Tuesday, June 24, 2008

Old Time Doc

Clueless at the time, when I applied to medical school I sort of imagined myself one day making house calls, good ol' Doc Schwab, paid in chickens and pies, smiles and blackberry jam. There I'd be, delivering babies on kitchen tables, patchin' up Old Lady Jones's leg on the sofa, shaking out thermometers and feeling foreheads.

One of my roommates in med school was the son of such a doctor, although instead of clopping around with a horse and buggy, he raced across the back roads of Kentucky in an Aston Martin DB4, before James Bond ever thought of it. State cops would look the other way: Aincha gonna stop 'im Jess? Do whut now?...hail no, that thar's Doc Munger, heading t' th' McCoy homestead, I reckin'...

I liked the whole idea of it.

More so in the early days of my practice, when I had a little extra time on my hands, but to some degree throughout my entire career, I actually made house calls. As time became more precious, I had to be realistic: not too far out of the way, people with a simple problem for whom a trip to my office was especially difficult. Or, once in a while, a friend. But as a youngster there were a few times when I went quite out of the way, and spent a lot of time.

For example: I've always had mixed feelings about "the phone call." A woman is awaiting the news of a breast biopsy; I call her and note the stoppage of breath at the other end of the conversation. To defer by saying she should come in is to let her know but provide no support. To give the news over the phone is in some way heartless. So I'd split the difference by breaking the news as gently as I could, and inviting her in for an immediate consultation. But sometimes, early on, I reversed the equation and said, "How about if I come over and we can talk about it?"

One time, in my pre-gray-hair days, after I'd spent at least an hour at their home, my patient and her husband gushed at how much they appreciated the visit and my care to that point, but they'd be going to Seattle to be treated. Probably thought I looked too young. And hungry. Pissed me off.

Most of the time, my house calls were to a post-op patient, usually older, having a hard time getting around: quick check of a wound, a little debridement, change a bandage, remove or unclog a drain. I'd load up with a few tools, some tape and gauze and ointments; sometimes I stuffed them into my black doctor bag, for my own nostalgia more than anything else. Walking to the door, wondering what the neighbors thought, figuring they'd be jealous, their neighbor had a heck of a doctor there.

Always the visit was greatly appreciated, and generally met with amazement. Sometimes it was my own: finding out how my patients lived, in a trailer, in an unkempt crumbling home, in a fancy joint with all the options. And I'd learn about how they were able, or unable, to carry out the instructions I'd given them. Which led to a much more practical and pragmatic approach to what I'd tell people about after-care at home. Dispensing with certain residua of academe.

Once I got a call from a feisty old lady for whom I'd recently done a mastectomy: she was worried about her wound, or a drain, or something. To her obvious delight I'd said, "Well heck, I'm almost done here, how 'bout I swing by your place on the way home and have a look?" She answered the door buck naked from the waist up, her unoperated side of the enormous variety; responding to my undisguised surprise she said, "Hell, I figured you'd want to see it anyway, so why get dressed?" Her home was right on a main street. No screeching tires, far as I recall.

Making those decreasingly frequent but career-continuous house calls always made me feel good. The benefits were invariably mutual. Part of my medical school curriculum was the matching of every first-year student with a family in which the wife was pregnant. We followed her through pregnancy and delivery and were involved in the care of the baby. At least one home visit was a requirement, and we met in groups afterward to discuss what we'd found. Among others, the import was in learning that patients' illnesses are part of an entire life and not just the little slice of the day during which we see them.

All doctors -- and most especially surgeons, who typically send people home very significantly altered (if only, hopefully, for a short while) -- would be amazed by and learn from seeing their patients in their homes. It is, of course, completely impractical and nearly wholly impossible nowadays, which are very good reasons why it rarely if ever happens. Not to mention the occasional fright of seeing an old lady naked at her front door.


rlbates said...

I love those fiesty old ladies (hope to be one someday). I have made a couple of house calls over the years, but (thankfully) never been met at the door like this.

egomosperficio said...

i think that's great, sid. of course, it makes me think of when i gave private music lessons in students' homes. i once showed up at one young ladies' house for a lesson and realized that her parents were out of town that week because she had decided to meet me at the door wearing nothing on top but a piece of lingerie.

did you ever have a patient misinterpret your motives when you offered to make a house call?

Devorrah said...

It's my habit to make home visits to all my students before the first day of class for all the reasons you mentioned. There's just no substitute.

Anonymous said...

Au contraire! House calls and home-based practices are making a comeback.

You write so passionately and wistfully about this - maybe it's the next chapter for your practice?

Sid Schwab said...

annie: yes, but it's sort of "either/or." Some set up their practices that way, but you can't have a traditional practice and do it. Plus, most of the new wave are premium-based, and for those who can afford to pay that premium. I never charged for a house call, but even if I had it would not come close to paying for itself at the going rates. (Nurses, actually, get more!)

Anonymous said...

"....but you can't have a traditional practice and do it"

That's ironic, isn't it, since house calls used to be the standard for traditional practice. I didn't realize that there was an organization for home visit-based physicians, but the FAQ is interesting.

What would be your vision of an ideal practice?

And just to be a gloom and doom purveyor, in the event of a flu pandemic, it'll be almost all home care and isolation/shelter in place. You could be REALLY ahead of the curve (hopefully not over the cliff)

Anonymous said...

Here's the modern day version for you Dr Schwab...


Margaret Polaneczky, MD (aka TBTAM) said...

Unless gas prices come down, tooling around to patient's homes anywhere but in a 20 block radius in Brooklyn like our firend Jay Prkinson will be too costly.

JP said...

My grandpa in Olympia just had surgery and received a house call from his (general?) surgeon when something-or-another wasn't draining properly. My whole extended family now knows this doctor's name. He holds lifetime hero status, as much for catching the close-call requiring surgery as for the house call that followed. I'm sure you hold hero status in many families, too.

Anonymous said...

My surgical career in Monterey/Pacific Grove CA could be superimposed upon Sid's in many ways, in particular, house calls. This essay is exactly my experience. I have talked to Sid about the joys of the house call and one thing he didn't say was that he (and I) never sent a bill.
My senior partner had a saying: "you make your friends in the office and at home, you make your money in the operating room."
Times have changed.