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

In Memoria: Do Justice

Last month, my beloved great Aunt passed away after battling illness with the same kind of  spirit she took on to address the challenges in her life applying tenacity, courage and a good sense of humor.  I had the honor and privilege of writing her obituary. It was a time of healing, reflection and contemplation. Memories, pictures and inquiries with family and friends helped me move through a century of American history to offer a vibrant narrative on her struggle and strength in living out a meaningful life.   

Remarkably, my Aunt was a leader in our family and community.  She was a critical thinker, agitator, strategist and organizer who kept a close view of the world and hand in our lives encouraging resiliency, progress and love.  

As a young woman, she and my maternal family escaped the threat of harm by moving from a small South Carolina town on the boarder of Georgia to New York City.  During the 1940s many black families were making the same travel plans because Jim Crow left many realizing that flight was a better response to their fears than a fight because so much blood had already been spilled. I believe as her eulogist suggested that untold horrific stories of her encounters with discrimination and racism moved my Aunt to work after work and family responsibilities in the civil rights movement. She taught me lessons about what it means “walk humbly, love mercy and do justice” in a world that doesn’t seem to favor the empowerment of people of color. In her eyes doing justice involved working actively in the community and beyond for the sake of humanity.

While the legislation of the Civil Rights Act of 1964 outlawed discrimination against blacks and women, including racial segregation there was still work to be done for progress.  For example, prior to 1964 it was illegal for people of color to go to a hospital to receive medical care anywhere in the United States, very few places had colored hospitals. Many organizations continue the push for justice in education, employment, housing, health care as well take on the criminal justice system for the well-being of our society.  Since 1909, the National Association of Colored People (NAACP) has been pivotal in leading the way by addressing injustice. Today, the aim is to bring an end to the death penalty in the United States, you can join this cause at http://action.naacp.org/EndTheDP

“When in Gregg v. Georgia the Supreme Court gave its seal of approval to capital punishment, this endorsement was premised on the promise that capital punishment would be administered with fairness and justice. Instead, the promise has become a cruel and empty mockery. If not remedied, the scandalous state of our present system of capital punishment will cast a pall of shame over our society for years to come. We cannot let it continue.”

           
          —United States Supreme Court Justice Thurgood Marshall, 1990

I’ve come to understand professionally that lethal injections are not good medicine.  According to the Innocence Project, “seventeen people have been proven innocent and exonerated by DNA testing in the United States after serving time on death row.” I agree with the National Urban League statement “disparities and problems cast a long shadow of doubt over our criminal justice system.”

The state of Georgia shamefully executed Troy Davis on September 21, 2011 despite serious doubts about his guilt. But our fight to abolish the death penalty lives on.”

                                                               —Amnesty International

In fifteen minutes, execution by lethal injection ended the life of Troy Davis with too much doubt. 

 

Matters of the heart

My sketch of the human heart during first year anatomy.

She whispered to me with bulging eyes of urgency, “something is not right, I’ve been in pain all night.” Her chief complaint was chest pain.  She had a routine work-up and some care with little relief.  The news came that all of her test results were normal.  Her body appeared tense, she looked panicked and afraid.  At bedside, the attending suggested endoscopy offering that her pain may be related to a gastrointestinal condition.  I introduced myself immediately as a medical student and quickly advocated for a cardiologist consultation. I mentioned that a few months prior she had been rushed to this hospital by ambulance with what had been determined as idiopathic ventricular fibrillation. The attending shook his head, he started moving toward the nurse’s station and I followed behind.  He reviewed her case with me again and then he shouted, “endoscopy” then I said “cardiology consult.” I left quickly without waiting for a response because I was trembling with fear.

As I sat outside trying to figure what my next steps would be, my phone rang and it was the nurse, she said that the attending had agreed to the cardiology consult. I returned to our house to care for my grandmother, in the absence of my mom she had no caregiver.  In the afternoon the cardiologist called me to express his concern with mom’s condition. He recommended, pending insurance approval that she be transferred to another hospital (the one that I had told her to go in the first place) for more tests and further observation.  This hospital did not have a full cardiology service and would be closing for good within next 72 hours.

