House Calls
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《新英格兰医药杂志》
In 1930, 40 percent of all doctor–patient visits were house calls. By 1980, the proportion had dwindled to less than 1 percent. Even in the 1990s, in the midst of an explosion in the home care business, the number of house calls continued to drop. At conferences, home care professionals were reported to laugh outright at the mere mention of physician involvement in home care.1
(Figure)
Doctors approach house calls much as politicians approach campaign finance reforms: everyone thinks they're a good idea, but few do anything to support them. A major reason, not surprisingly, is money. Traveling to patients' homes is inefficient and is rarely profitable. Another reason is lack of training. Few medical schools or residency programs expose trainees to house calls. This lack of mentoring virtually ensures that young doctors won't take up the practice once they go out on their own.
Veronica Lofaso, a geriatrician in Manhattan, is trying to change that. In 1998, she started a physician house-calls program at New York Presbyterian Hospital, joining five other programs in New York City. Lofaso and her colleagues now make about 20 house calls a week and have about 70 patients. On most days, they bring along medical students, residents in internal medicine, and fellows in geriatrics.
One day this past May, I accompanied Lofaso and her team on their rounds. We began at an assisted-living facility on the Upper East Side, visiting a 93-year-old woman with a history of congestive heart failure. Lenore Williams (not her real name) was resting on a recliner when we entered her apartment. She was glad to see us though a bit surprised; she had forgotten we were coming.
Lofaso walked around the studio apartment, inspecting it for items that might cause falls. She removed a telephone cord. She tugged gently on the grab bars in the bathroom. "We don't want you to fall," she called out to Williams.
"Yes," Williams replied. "Been there, done that."
Lofaso and a geriatrics fellow helped their patient into bed. Lofaso listened to Williams's heart and lungs and pressed gently on her edematous legs. Then she took a sphygmomanometer out of her black bag and checked Williams's blood pressure. She put a pulse oximeter on her finger. She tied a tourniquet around her arm and drew several vials of blood, disposing of the needle in a portable sharps box. She even took out what looked like an old typewriter and performed an electrocardiogram. "We can do almost anything in the home," Lofaso told me. "Echocardiograms, chest x-rays, portable blood chemistries, you name it. We can create a virtual office in the home."
I couldn't help but recall my first house call. My patient — I'll call him Roberto Gonzalez — had metastatic prostate cancer. After he had missed a couple of clinic appointments, his visiting nurse called me one afternoon in the middle of my internship. I had never spoken with her before. (Admittedly, I had even been a bit lax about filling out the home care order forms that periodically appeared in my mailbox.) "He's getting sicker," she told me. "He would love to see you."
"How can we get him into the office?" I asked sincerely. (Did she want me to fill out another transportation form?)
"You could pay him a visit," she suggested delicately. It hadn't even occurred to me. At no time during my education had I seen a doctor make a house call.
I went to see him one evening after work. His neighborhood in Spanish Harlem had the usual mix of pawn shops, check-cashing stores, and dilapidated storefronts painted with colorful murals. When I rang the door buzzer, a teenage girl popped her head out of a fourth-floor window. "Dr. Jauhar is here!" she cried.
Inside, I climbed a cracking limestone staircase. It was a steep climb; no wonder he had been unable to come see me. At the top of the stairs, I was greeted by a shawl-covered woman in her 60s. She clasped my hand. "Thank you, doctor," she said. "Thank you for coming."
The apartment was well kept and filled with Catholic adornments. I followed her to his room. He was lying in bed, wearing a diaper, his crumpled body barely making an impression on the crisp sheets. His lips and eyes were coated with crust, and his face was sunken. A plate of rice and beans was sitting on his bureau, untouched. "Dr. Jauhar is here," his wife said. "He has come to see you." He extended his hand weakly, and I held it. I asked him how he was feeling. "A little better," he whispered. "But I'm sick of going in the bed. I'm sick of being a child."
Instinctively, I reached for my stethoscope, but then I realized that I had left it at the hospital. In fact, I had brought nothing with me: no penlight, no blood-pressure cuff, no prescription pad, nothing. I looked up at his wife's smiling face, wondering if she noticed.
