What Ever Happened To The House Call?

A recent event of a rather personal nature has prompted me to add one more essay to this series on the suggested, workable means for a reduction in the insidiously rising tide of healthcare costs in our country. A close relative is currently experiencing the terminal phase of her courageous four year battle with cancer. My wife and I have been intimately involved with the process of providing aid and comfort to her end of life care, in conjunction with some very dedicated servants in the home health and hospice programs.

In order to qualify for pain medications (narcotics) that will afford her comfort as her demise steadily and surely approaches, the law requires that she be evaluated by her attending physician on a regular basis. Because her personal physician does not routinely make house calls it has become necessary to transport this very frail, physically weak and terminally ill patient by ambulet van to her physician’s office, located less than three miles away. Her son, a highly respected professor of medicine in one our state’s finest medical schools and an individual who trains future physicians in the ethic, art and science of the practice internal medicine, has patently stated that it is quite an ordinary practice these days for physicians not to make house calls; unless he added, the patient is dying. That is apparently not high on the list of priorities that he is now teaching to these future internists. Not only does that strike me as heartless, it is also quite expensive since that transportation by ambulet will cost an extra $150 (minimum) to transport my terminally ill relative back and forth. Whatever happened to the compassion that drove physicians to the bedside of their home bound, chronically ill patients?

When I entered the practice of medicine in 1967 house calls were a routine service that a physician was expected to provide to his or her patients. Every physician I ever knew had a black leather bag in which he or she carried a stethoscope in order to listen to the patient’s heart and lungs, a blood pressure cuff and special tools for examining the eyes, ears, nose and throat. In addition there were certain drugs that were needed on an emergency basis including cardiac medications, injectable antibiotics and narcotics. A most treasured gift from my wife to punctuate and celebrate the start of my medical practice was a beautiful, engraved, black leather bag and it regularly accompanied me on thousands house calls for the next 31 years.

The house call enabled a physician to thoroughly examine the patients, assess possible changes in their physical status and adjust medication doses, or add new ones, as the case may have been. The patients, and their family members, felt a deep sense of security knowing that their attending physician was well informed about their current clinical situation and was making the proper adjustments in the delicate management of their long term care. Routine calls were scheduled on a day when we did not hold regular office hours: in my case it was Thursday. It was not at all uncommon for me to make five or six routine house calls on that day of the week attending to the needs of those patients who were home bound due to strokes, end stage cancer or other severe, physically disabling diseases. In addition to the routine house calls, I made emergency visits when a patient was too ill to be seen in my office, usually scheduled after office hours or over the lunch hour (if they could wait for a couple of hours) or unscheduled in the middle of the night. The last day I practiced I made a final regular and routine house call on a 100 year old lady who had not been in to the office for four years. There were times when my house calls took me deep into the surrounding farm communities adjacent to Poland, Canfield, Hubbard, Austintown, North Jackson, Coitsville, New Middletown, and the like. When folks could not afford to pay me they gave me fresh vegetables, canned goods, eggs, frozen meats they had previously butchered or freshly slaughtered chickens.

I recall with fond memory an elderly, black couple (probably about my age now) that lived in the lower Southside in what we now refer to as the ghetto; their children were grown, married and still living in the area. She had suffered a stroke, could not speak and was paralyzed on one side. Her loyal and loving husband had vowed to keep her at home if I would simply agree to attend to her needs on a reasonably regular basis. He was an extremely devoted husband, an immaculate house keeper (both in and outside) and a wonderful cook. I made routine visits to their home early on Thursday mornings, once a month as I was on my way to Southside Hospital for clinical rounds and a medical conference. When I had finished seeing his wife Elizabeth upstairs, George always had breakfast waiting for me in the kitchen. We sat and talked while I enjoyed bacon, eggs and home fired potatoes (or grits), embellished with toast and homemade jam from his strawberry patch and good, strong coffee. George and I became very good friends.

One summer’s evening in 1969, during a period of serious racial tension in Youngstown, I received a call from George saying that Elizabeth was burning up with a fever and coughing up blood. I had been watching the evening news and folks were being advised to stay safely in their homes in order to permit a state of martial law to quell the disturbance. The Governor of Ohio (James Rhodes) had called out the state militia and there were National Guardsmen on many of the Southside street corners. As I remember there was a curfew every night and the racial tension followed for some time. George asked apologetically if I would come to his home and examine Elizabeth. I agreed, much to the chagrin of my family.

As I approached the corner Market Street and Falls Avenue I was greeted by a Staff Sergeant, Ohio National guardsman who held up his hand in a halting position. Behind him was a military truck and sitting in the bed of the vehicle facing me was a guardsman armed with a fifty caliber machine gun. Parenthetically, I have since been told that none of the weapons used that night contained live shells; I am not certain how true that is. At the time I had an orange colored, 1968 Buick, Skylark convertible with a white “rag top” and white leather seats; hardly an inconspicuous (stealth) mode of travel on such a precarious evening. The sergeant approached my car, its top down, and asked me where the BLANK I thought I was going (his superlative deleted for the readers’ sake). Holding up my black leather house call bag, I told him about my gravely ill patient and said that I needed to proceed into the ghetto. He said that I was crazy, being white and sitting in a bright colored vehicle that offered no protection, and he was certain that I would be drawing rioters like ticks on a hound dog. I then asked for a military escort. He called his commanding officer and got permission to accompany me to the house where Elizabeth and George lived; I led the way.

When we arrived at the humble residence the military escort departed and I went in to see Elizabeth. As I had suspected from some questions I had earlier posited to George on the phone, my physical examination revealed pneumonia: her temperature was over 105 degrees F, her breathing was markedly labored and she needed to be hospitalized immediately. I called Gold Cross Ambulance. The dispatcher knew me and asked where I was. When I told him he said, “You’re where? Dr. Mc Gowen, are you out of your mind?” I assured him of my sanity and informed him that his ambulance crew would find a willing escort at the corner of Market and Falls and because of my gravely ill patient they should proceed without delay. They did, we got Elizabeth to Southside Hospital for a one week stay and she lived four more years while I enjoyed George’s fabulous cooking, some of which I purposely planned for lunch time visits.

Please believe me when I say that I have not said all of this in any boasting manner. I merely did what most primary care physicians did in those days; it was expected, it was the right thing to do and it was only one part of our total responsibility to our patients. I am simply pointing out the fact that it will be one more cost saving measure that should once again become part of the American medical scene. When I graduated from medical school on June 10, 1961 I raised my right hand and took the Oath of HIPPOCRATES. It reads in part, “Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption.” The house call was not a badge of courage it was merely a sign of commitment; a promise kept.

A hands on approach will spare many people from making costly and unnecessary visits to the ER. When a physician cannot decide over the phone as to the need for a patient’s hospitalization he or she must see and examine the patient. When that patient is too weak or ill to come to the office (such as my terminally ill relative), but they are not in need of immediate hospitalization, the physician should see them in their home. Currently many medical communities have physicians known as “hospitalists” who staff the general hospital and obviate the need for the private physician to make daily hospital rounds. It may come to the point where we will need a special breed of physicians who only make house calls and nursing home rounds. Be that as it may, it will be one more vital step, a patient friendly way, to reduce the rising cost of medical care.