Nostalgia for the house-call
This is one from the archives, by the way, but it remains true. What we miss in medicine is probably less about money and more about freedom, connection and control.
Not too long ago, I made a house call. As a physician accustomed to working in the emergency department of a hospital, this was quite a change of pace. But it involved dear friends and their sick child, and it was a joy. We had spoken on the phone and I had some concerns about their infant, who was stricken with a high fever. When I went to their home I took only my stethoscope. That and my experience as a physician and parent of four.
When I walked through the door on Friday evening there were candles burning as dinner was prepared. There were no florescent lights. There was none of the chaos of a waiting room. No ambulances idled outside. No bloody, angry drunk screamed profanities. No one was stood by their exam room door, arms crossed in annoyance with waiting. It was a quiet place to be; and the child, on his worried mother’s hip, was quiet as well. He was in a place where he felt safe and was thus able to tolerate my poking and prodding.
I examined him and decided that he was not seriously ill. Because his mother had described him as lethargic when we spoke, I had been concerned that he might have meningitis. This was not actually the case. His parents and I were obviously relieved.
After he was dosed with ibuprofen and put to bed, I chatted a while with his mom and dad, then left for home. As I drove home I realized that, although the family had thanked me, it was I who owed them thanks. I owed them thanks for helping me to realize the essence of what I do, and for letting me enjoy it in such a peaceful setting.
What was it that made this so different from my day to day practice? I asked myself this question and realized that there were many answers. For one thing it was voluntary. This is very important. Medicine today is so much under the control of private and government regulatory agencies that practice always seems compulsory. Of course, I do my job by choice. But federal law says that I must see everyone who comes through the door, without any promise of payment. For most patients, this is fine. But there are some that I wish I had the option to refuse, because they repeatedly abuse a system designed to protect them. Furthermore, this visit did not involve any sort of entitlement. The child’s parents did not say to me “I have a right to your care! You owe me your expertise!” My services still had value. Entitlement to health care, or anything, cheapens it in the end, and opens the door to its abuse.
Further, it did not involve any paperwork. Modern charting is a nightmare. It must be done correctly for legal reasons, in case a patient encounter ends up in court. It must be done correctly for billing reasons, because (especially with Medicare) if a chart is not dictated or written according to a meticulous and complex formula, then appropriate payment is denied. My house call was free, and I would have been insulted by any offer of compensation. But the labyrinthine regulations imposed by the government have made reimbursement in my normal practice very difficult. Worse, incorrect billing, even if it involves an honest mistake, is now viewed as fraudulent. Physicians can be investigated by the government for charging too much, or too little. Likewise, paperwork must be done properly to avoid other federal legal entanglements. A simple transfer form filled out incorrectly can result in tens of thousands of dollars in federal fines and loss of Medicare participation. To the federal government, there are no accidents, only criminal acts.
I’m not whining, I’m lamenting. I’m lamenting the passing of an era when being a physician was not only a privilege, but a pleasure. Some people believe that the only answers to medicine’s problems involve the increasing intervention of government and industry to regulate the activity of physicians. This is tragic. Because it robs physicians of the sustaining professional virtues of honor, compassion and duty to humanity, and replaces them with legalistic guidelines devised by middle management and civil functionaries; persons who have never experienced the joys and sorrows of the wonderful profession they seek to regulate.
I suppose it’s no wonder house-calls are rare. The nostalgia they invoke may just be too painful to bear.