Mom was transferred that night, additional test results showed significantly block coronary arteries. Early the next morning she had cardiac catheterization to open her blocked blood vessels. After a short hospital stay in she returned home. 

For a medical student learning to observe in clinical settings is a skill that comes with practice, time as well as teaching.  Furthermore, bearing witness involves seeing the whole patient taking aim at focus beyond the chart to examine the situation. The recently released book by Dr. Augustus White, Seeing Patients: Unconscious Bias in Health Care (Harvard University Press, 2011) offers the following:

“...the race and sex of patients [influences] physicians’ decisions about whether to refer patients for catheterization...If you were black, the report (Schulman et.al) concluded, you were less likely to be referred.  If you were a woman, you were also less likely to be referred.  And if you were a black woman, you were especially less likely to be referred.”

While some have criticized Dr. Schulman’s research as “exaggerating the disparities” inequalities in treatment and care are demonstrated in his efforts providing evidence for the need to improve health care as discussed in the report  Unequal Treatment Confronting Racial and Ethnic Disparities in Healthcare by Brian Smedley et. al.  As an African American woman who is a physician-in-training, I’m glad to witness good medicine as well as mom’s progress.

Cross-posted  at KevinMD.com

Our world and families in the days ahead

Today in America you have a 50% chance of living beyond 100 years. Those who are aging and living well make this mark with survival stories of resiliency by allowing the power of hopefulness to help them with setbacks in life, they overcome stress with success.  Another  key is having a network of care and love from families, friends and supportive communities. We need our families and beloved communities for long and healthy lives.

The United Nations set May 15, 2011 for the observance of the International Day of Families with a theme of "Confronting Family Poverty and Social Exclusion." It’s a call to recognize that families around the world are vulnerable especially given the persistence of violence, poverty and the uprising of natural disasters in an already unstable and unbalanced climate.  From my view convening a global or national dialogue on family requires a look beyond strategies of war, approaches to economic market stability or business as usual in search of policies and practices that mobilize resources to value, connect, unify and empower communities and families who are interconnected by blood lines across generations and living together, in close proximity through relationships and/or sharing physical location.  What’s the challenge?

“Social exclusion is often at the root of the problem. Discrimination and unequal access to social services deprive families of the opportunity to plan a better future for their children. Certain types of families are at particular risk, including large families, single-parent families, families where the main breadwinners are unemployed or suffer from illness or disability, families with members who suffer discrimination based on sexual orientation, and families living in urban slums or rural areas. Indigenous and migrant families, as well as those living through conflict or unrest, are also on the front lines of marginalization and deprivation.”  

Secretary-General's Message for 2011

The aftermath of earthquakes in Haiti and Japan show people struggling to find their children and other family members.  In Haiti the rising levels of cholera puts families and communities at risk for illness that without access to clean drinking water, nutrition and health care increases preventable deaths. In a technology meets volunteerism equals innovation, crisis mapping has helped bring response teams with resources to critical areas of the world.  A website and portal www.Ushahidi.com helps users “call for help” using mobile devices via email, sms and tweets to map locations of distress based.  Many countries like Hait don't have a 911 response system. Volunteers around the world have helped to develop the sophisticated system using Facebook, Twitter and Google maps with people on the ground to reconnect some children and families when geography seemed to be an impossible barrier. A vivid example showing the power and possibility of connection, for families around the world.

The recent devastation of tornadoes and floods in southern and mid-western parts of the United States have left many families homeless, disconnected and grieving the loss of loved ones.  Who will help them heal?  In her book, The Warmth of Other Suns” author Isabell Wilkerson tells the migration stories and now more so the return of African American families to their southern roots, which perhaps still remains tied to the search for relief from discrimination and racism. Yet, remarkable and significant progress has led to stunning diversity in America visible in neighborhoods, schools and the workplace, but also shows clear evidence of inequity at the cost of lives, comprising health and society. Here we have to continue the dialogue to realize for better outcomes for the future.

What can we do to strengthen our families?  We can take on acts of empathy, compassion and love without delay.