community with attending physicians to deliver home care to mothers and children. Since the 1970s, every fourth-year student has gone through a mandatory four-week geriatric rotation, which includes home visits, nursing home care, and attendance at adult day-care centers. “It's an incredibly memorable experience for the students,” says Sharon Levine, a MED associate professor, education director of the Geriatrics Section, and the 1998 winner of the Metcalf Cup and Prize, the University's highest teaching honor. Many MED alumni returning for their 50th reunions have vivid memories of their home care rotation, and say the home care experience profoundly affected the way they practice medicine.
Home care rotations are still relatively rare among American medical schools, says Rebecca Silliman, a MED professor of medicine and chief of the Geriatrics Section. There are only 12 schools nationwide where a geriatrics rotation is mandatory, but that may soon change. “Considering the aging of our population,” she says, “I think medical schools are recognizing that expertise in geriatrics and home care needs to be part of every clinician's training.”
One of the important lessons students learn, Hardt says, is that doctors cannot be prima donnas. “I think most doctors develop an insular point of view,” he says. “If there's something they don't know something about — social work or nursing — they tend to write it off as not important. If we haven't been trained to do it, then how could it possibly be a hard job or important? And so you have docs who go out and practice, and they're ineffective in certain situations because they don't understand nursing, social work, or physical therapy. They're impotent as doctors. We teach our students from day one that even if they might not be personally doing the nursing, it's critical they know what it is that is being done.”
The home care rotation has changed many medical students' perception of geriatrics. “I think students experience the rewarding parts of geriatrics, which is not always thought to be a very rewarding field,” says Bryant. “A lot of people think it's depressing, that there's no hope, that people never get well. But once students are in the home setting, they learn what the real obstacles are to the patients getting better. Maybe they never picked up their medication; maybe they never learned how to take it appropriately; maybe they're overdosing. These are the simplest things to fix, and that can be immediately rewarding.”
For the doctors, the rewards of house calls are obvious. “Those people who do home care love it,” Silliman says. “It's a very special way of connecting with people.” Hardt, who remembers tagging along on house calls with his physician father in Connecticut in the 1950s, says that early on in his career, treating patients in their homes became one of the most invigorating parts of his practice. “It soon became the most fun and creative part of what I did,” he says.
The hardest part of the job, Levine says, is losing the patients you care for. “We're very much a part of our patients' lives,” she says, “and that means going to many funerals every year because that's part of caring for my patients. It helps me to achieve closure in this big circle of care and in this family that I've been a part of. It really gives me meaning in my life. I love my job and I love many of the patients I take care of. As a physician, that's the bottom line.”