January 27, 2021

It’s Wednesday again. Three weeks ago on Wednesday, the Capitol was attacked. Two weeks ago on Wednesday, the previous president was impeached for a second time. One week ago on Wednesday, the new president was inaugurated. I’m kind of disappointed something momentous didn’t occur today as well. There’s still a couple of hours left before midnight, unless you’re east of Nova Scotia, so I suppose it’s possible we’ll have something major before the end of the day but it may be that it’s just as well that the rule of three is holding and we’re all being given a chance to catch our collective breath. We’ve all been given a lot to absorb and process the last few months and I, for one, could use a little down time. I don’t know how the generation that made it through World War II was able to keep it up for six years.

The news is mixed from Covidland. It hasn’t gone away despite having been driven off the front pages recently by political news. On the good side, it looks like the surge fueled by holidays is definitely starting to recede. Numbers are down in general. Here at UAB, inpatients are down about 25% from the peak from about 300 to about 220. It’s still far too many and the numbers in general remain grim. World wide, the count has broken nine figures with over 100 million cases recorded. (Almost certainly an undercount by a significant margin). In the US, we’re at about 25.5 million. The speed with which we’re experiencing new cases and deaths has begun to slow. Whether that’s due to behavior change, vaccine distribution, or other reasons is not yet clear. On the bad side, the new UK variant that’s significantly more contagious is definitely spreading in the US and this may be enough to knock numbers back the wrong way again. Even here in Alabama, several cases of the new strain have been identified.

Vaccine is finally being more appropriately distributed and everyday I hear from a friend or a patient that they’ve received their first dose and are scheduled for their second. Systems are falling into place at both the federal and state levels to keep supplies up, the current limiting factor. My VA house call program has solved the logistical problems with transporting the vaccine during its safe post thaw window around the state to our bedbound house call patients and we are getting them slowly but steadily taken care of. Large sigh of relief. There’s still a lot of work to be done to reach and educate underserved communities and there’s still significant political stigma associated but that seems to be waning somewhat as the vaccine rolls out with minimal side effects.

It’s been gratifying for me to see the return of the house call to a more prominent place in medical practice in recent years. I have always believed that they are central to helping people maintain good health. Back in the day, before my time, most primary care medicine was done in the home. The doctor made the rounds in a mule cart or Model T and treated what he could, educated families in proper nursing, and always comforted when there wasn’t much else available. Following World War II, doctors migrated into offices, usually attached to hospitals in some way so they could care for both outpatients and inpatients at the same time. They still did occasional house calls. The introduction of the federal payment structures of Medicare and Medicaid and the rise of for profit insurance nearly killed them completely with growing emphasis on time efficiency and volume.

When I entered medicine in the 1980s, there were no opportunities to observe or learn about the art of the house call. I was never exposed to one, even with my wandering around rural communities as part of the University of Washington’s program to create primary care doctors with roots in small town Northwest US. Neither house calls nor geriatrics were part of my curriculum either in medical school or in residency. (I never met a geriatrician until I was nearly finished with my internal medicine training). When I opted for geriatrics, one of my first assignments was to UC Davis’s small outpatient geriatrics clinic. On one of my first weeks there, the ambulance pulled up and offloaded a poor lady on a stretcher. She couldn’t get out of bed at home. The process of transferring her from the bed to the ambulance and then into the clinic had aggravated her arthritis and she was crying from pain. She was demented and not able to tell me much of anyting about her condition. No member of her family had come with her. The ambulance drivers knew little about her other than the address from which they had picked her up. I called her home, got her daughter (she hadn’t been allowed in the ambulance and didn’t have access to a car to have come on her own) and learned a bit about the patient. When I asked where the family lived and figured out it wasn’t more than a few miles from my house, I told them that next time the patient needed medical care, I was going to come to them.

“Can’t you fellas read the sign? I can’t let you wheel him in here.”

I had no idea how to do a house call. I went to the powers that be at UC Davis and told them I intended to do them on certain clinic patients like that one who would otherwise require ambulance transport. There was no objection. I located a group, the American Academy of Home Care Physicians and attended their annual meeting looking for ideas. (It fit in a classroom as there were fewer than fifty members nationwide). I learned that the reason there were so few housecalls was due to the Medicare reimbursement scale for physicians which at that time simply made it financially unfeasible to do them. As a fellow in an educational program, this wasn’t an issue. I learned by doing. I did more.

I started to realize how much I missed only seeing patients in the artificial environment of the clinic setting. I discovered the family where all the medications were poured into a candy dish and grandma picked out the ones she felt like that day. I learned to equate chronic GI issues with unsanitary kitchens and help teach patients food safety. I learned to carry a large bottle of Febreze and spray myself down after visiting certain homes so I wouldn’t smell like an ashtray the rest of the day. I learned how not to touch the furniture in some places. I put up with the occasional case of scabies from unwashed bed linens.

By the time I left Sacramento, I had built a thriving academic house call practice that taught house call medicine to residents and medical students and provided care to a uniquely vulnerable segment of the population. I became comfortable with people on ventilators at home, and families that more or less ran an ICU out of their kitchen. The program disappeared in the collapse of clinical geriatrics at UC Davis that forced me to leave California in search of alternate employment, but when I got to Birmingham, I brought that skill set with me. The Birmingham VA had a functional home care service that I became part of for a while. I’m back with it again after a decade hiatus for other projects. I introduced the UAB system to house calls and more or less did them on my own hook for years and years as they were the right thing to do. UAB eventually saw the wisdom in them and has built a robust house call service over the last few years but for the most part I haven’t been involved as I have simply had too much on my plate.

Going into someone’s home as a physician gives you a unique perspective on a patient. You start to learn about who they are as people. What’s important to them. You meet their families. You meet their pets. You see the photos on the walls and meet their ancestors and their family histories. You also meet them on their own turf. The power relationship is reversed. You are on their ground and they are the ones in charge of what will and will not happen. There are times when I wouldn’t have it any other way.

Sign up for your vaccine when you can. Even if you’ve gotten it, you know what to do: Wash your hands, wear your mask, social distance, don’t take random pills out of a candy dish.

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