"The doctor will come to see you"

Once a dying art, house call practices are making a comeback

By Graham Lanktree

"It doesn't make sense for frail people to go to a physician's office," says Vancouver house call doctor John Sloan. "There are all kinds of time constraints there forcing you to do a half-baked job."

Over the past 12 years Dr Sloan has built a rare kind of practice out of his home, one which relies purely on the house calls he makes to house-bound patients throughout the day. He says going to his patients allows him to keep on top of their conditions and prevent them from becoming bed-blockers in a hospital emergency room.

But when Dr Sloan retires from his pioneering practice at the end of this month, many worry the state of this special breed of care will be up in the air. "It's going to be a huge loss for the people who use his service," says fellow house call full-timer, Victoria's Dr Ted Rosenberg, of his mainland colleague. Luckily, younger docs in big cities are starting to see the value of this care model.

SHOW ME THE MONEY
The frail are such complex, hard-to-examine patients, Dr Sloan says, that the information doctors need is only available if they see first hand how the patient functions at home. For instance, how they take their meds and whether their homes are set up for fall prevention.

But this kind of care is time-consuming. Dr Sloan has a small roster of 250 patients in his family practice. How can he make ends meet with so few patients? "Income wise, it's about equivalent to a regular practice because the overhead cost of the office is missing," he says. "There are costs, but it works out to be the same and it's just much more interesting."

So why aren't more MDs getting involved? Dr Rosenberg has a pretty good inkling. "It's hard to mix general practice with this sort of model," he says. "I can definitely see how it's harder for doctors who only have 20 house-bound patients to ramp up for this sort of thing."

Dr Rosenberg serves 335 patients in his practice, with the aid of a nurse practitioner and one and a half gerontological nurses. He says this team approach to home care and house calls is the most efficient and one where technology should play a large role. "We have a virtual team, and I only see the staff once a month. We have electronic records and at the end of the day each member sends me progress notes by email so I can make comments."

Dr Rosenberg's team also uses cell phone text messages and tablet PCs with file sharing programs for constant communication.

He says much of his time is also spent on the phone providing refills or responding to emails from his patients and their families. One problem, he says, is the public system doesn't pay for this communication. "In BC, you get paid between $32 and $65 for a house-call, so I have to charge my patients a practice fee of $1,250 a year. That's something the public system could cover, especially since it would cost $1,000 a day if my patients were hospitalized."

TORCH BEARERS
Dr Rosenberg identifies another problem: training med students in the techniques of home care and house calls. Dr Rosenberg says that some family physicians bring in students for on-site training, but there is hardly a systemic approach to passing the torch.

Dr Stephen DiTommaso, director of University of Montreal's family medicine program, is only too aware of the challenges of getting med students excited about house calls. In 2004, after too many students appeared bored and disinterested when he brought them along to visit the house-bound, Dr DiTommaso started a unique approach to home care in his program. "For years it was unpleasant," he recalls. "Students were merely spectators when they accompanied a doctor to a home."

Now, after they've observed professors making house calls for at least a month, students arrive at Dr DiTommaso's office one morning to find their prof missing and a black medical bag filled with directions to the patient's home along with medical charts and a 'special mission' envelope with instructions to appraise the patient's health status and resources. "When we added an element of surprise to the program, making the home care call became thrilling to them."

"I don't have follow up data, and don't know how many students actually end up going off and doing home care in a CLSC [a community clinic] or other practice," Dr DiTommaso says. "What we do here is encourage students to do home-care, or at least know how to, by giving them some practice."

GENERATION NEXT
In school it was hard to find mentors who believed in home-care services, says Dr Jean Zigby, a palliative care specialist in Montreal. "When I went it wasn't preparing me for the future, it was preparing me for the past. I had to seek out and follow the few wise mentors who were willing to train me."

The CLSC, which Dr Zigby joined in 2001, has been delivering home care ever since it opened in the early 90s. "In the urban centres there's been a small resurgence in home care," he says. "I know many doctors who do it as a full-time job."

As the Canadian population ages there will be even more necessity and demand to provide these services. The number of Canadians aged 55 to 64 jumped 28% in the past five years to 3.7 million.

Dr Zigby suggests one main problem is that there's no formalized structure requiring physicians to make house calls as he and Drs Sloan, Rosenberg, and DiTommaso do. "It's too easy to say no, sit on your butt in an office, and have everyone come to you. If you want to behave like that you aren't providing the services that people need."