October 14, 2011

Making House Calls: A Story for Primary Care

A community doctor allowed me the privilege of bearing witness to his private practice by providing a training ground for early lessons in the practice and art of medicine. 

Hypertension, diabetes, glaucoma, diverticulitis, gout, cardiovascular disease, lung and breast cancers were among the most frequent of memorable cases that I recall from months that I spent one day a week observing patient care and providing administrative support — a premedical student’s dream. Office hours began in the afternoons and continued late into the evenings with overwhelming demand peaking during the winter months when cold and flu were on the rise. The office was open late because most of the patients worked full-time, but were often underemployed and/or underinsured and needed evening hour appointments. The small waiting area was always crowded, but most endured the wait with resolve because they respected for his commitment to care.  Patients knew that he would take the time to listen when it was there time.  This came through when they called for appointments and checked-in at the desk.

Patients usually lived within a five mile radius of the office, which was on the lower level of the doctor’s modest home, a few blocks away from my grandparents’ house.  He was their neighbor and physician, too. There were significant numbers of couples and intergenerational families in this patient population. I’d learn that most had been patients for many years. There was also an increasing number of new patients, who were always offered appointments near the end of office hours to accommodate more time as were the patients with complicated situations.

When illness loomed beyond his reach, the doctor helped his patients navigate a world of specialists and the hospital experience by managing expectations, explaining procedures and calming their fears while acknowledging the uncertainty. He held regard for and equipped caregivers, too.

A few times a week, the doctor made house calls to a few select patients with urgent care needs. I remember when he visited my grandmother when she had too much leg pain to get out of bed. He diagnosed her sciatica, gave instructions about rest, wrote a prescription and a note for work. Many years later he’d return to our home to see my grandfather for respiratory distress, the house call focused on helping our family come to terms with the pressing need for his hospitalization as well as to come to grips with the gravity of his condition. 

Physician house calls give a glimpse of the patient’s environment, lifestyle and dynamics that can go untold during history-taking. A vegetable garden growing on the side of the house may confirm some commitment to nutrition. Indoor odors with a hint of bleach may offer notes on cleanliness.  On the other hand, the smell of alcohol or tobacco may match symptoms visible in the chart. House calls offer a glimpse of the patient en vivo informing diagnosis, treatment and decision-making.

In this primary care practice setting, I gained a profound sense of the trust and respect necessary in the relationship between doctor and patient as well as the connection between community and doctor. 

I learned others lessons that I look forward to sharing in forthcoming posts.

N.B. Doctors providing primary care services deliver “definitive care to the undifferentiated patient at the point of first contact and [taking] continuing responsibility for providing the patient's care...Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient's medical and health care needs - not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.”
—American Academy of Family Physicians

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