House calls
Posted: 04 January 2014 09:08 AM   [ Ignore ]
Sr. Member
RankRankRankRankRankRankRankRankRankRank
Total Posts:  2602
Joined  2012-10-27

I came across this humorous opinion piece purporting to give the reason doctors no longer make house calls (anyone remember those?)

I thought MAcGyver might enjoy it.

http://www.kevinmd.com/blog/2013/05/reason-house-call-dead.html

Lois

Profile
 
 
Posted: 04 January 2014 10:11 AM   [ Ignore ]   [ # 1 ]
Sr. Member
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  2142
Joined  2007-04-26

Its an interesting viewpoint and I largely agree with him although I don’t believe that most doctors prefer this arrangement in order to distance themselves from their patients as he suggests. Some may, but not most. I have made a few house calls during my career but very few unfortunately. I remember each one because they are a far more personal interaction and much more meaningful than most office visits.

The problem is indeed money but not quite in the way that the writer implies. Medicine has become a much less profitable business over the past 20 years. This is especially true for primary care physicians like internists, pediatricians and family practitioners. These are the doctors who would normally make most house calls. Those of us in the primary care fields have always been paid much less than specialist in our screwed up system and as reimbursements have dropped and overhead ( employee salaries, malpractice insurance, rent) have all increased our incomes have dropped. The mathematics of this require us to see more patients per hour than ever before. This unfortunately means that a physician who forgoes an hour of office visits to travel and see a patient pays a steep price. We can only charge what the insurance company allows and not a penny more for a house visit. If a physician makes a house call he may have to work and extra two hours that day just to make enough money to pay the overhead he was unable to cover during the hour he was gone making a house call. The net result of 1 one hour house call and two hours of extra office time will be no payment to the physician at all for the three hours of work. He would have to be happy just to have made just enough to pay his overhead.

Its a shame. I think we all treat each other more humanely when we see each other as a whole human being. Doctors may give more compassionate care and patient may have more respect for the efforts their doctor makes on their behalf if they had a more personal connection. Like the author though, I am not optimistic that house calls will return any time soon unless the economics are changed. I think we would all be better off if the insurance companies and the government realized the value of house calls and changed the reimbursement system in such a way as to allow and encourage more of them.

 Signature 

For every complex problem there is a solution that is simple, obvious,.... and just plain wrong

Profile
 
 
Posted: 04 January 2014 12:16 PM   [ Ignore ]   [ # 2 ]
Moderator
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  4065
Joined  2006-11-28

Always interesting to compare the human and veterinary domains, which are based on very different economic models and have many other differences. For large animals, of course, houscalls are the rule since it is much easier to move a veterinarian than a herd of cows or a wild thoroughbred stallion!

In small animal medicine, there is a subset of veterinarians who have housecall-only businesses. The advantage is the convenience of the client and the decreased stress for the patient. The disadvantage is that they often can’t do much in the way of diagnosis and treatment for significant health problems. It is not unusual for me to see a pet brought in for weight loss and inappetence and have a full cbc and blood chemistry, chest x-rays, abdominal ultrasound, a cytology diagnosis of lymphoma, and the first dose of chemotherapy administered within the hour, which cannot happen in a housecall setting. Of course, human medicine is structured very differently, so it wouldn’t happen there either, but in veterinary medicine GPs have a much broader range of duties, and this requires the support of staff and the resources of a hospital.

I only make housecalls for euthanasia, and even that is rare these days for non-housecall veterinarians. Partly, this is due to the difficulty in recouping the cost of the doctor and staff leaving the hospital. But it’s also because a lot of veterinarians are uncomfortable with the uncontrolled home environment. I’ve shown up for euthanasias and had clients who were drunk, pets who could not be found or caught, and other such challenges, so I see why a lot of vets don’t want to do it. Still, my clients really appreciate it, and so far I’ve been able to convince my boss to let me continue doing ti for those who ask.

 Signature 

The SkeptVet
The SkeptVet Blog
Militant Agnostic: I don’t know, and neither do you!

