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The Modern Iteration of the House Call

Kwan, Brian MS

doi: 10.1097/ACM.0000000000001628
Teaching and Learning Moments
AM Rounds Blog Post

B. Kwan is a fourth-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island; e-mail: Brian_Kwan@brown.edu.

An Academic Medicine Podcast episode featuring this article is available through iTunes.

I must confess that I wasn’t even aware that physicians did home visits in this day and age. They seemed a relic of the past, something I associated with Norman Rockwell’s Doctor and Doll, the classic depiction of a physician intently listening to the heartbeat of a small girl’s doll, the iconic black leather bag at his feet. Shortly after being accepted to medical school, my father passed on to me a similar leather bag given to him by his parents when he graduated from medical school. The bag was decades old, but I distinctly remember its pristine appearance. It had never been used.

It was with more than a bit of surprise then that I learned that I would be participating in a home visit as a medical student. I heard the highlights of the patient’s history as we drove to her house. She was in her early 90s and had vascular dementia with severe cognitive impairment, hypertension, hyperlipidemia, and diabetes. The patient’s daughter (herself in her 70s) was the primary caregiver. Both were born, raised, and lived in the same city their entire lives.

We arrived outside a small, one-story rambler, with peeling paint and a general aura of fatigue. The patient’s daughter met us at the door and immediately hugged the resident and nurse practitioner, something I had never seen in the clinic. After we entered the house, we engaged in several minutes of chit-chat, which, to the casual observer, may have seemed marginally inane. As I watched the resident and nurse practitioner, though, I realized that they were subtly, and astutely, starting to write their HPI. How was the patient doing since the last visit? Were there any syncopals or hypoglycemic episodes? How was her memory? Had she been able to get out of bed at all?

The patient lay in a hospital bed in the living room. A plethora of family pictures on the walls told us about her life—she had eight children, a career in retail, and was quite the chef for her family during the holidays. Her appearance was the exact opposite of the relentlessly aging house. The sheets were starched and glowing white, with crisp hospital corners. Despite being bed-bound, she was immaculate—skin clean and moisturized, wearing a spotless gown, and not a decubitus ulcer to be found. The patient’s pristine appearance was the physical manifestation of her daughter’s love.

Norman Rockwell’s physician would have recognized our examination—heart rate, respiratory rate, and blood pressure all measured manually. Not merely listening to, but actually taking the time to hear, the heart and lungs. Carefully palpating the abdomen. Thoroughly inspecting the skin. Making a few minor medication adjustments. Even without the Meaningful Use checklists, the requisite clicks in the electronic health record, typing that “a 12-point review of systems was performed,” and including the mandatory prepackaged, and often only tangentially useful, Patient Education text, it was obvious that medicine was still being practiced. There was no customer satisfaction survey to complete; nevertheless, the gratitude of the patient and her daughter was evident.

Those 30 minutes taught me a great deal—that family members are important providers in their own right; that there is much more to a patient than a collection of symptoms; that a careful examination of the patient’s general appearance and surroundings yields valuable clinical clues; and that looking a patient in the eye and examining her still matters, certainly to the patient, but perhaps even more to me. It was obvious that the value and substance of this experience would be impossible to recreate under the harsh, synthetic fluorescent lighting of an exam room.

Perhaps this experience was only an ephemeral, albeit magnificent, anachronism. If the patient were critically ill, we would absolutely need a modern hospital. And yet, as we left the house, I smiled as I saw that my stethoscope, blood pressure cuff, and ophthalmoscope filled my hands. I should’ve brought that black leather bag after all.

Acknowledgments: The author would like to thank Malasa Jois Kahn, DO, Alicia Curtin, PhD, GNP-BC, and David Anthony, MD, MSc, family medicine clerkship director, Warren Alpert Medical School of Brown University, for providing this clinical experience, as well as Hedy Wald, PhD, and Jenifer Kwan for editorial assistance.

Brian Kwan, MS

B. Kwan is a fourth-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island; e-mail: Brian_Kwan@brown.edu.

© 2017 by the Association of American Medical Colleges