by Dr. Michael Miller
Health care providers are by nature an altruistic bunch. I have the honor of interviewing potential entries to my beloved profession as part of the admissions process at the newest Osteopathic Medical School in Indiana, Marian University. The process is unique in that it does not simply ask the age old questions of “Why you want to be a physician ?”, (“Because I want to do primary care in a rural area”). No, our probing involves scenarios in which they have to look at a social situation, identify their thoughts, those of the opposing views and then cohesively demonstrate intelligence, confidence, logical thought processes and humanity…all in an 8 minute period repeated 7 times. Their responses juxtaposed against what I see in my day to day always gives me pause to think about how the practice of medicine has been so perverted by the promotion of self abdication of responsibility. The “let your government do it for you” mantras and newest politically correct definitions of disabled (encompassing everything from melancholia to dislike of red M and M’s) have resulted in a major paradigm shift in medicine. Whereas, the hospitals once touted their ability to heal all manner of maladies, they now recognize their cost ineffectiveness, more detrimental than beneficial care (just check the nutritional parameters of anyone pre and post hospitalization) and the downright danger of going to one, unless you are a burgeoning superbug.
So the shift is to the home, the place where the heart is, to where you bring the bacon and where the cows may yet arrive. House call medicine, once relegated to Marcus Welby MD (A TV show from the 60’s that dripped of altruistic, medical honey) is now the hot new medical paradigm. Reimbursement is actually a touch better recognizing that these visits involve the doctor on the move with what instrumentation can be carried in the standard car and a trusty assistant sidekick. Much like the US Post Office, “Neither snow nor rain nor heat nor gloom of night stays these couriers from the swift completion of their appointed rounds” EXCEPT for patient compliance. The official definition of someone being home bound and thus eligible to receive home based services is that their leaving home must be a “Taxing” effort. They are allowed to leave for church, certain specific personal issues and most interestingly for medical care.
And so to home we go, the place where the infirmed lay in wait for their scheduled visits done so at their convenience. While I recognize the basic human rights of privacy and the ability to be respected for one’s personal issues, having patients delineate the exact timing of their visits seems a bit out of sorts. I mean, they are “Home bound”, right ? More, there are those who watch the clock like a mission control countdown in which coming 10 minutes before or after the “scheduled “ time means risking their wrath. How many times have I contacted the patient days before with confirmation and then reconfirm the visit while at the encounter before only to be told it is now inconvenient, that they have company, they have another doctors appointment, that they are too sick to have the visit, or they are not dressed (always an interesting conversation with my truncal bedsore patients). Of course, the real risk of the house call is that the house is something from a hoarders episode, the ubiquitous GIANT friendly dog, or the family members reminiscent of Uncle Fester and Lurch.
The underlying problem is the now so pervasive entitlement mentality that a house call visit, once done with the utmost humanity, compassion and at huge inconvenience to the providers has become little more than a game of flashlight tag in which the patients have all the batteries. And so the question is, how do we solve this ? Unquestionably, many home bound patients are truly and solely home bound and their ability to get out of the house without a trained ambulance crew or other equal transport is onerous at best. To these patients, I am delighted to offer that which I have pledged in the name of Hippocrates. The key however is that not enough of them show neither simple appreciation nor preparation for what we house-call Medicare indentured servants do. The acknowledgement that our goal is to provide the highest quality medical care in locations far too often unsuitable seems far too alien far too often. But have no fear, the powers that be are looking at the documentation and starting to examine those all too powerful words “Taxing Effort”. My plea is they not question someone’s need for home based services and their provision. Rather, the goal should be to make patients responsible for them, that the definition of home bound means that you are so. Being too ill to have someone provide medical care in your home is ludicrous. Mandating rigid schedule adherence is something that only Pizza delivery boys can attain. Scheduling a home visit with all the attendant preparation of making the schedule, mapping a logical route, arranging to meet their home health care nurse and the attendant costs of time and money there means planning worthy of Bruce Jenner’s Pending surgery. And finding no one home or the patient “unavailable” means more than simply an earlier lunch.
House call Medicine, the ultimate in patient centered medical service. On demand care…Of the patient, by the patient , for the patient, but at who’s convenience ?
Until we ramble together next time…