Profile
 
 
Posted: 04 January 2014 07:43 PM   [ Ignore ]   [ # 3 ]
Sr. Member
RankRankRankRankRankRankRankRankRankRank
Total Posts:  690
Joined  2012-04-25

Yet another example of the disease of Capitalism. The really sad thing is that there are probably doctors out there (hopefully not in this forum) who have succumbed to the disease, and would completely disagree with macgyver.

Profile
 
 
Posted: 04 January 2014 07:57 PM   [ Ignore ]   [ # 4 ]
Sr. Member
RankRankRankRankRankRankRankRankRankRank
Total Posts:  2602
Joined  2012-10-27
mckenzievmd - 04 January 2014 12:16 PM

Always interesting to compare the human and veterinary domains, which are based on very different economic models and have many other differences. For large animals, of course, houscalls are the rule since it is much easier to move a veterinarian than a herd of cows or a wild thoroughbred stallion!

In small animal medicine, there is a subset of veterinarians who have housecall-only businesses. The advantage is the convenience of the client and the decreased stress for the patient. The disadvantage is that they often can’t do much in the way of diagnosis and treatment for significant health problems. It is not unusual for me to see a pet brought in for weight loss and inappetence and have a full cbc and blood chemistry, chest x-rays, abdominal ultrasound, a cytology diagnosis of lymphoma, and the first dose of chemotherapy administered within the hour, which cannot happen in a housecall setting. Of course, human medicine is structured very differently, so it wouldn’t happen there either, but in veterinary medicine GPs have a much broader range of duties, and this requires the support of staff and the resources of a hospital.

I only make housecalls for euthanasia, and even that is rare these days for non-housecall veterinarians. Partly, this is due to the difficulty in recouping the cost of the doctor and staff leaving the hospital. But it’s also because a lot of veterinarians are uncomfortable with the uncontrolled home environment. I’ve shown up for euthanasias and had clients who were drunk, pets who could not be found or caught, and other such challenges, so I see why a lot of vets don’t want to do it. Still, my clients really appreciate it, and so far I’ve been able to convince my boss to let me continue doing ti for those who ask.

Interesting point of view.  I guess veterinary medicine isn’t like it was on All Creatures Great and Small, though James Herriott/Alfred Wight was dealing mostly with large farm animals.  It would be difficult, even today,  to bring a cow, a sheep or a horse to the office!

Lois

Profile
 
 
Posted: 04 January 2014 08:02 PM   [ Ignore ]   [ # 5 ]
Sr. Member
RankRankRankRankRankRankRankRankRankRank
Total Posts:  2602
Joined  2012-10-27
macgyver - 04 January 2014 10:11 AM

Its an interesting viewpoint and I largely agree with him although I don’t believe that most doctors prefer this arrangement in order to distance themselves from their patients as he suggests. Some may, but not most. I have made a few house calls during my career but very few unfortunately. I remember each one because they are a far more personal interaction and much more meaningful than most office visits.

The problem is indeed money but not quite in the way that the writer implies. Medicine has become a much less profitable business over the past 20 years. This is especially true for primary care physicians like internists, pediatricians and family practitioners. These are the doctors who would normally make most house calls. Those of us in the primary care fields have always been paid much less than specialist in our screwed up system and as reimbursements have dropped and overhead ( employee salaries, malpractice insurance, rent) have all increased our incomes have dropped. The mathematics of this require us to see more patients per hour than ever before. This unfortunately means that a physician who forgoes an hour of office visits to travel and see a patient pays a steep price. We can only charge what the insurance company allows and not a penny more for a house visit. If a physician makes a house call he may have to work and extra two hours that day just to make enough money to pay the overhead he was unable to cover during the hour he was gone making a house call. The net result of 1 one hour house call and two hours of extra office time will be no payment to the physician at all for the three hours of work. He would have to be happy just to have made just enough to pay his overhead.