Without my tools, I didn't know what to do, so I just sat at his bedside, stroking his hand. Afterwards, in the kitchen, I sat with his wife. I asked her how she was holding up. "He wants me to wait on him hand and foot," she said with a mixture of resentment and resignation.
"It takes a lot of love," I said, not knowing how to respond.
"I don't know if I love him so much anymore," she replied matter-of-factly. "Now it's more like I just take care of him."
Gonzalez died a couple of months later. It was two years before I made another house call. What I remember most about that first one was how impotent I felt. Outside the familiar terrain of the clinic, with no equipment or physician backup or formal training to speak of, I didn't know what to do. Later, when I mentioned the house call to a senior physician, he scolded me for having created a liability risk for the hospital by taking on this task without supervision from an attending physician. Overall, the experience seemed, at best, to have been a waste of time. I was therefore surprised two years later when I got a letter from Mrs. Gonzalez. "I just wanted to thank you again for coming to see my husband when he was ill," she wrote. "My family and I will never forget what you did." My small, reluctant act of kindness had made a lasting impression.
House calls are a specialty, and like any specialty in medicine, they require training. Today, teaching hospitals are starting to provide that instruction, seeing house calls as "a great place to train students and residents in humanistic and community medicine," according to Jeremy Boal, director of the Visiting Doctors Program at Mount Sinai Hospital in Manhattan. Doctors in Boal's program, launched in 1996, now make 6000 house calls annually to about 800 patients. Participation is a required rotation for all third-year medical students and second-year medical residents.
Outside of academia, too, house calls are on the upswing. In 1998, Medicare reimbursement for house calls was increased by nearly 50 percent — providers are reimbursed $90.24 for a typical house call today, whereas a typical outpatient visit might bring in less than half that amount ($41.84); since the raise went into effect, the number of house calls made by physicians in the United States has increased by nearly 15 percent, from fewer than 1.5 million in 1999 to more than 1.7 million in 2002.
The change could not be coming at a better time. It is predicted that in the next 10 years, the number of persons older than 65 years of age in the United States will increase by 10 million. (The number older than 85 years is expected to double by 2040.) Already, 2 million Americans are permanently housebound. In controlled studies, house calls have been shown to reduce the rate of emergency room visits, the average length of hospital stays, and the number of admissions to nursing homes.1 Some data suggest that they might even prolong life.
After the visit to Lenore Williams, Lofaso and her team went to see a new patient with tachycardia on the Upper West Side. An elderly man let us into the elegantly decorated pre–World War II apartment. As we sat in the living room next to a grand piano, he went to get his wife.
"I'm not coming out," I heard her scream. "Let them see me like this."
When he returned, he apologized. "Before you leave," he asked Lofaso, "could you please address the drinking?"
The curtains were drawn in her bedroom, which was permeated by a fetid odor. ("Lighting is always telling," Lofaso told me later. "When rooms are dark, people are usually depressed.") The woman was lying on gray sheets that looked as if they needed washing. Her hair was matted down and her eyes were bloodshot; she was clearly drunk. Lofaso tried talking with her, but the woman kept swinging wildly between calm introspection and obscene tirades. "My life is ruined," she kept saying.
For 45 minutes, Lofaso tried to calm her down. She suggested a brief hospitalization. "Let us help you get things in order," Lofaso implored. "We want to take care of your mind and body." The woman refused. "I don't think I'll ever be able to stop drinking," she said tearfully. The negotiation went on and on, back and forth. Finally, when it seemed fruitless, Lofaso got up, told the woman that she would be back in a week to check on her, and went to the bathroom to wash up. When she returned, she told us to "go check it out." Lining the white toilet were black and maroon streaks. The melena cast the woman's tachycardia in a whole new light. Lofaso resumed her negotiations, now with a new sense of urgency. After a few minutes, the woman finally relented. "You're beautiful," she said to Lofaso, breaking into tears.
As we waited for the ambulance, Lofaso told me: "You really have to go into the home to know a patient's reality. It's a whole new adventure every time you open the door."
I nodded, thinking about what I had seen that afternoon. House calls are a small, good thing. Sometimes, they can even be lifesaving.
