Monday, March 15, 2004

Is There a Doctor in the House?

8 patients so far, and 1 house call. The house call was to the home of a 92 year old woman who had seen me once, and we agreed it'd be easier for her to just have me visit her at home for a follow up. The first thing she said when I arrived was that her granddaughter knew me. It turns out her great-grandchildren share the same piano teacher as my daughters, and that we'd seen each other before at piano recitals. What a small world!

We spent some time talking about her family, and other things. I focused most of my questions on gathering a medical history, but naturally the conversation wandered into areas such as safety of various medications, osteoporosis prevention, and personal alert button in case she falls and can't reach the phone. In all, I spent about an hour there, and we had such a pleasant conversation I'm sure I could have easily spent another hour there, except that I had made an appointment with another patient (for which I was now late). So when it came time to pay, I told her I would only charge her for a 30 minute house call, since I felt guilty about charging her for an hour. The old "undervaluing my time" complex again. In all, I charged $125 for the house call, but because I offered a 20% discount for prompt pay, it worked out to $100.

This article discusses some nuts and bolts about how to do house calls.

There are some practices that do house calls only. Housecall Family Practice is one. This is a nationwide referral list of the American Academy of Home Care Physicians, but it looks like it only lists its own members (naturally). This site talks up house calls as an alternative practice style for physicians.
Want to feel like a Doctor again?

Our physicians, seeing just 7 patients a day, can earn $130,000 to $170,000+ annually. They're rarely on call, and no one ever tells them how to practice medicine.

Sounds too good to be true.

But there is something about house calls that does make me feel "more" like a doctor than just an average office visit. I think because I feel like I'm doing something above and beyond what an ordinary doctor would do. I also feel this way when I feel like I've made a great diagnosis that I think few others would have made.

While at Kaiser, I made a few house calls. It is certainly not a routine service that I did, but there were times when it seemed appropriate. Like the time a patient's daughter called because her mother fell out of her chair and couldn't get back up because she weighed over 400 lbs. She called the advice nurse first and they told her a home health nurse wouldn't be able to get out to them until tomorrow. I thought this was inhumane and ridiculous that she'd have to spend the night on the floor, so I walked down the hallway and recruited another family physician, and we drove to her apartment. With the help of a neighbor, we managed to get her into bed. Since then, she's lost over 100 lbs through bariatric surgery and I've seen her at the clinic.

Another housecall was to a little old man who had been bedridden for over a year because of a compression fracture in his spine. He was having trouble breathing and coughing a lot. When I listened to his lungs, he had rales halfway up. I had a long discussion with his wife and (by phone) son concerning what might be the best way to manage this probable pneumonia. In the end, the wife and patient elected not to go to the hospital, so I prescribed Zithromax but before his family could pick it up the next day, he passed away.

There was a little old lady who called me because she wanted to know what she should take for cold symptoms. I told her, but because she didn't drive, couldn't get any medicines until she could find someone to drive her to the pharmacy. Instead, I told her, we would just deliver them to her house. So after work, I bought a $5 bottle of Robitussin DM, and drove it to her house myself. Naturally, I didn't ask her to pay me back.

None of these home visits were compensated financially, but as a family physician, that's not the main impetus for doing this. However, as a solo family physician, I now am keenly interested in financial compensation because otherwise I can't keep on being a solo family physician.

I remember checking out this site several months ago when I first considered doing house calls. It was one of the few I could find that actually listed its fees. Basically, $79-224 per visit depending on complexity and length, plus $35-95 "transportation fee". By comparison, I'm a bargain!

And yet, no massive influx of patients or calls for home visits. That's either because a) there isn't a demand for these services or b) they just don't know about me yet. I'm hoping it's b.