Its a shame. I think we all treat each other more humanely when we see each other as a whole human being. Doctors may give more compassionate care and patient may have more respect for the efforts their doctor makes on their behalf if they had a more personal connection. Like the author though, I am not optimistic that house calls will return any time soon unless the economics are changed. I think we would all be better off if the insurance companies and the government realized the value of house calls and changed the reimbursement system in such a way as to allow and encourage more of them.

Thanks for a professionsl view of house calls.  It is a different world and I can’t see physicians making them these days. It’s a very inefficient way to attempt to deliver medical care, though it would be wonderful resource in certain situations.

Lois

Profile
 
 
Posted: 05 January 2014 01:25 AM   [ Ignore ]   [ # 6 ]
Sr. Member
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  2634
Joined  2011-04-24

My impression was that house calls only ever happened if the patient was rich, or the doctor was a family friend.

From a patients POV, I would rather go to them, than have them come to me.

 Signature 

Raise your glass if you’re wrong…. in all the right ways.

Profile
 
 
Posted: 05 January 2014 06:59 AM   [ Ignore ]   [ # 7 ]
Sr. Member
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  9292
Joined  2006-08-29

And I would like to have a helipad on my roof so that the doctors could be at my house within a few minutes. But our corrupted government doesn’t seem to think it’s important.

Profile
 
 
Posted: 05 January 2014 08:13 AM   [ Ignore ]   [ # 8 ]
Sr. Member
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  2142
Joined  2007-04-26

In response to Mid and George’s comments, house calls are not a replacement for the office visit. Some people would not be comfortable with having the exam done in their home. Much more can be done in the office than can be done at home and for cost reasons alone house calls will never be offered as a convenience.  For those of the point and click generation who want everything at their doorstep at the click of a button, that will never happen with medical services. You’re not going to get a doctor in your house simply because you don’t want to get off the couch to have your sore throat checked out.

There are some situations where a house call would be very helpful though. Just as some animals can not easily be brought to the vets office some patients are not easily moved like those with severe dementia or disabilities. For those patients a house call would be a valuable service.

 Signature 

For every complex problem there is a solution that is simple, obvious,.... and just plain wrong

Profile
 
 
Posted: 05 January 2014 11:38 AM   [ Ignore ]   [ # 9 ]
Moderator
RankRankRankRankRankRankRankRankRankRank
Total Posts:  5500
Joined  2010-06-16

As I recall from a long time ago house calls were made when the person was too ill to make it to the office or wait till office hours.  These have been replaced by the 911/ambulance/emergency ward which is probably far more effective in treating the problem.

Occam

 Signature 

Succinctness, clarity’s core.

Profile
 
 
Posted: 05 January 2014 12:33 PM   [ Ignore ]   [ # 10 ]
Sr. Member
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  2142
Joined  2007-04-26
Occam. - 05 January 2014 11:38 AM

As I recall from a long time ago house calls were made when the person was too ill to make it to the office or wait till office hours.  These have been replaced by the 911/ambulance/emergency ward which is probably far more effective in treating the problem.

Occam

Yes and No. Certainly a person having a heart attack or a stroke is better served in the ER but there are many circumstance where a visit to the ER is far from the best way to treat a patient. Two examples that jump out immediately are:

1) Elderly patients with minor problems frequently get admitted to the hospital. Usually this is because the ER doc is not familiar with the patient. I have often joked with my colleagues that if they are over 65 and have a temp over 99 they better not walk through the ER because they will end up strapped to a gurney and admitted to the hospital. Older patients will almost always be admitted to the hospital if they go to the ER with a fever even if its a minor virus or a urinary tract infection. Unfortunately once admitted they are at increased risk of nosocomial infections and other iatrogenic problems like disorientation and falls brought on by a change in their environment. Many of these patients would have fared much better if they had been seen at home by a doctor who not only knows their history but is familiar with their social support system and with what they would want.