Source Information
From the Heart Failure Program, Long Island Jewish Medical Center, New Hyde Park, N.Y.
References
Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci 2001;56:M603-M608.(Sandeep Jauhar, M.D., Ph.)
(Figure)
Doctors approach house calls much as politicians approach campaign finance reforms: everyone thinks they're a good idea, but few do anything to support them. A major reason, not surprisingly, is money. Traveling to patients' homes is inefficient and is rarely profitable. Another reason is lack of training. Few medical schools or residency programs expose trainees to house calls. This lack of mentoring virtually ensures that young doctors won't take up the practice once they go out on their own.
Veronica Lofaso, a geriatrician in Manhattan, is trying to change that. In 1998, she started a physician house-calls program at New York Presbyterian Hospital, joining five other programs in New York City. Lofaso and her colleagues now make about 20 house calls a week and have about 70 patients. On most days, they bring along medical students, residents in internal medicine, and fellows in geriatrics.
One day this past May, I accompanied Lofaso and her team on their rounds. We began at an assisted-living facility on the Upper East Side, visiting a 93-year-old woman with a history of congestive heart failure. Lenore Williams (not her real name) was resting on a recliner when we entered her apartment. She was glad to see us though a bit surprised; she had forgotten we were coming.
Lofaso walked around the studio apartment, inspecting it for items that might cause falls. She removed a telephone cord. She tugged gently on the grab bars in the bathroom. "We don't want you to fall," she called out to Williams.
"Yes," Williams replied. "Been there, done that."
Lofaso and a geriatrics fellow helped their patient into bed. Lofaso listened to Williams's heart and lungs and pressed gently on her edematous legs. Then she took a sphygmomanometer out of her black bag and checked Williams's blood pressure. She put a pulse oximeter on her finger. She tied a tourniquet around her arm and drew several vials of blood, disposing of the needle in a portable sharps box. She even took out what looked like an old typewriter and performed an electrocardiogram. "We can do almost anything in the home," Lofaso told me. "Echocardiograms, chest x-rays, portable blood chemistries, you name it. We can create a virtual office in the home."
I couldn't help but recall my first house call. My patient — I'll call him Roberto Gonzalez — had metastatic prostate cancer. After he had missed a couple of clinic appointments, his visiting nurse called me one afternoon in the middle of my internship. I had never spoken with her before. (Admittedly, I had even been a bit lax about filling out the home care order forms that periodically appeared in my mailbox.) "He's getting sicker," she told me. "He would love to see you."
"How can we get him into the office?" I asked sincerely. (Did she want me to fill out another transportation form?)
"You could pay him a visit," she suggested delicately. It hadn't even occurred to me. At no time during my education had I seen a doctor make a house call.
I went to see him one evening after work. His neighborhood in Spanish Harlem had the usual mix of pawn shops, check-cashing stores, and dilapidated storefronts painted with colorful murals. When I rang the door buzzer, a teenage girl popped her head out of a fourth-floor window. "Dr. Jauhar is here!" she cried.
Inside, I climbed a cracking limestone staircase. It was a steep climb; no wonder he had been unable to come see me. At the top of the stairs, I was greeted by a shawl-covered woman in her 60s. She clasped my hand. "Thank you, doctor," she said. "Thank you for coming."
The apartment was well kept and filled with Catholic adornments. I followed her to his room. He was lying in bed, wearing a diaper, his crumpled body barely making an impression on the crisp sheets. His lips and eyes were coated with crust, and his face was sunken. A plate of rice and beans was sitting on his bureau, untouched. "Dr. Jauhar is here," his wife said. "He has come to see you." He extended his hand weakly, and I held it. I asked him how he was feeling. "A little better," he whispered. "But I'm sick of going in the bed. I'm sick of being a child."
Instinctively, I reached for my stethoscope, but then I realized that I had left it at the hospital. In fact, I had brought nothing with me: no penlight, no blood-pressure cuff, no prescription pad, nothing. I looked up at his wife's smiling face, wondering if she noticed.
Without my tools, I didn't know what to do, so I just sat at his bedside, stroking his hand. Afterwards, in the kitchen, I sat with his wife. I asked her how she was holding up. "He wants me to wait on him hand and foot," she said with a mixture of resentment and resignation.