2) Young patients who go to the ER with minor issues - These visits do not usually result in an admission but an ER visit for even a minor problem can result in unnecessary tests and cost thousands of dollars. I have seen patients go to the ER for sore throats, bronchitis, pneumonia, shingles, urinary tract infections, headaches, weakness, nausea and many other non-urgent problems. Instead of a $50 office visit they incurred at least a $500 ER charge. Not all of these are worthy of a home visit either. Most of these patients would be better served going to an urgent care center or just by speaking to their doctor on the phone.

 Signature 

For every complex problem there is a solution that is simple, obvious,.... and just plain wrong

Profile
 
 
Posted: 05 January 2014 02:50 PM   [ Ignore ]   [ # 11 ]
Moderator
RankRankRankRankRankRankRankRankRankRank
Total Posts:  5500
Joined  2010-06-16

True, but there are other cases; I’ve been to the ER twice.  First was when I had my heart attack.  It was apparent but not extreme so I called 911 packed a bag with a couple of underwear changes, my Rxs and some reading material then waited at the curb until the ambulance showed.  I was admitted and think it was better that way. 

The second time I had severe ear pain on a Friday.  My ENT MD had recently retired so I went to ungent care where the MD took a swab and gave me some generic antibiotic.  Monday late night it hit again so I went to the ER and was given a different antibiotic.  Tuesday morning I stopped at the urgent care for the swab results to bring to an ENT and learned it was a candida infection.  I flushed my ear out with dilute vinegar for a few days and all was well.  I didn’t need an office visit. LOL

Occam

 Signature 

Succinctness, clarity’s core.

Profile
 
 
Posted: 05 January 2014 03:27 PM   [ Ignore ]   [ # 12 ]
Sr. Member
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  420
Joined  2012-02-02

It would be interesting (in the abstract sense, not the actual sense, of course) to see what would happen with house calls in the advent of a major epidemic, if doctors would resume making them, or if people would be required to go to increasingly crowded hospitals.  I grew up in a small town and part of the local lore was than during the 1918 flu pandemic, the town’s doctor (there was only one) and his nurse (who was also his wife) slept in their car for days in the center of town, so that people could easily find them.  The doc and his wife would then drive out to the person’s house to treat them.

Profile
 
 
Posted: 06 January 2014 05:11 PM   [ Ignore ]   [ # 13 ]
Sr. Member
RankRankRankRankRankRankRankRankRankRank
Total Posts:  1742
Joined  2007-10-22

I hated seeing the MD come through the door when I was a kid.  The first thing he did was pull out a needle.  grrr

 Signature 

Gary the Human

All the Gods and all religions are created by humans, to meet human needs and accomplish human ends.

Profile
 
 
Posted: 12 January 2014 03:41 AM   [ Ignore ]   [ # 14 ]
Sr. Member
Avatar
RankRankRankRankRankRankRankRankRankRank
Total Posts:  7664
Joined  2008-04-11
Coldheart Tucker - 05 January 2014 03:27 PM

It would be interesting (in the abstract sense, not the actual sense, of course) to see what would happen with house calls in the advent of a major epidemic, if doctors would resume making them, or if people would be required to go to increasingly crowded hospitals.  I grew up in a small town and part of the local lore was than during the 1918 flu pandemic, the town’s doctor (there was only one) and his nurse (who was also his wife) slept in their car for days in the center of town, so that people could easily find them.  The doc and his wife would then drive out to the person’s house to treat them.

Now-a-days, that ‘treatment’ often includes IV fluid for dehydration, because by the time they come in, they are usually quite dehydrated. They have quite often developed a secondary bacterial infection, pneumonia often accompanies a bad flu, so they get antibiotics, and our ICUs fill to the brim with intubated patients who go into respiratory failure and shock from the flu. No one could treat these patients at home and expect them to survive. In 1918 and 1920, the H1N1 flu had an extremely high mortality rate. Now the rate is ~35,000 deaths/yr thanks to advances in medical care, but could be reduced dramatically just by convincing the public to vaccinate every year.

 Signature 

Church; where sheep congregate to worship a zombie on a stick that turns into a cracker on Sundays…

Profile