"It takes a lot of love," I said, not knowing how to respond.
"I don't know if I love him so much anymore," she replied matter-of-factly. "Now it's more like I just take care of him."
Gonzalez died a couple of months later. It was two years before I made another house call. What I remember most about that first one was how impotent I felt. Outside the familiar terrain of the clinic, with no equipment or physician backup or formal training to speak of, I didn't know what to do. Later, when I mentioned the house call to a senior physician, he scolded me for having created a liability risk for the hospital by taking on this task without supervision from an attending physician. Overall, the experience seemed, at best, to have been a waste of time. I was therefore surprised two years later when I got a letter from Mrs. Gonzalez. "I just wanted to thank you again for coming to see my husband when he was ill," she wrote. "My family and I will never forget what you did." My small, reluctant act of kindness had made a lasting impression.
House calls are a specialty, and like any specialty in medicine, they require training. Today, teaching hospitals are starting to provide that instruction, seeing house calls as "a great place to train students and residents in humanistic and community medicine," according to Jeremy Boal, director of the Visiting Doctors Program at Mount Sinai Hospital in Manhattan. Doctors in Boal's program, launched in 1996, now make 6000 house calls annually to about 800 patients. Participation is a required rotation for all third-year medical students and second-year medical residents.
Outside of academia, too, house calls are on the upswing. In 1998, Medicare reimbursement for house calls was increased by nearly 50 percent — providers are reimbursed $90.24 for a typical house call today, whereas a typical outpatient visit might bring in less than half that amount ($41.84); since the raise went into effect, the number of house calls made by physicians in the United States has increased by nearly 15 percent, from fewer than 1.5 million in 1999 to more than 1.7 million in 2002.
The change could not be coming at a better time. It is predicted that in the next 10 years, the number of persons older than 65 years of age in the United States will increase by 10 million. (The number older than 85 years is expected to double by 2040.) Already, 2 million Americans are permanently housebound. In controlled studies, house calls have been shown to reduce the rate of emergency room visits, the average length of hospital stays, and the number of admissions to nursing homes.1 Some data suggest that they might even prolong life.
After the visit to Lenore Williams, Lofaso and her team went to see a new patient with tachycardia on the Upper West Side. An elderly man let us into the elegantly decorated pre–World War II apartment. As we sat in the living room next to a grand piano, he went to get his wife.
"I'm not coming out," I heard her scream. "Let them see me like this."
When he returned, he apologized. "Before you leave," he asked Lofaso, "could you please address the drinking?"
The curtains were drawn in her bedroom, which was permeated by a fetid odor. ("Lighting is always telling," Lofaso told me later. "When rooms are dark, people are usually depressed.") The woman was lying on gray sheets that looked as if they needed washing. Her hair was matted down and her eyes were bloodshot; she was clearly drunk. Lofaso tried talking with her, but the woman kept swinging wildly between calm introspection and obscene tirades. "My life is ruined," she kept saying.
For 45 minutes, Lofaso tried to calm her down. She suggested a brief hospitalization. "Let us help you get things in order," Lofaso implored. "We want to take care of your mind and body." The woman refused. "I don't think I'll ever be able to stop drinking," she said tearfully. The negotiation went on and on, back and forth. Finally, when it seemed fruitless, Lofaso got up, told the woman that she would be back in a week to check on her, and went to the bathroom to wash up. When she returned, she told us to "go check it out." Lining the white toilet were black and maroon streaks. The melena cast the woman's tachycardia in a whole new light. Lofaso resumed her negotiations, now with a new sense of urgency. After a few minutes, the woman finally relented. "You're beautiful," she said to Lofaso, breaking into tears.
As we waited for the ambulance, Lofaso told me: "You really have to go into the home to know a patient's reality. It's a whole new adventure every time you open the door."
I nodded, thinking about what I had seen that afternoon. House calls are a small, good thing. Sometimes, they can even be lifesaving.
Source Information
From the Heart Failure Program, Long Island Jewish Medical Center, New Hyde Park, N.Y.
References
Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci 2001;56:M603-M608.(Sandeep Jauhar, M.D., Ph.)