Over the last fifty years, doctors have been making fewer and fewer house calls.
There is little doubt that patients value physician house calls, particularly from a doctor with whom they have an ongoing relationship.
Lack of appropriate training and mentors, financial disincentives, and the changing culture of family medicine are all barriers to increasing the number of doctors that do house calls.
Every Friday morning, family physician Sabrina Akhtar spends several hours making house calls, visiting a few elderly patients in her practice who find it difficult to come to her office. For these patients, she feels home visits are an essential part of keeping them healthy and out of the province’s hospitals and emergency departments. She is a recent graduate with a new practice and says that “these visits are an integral part of how I intend to practice family medicine.” However, her views are relatively uncommon, because only a small proportion of family doctors in Ontario make house calls on a regular basis.
The history of house calls
In centuries past, many patients received all their medical care in their own homes. But as medicine became more “high tech” in the early 20th century, doctors began to specialize and set up practice near universities and hospitals, where expensive diagnostic and therapeutic technologies were available. As a result, the proportion of doctor-patient encounters that occurred in clinics and hospitals began to increase, and probably made up more than half of all medical interactions even prior to World War II. This trend continued and by the end of the 20th century, about half the family doctors in Ontario were not doing any house calls at all.
Renewed interest in home-based care
As our health care system grapples with how to provide care to an aging population with an increasing burden of complex chronic disease, policymakers seek solutions that shift away from the focus on hospitals and clinics. In Ontario, the provincial government has recently announced multiple initiatives in response to this challenge.
For example, in 2007 the government announced the Aging at Home Strategy, with the promise of $1.1 billion in funding over four years to expand community services for older adults and their caregivers. Funding is being provided to projects that are senior-centred and integrated with the broader health care system. The funding is distributed to each of the Local Health Integration Networks (LHINs), so that each region can fund projects important to their local geriatric population. The bulk of this funding has supported projects that increase home-based services for older adults, and a few initiatves have included house calls conducted by family physicians or specialist physicians.
However, despite the popularity and perceived need for house calls, they still occur infrequently. There are several reasons for this.
Training to do house calls
Most family medicine residents – doctors in training – are not required to do house calls by their university-based residency programs.
Akhtar recalls that she had no prior exposure to home visits until she trained with Mark Nowaczynski, a family doctor who has been a long-time champion of house calls. Her experience with Nowaczynski prompted her to seek out opportunites to do more house calls during her training. Akhtar feels that she was fortunate to be in a program that required a house calls experience. She says, “without this experience, I may never have realized how home visits can be part of my family medicine practice. I would have been unlikely to start on my own.” Akhtar’s sentiment is backed by a recent survey she sent to the family medicine residents at the University of Toronto about the perceived barriers to doing house calls in their future practices. In her survey, lack of experience and mentorship were among the most frequent responses.
Volumes and money
Once in practice, family doctors continue to face barriers if they want to make house calls, one of which is the struggle to manage large patient volumes. Recent strategies by the government to increase the number of family doctors have not yet had a major impact on family doctor workloads, and Canada continues to have one of the lowest per capita ratios of primary care doctors in the developed world.
As well, financial compensation is reported by many physicians to be an important factor, because the number of patients that can be seen in a half-day clinic is often 3 to 4 times the number that can be seen spending the same amount of time making house calls. Since most doctors continue to be paid by fee-for-service, fewer patients results in less payment, as the current payment for a house call is only about ten dollars more than a similar assessment done in the office. Physicians can claim additional fees for travel, but spending an afternoon visiting frail patients with multiple medical problems in their own homes is still much less lucrative than seeing patients in an office. New payment schemes have been introduced in recent years that compensate doctors for the number of patients they care for rather than the number of services they provide. However, even in these models, visiting a patient at home can be seen as a barrier to enrolling more patients in one’s practice.
The importance of culture
Phil Ellison is a family doctor and former director of the family medicine program at the University of Toronto. He has always done house calls as part of his practice over the last 31 years, and feels there are cultural factors at play as well. With more urbanization, he says that “doctors can increasingly practice with anonymity, allowing them to avoid some patient-centered activities such as house calls.” In contrast, Ellison says that in some rural communities, “if you left someone high and dry, the community would hold you accountable.”
The culture of house calls is even more embedded in countries like the United Kingdom. Parvin Dhalla, a general practitioner in southeast England, is not aware of any requirement to do house calls, yet she says “I can’t think of any practice that would ever refuse to provide this service to patients. It’s part of our tradition. It’s part of providing a complete care package.”
Shelagh McRae, a family doctor who has been making house calls on rural Manitoulin Island for 29 years, agrees that her community would hold her accountable. She says that when she eventually retires “the physician who takes over my practice will be met with strong expectations to continue doing home visits.” It may be this culture of accountability to patients that keeps more Canadian rural family doctors doing house calls, as the obstacles they face to provide this service are often greater than their urban counterparts, frequently including larger distances between patients and fewer support staff. Despite these obstacles, studies done in Ontario that rural doctors are more likely to make house calls than those in urban areas.
For those family doctors who do make house calls, the volume and quality of care they can provide in the home is limited by a lack of coordination in the system. Pauline Pariser, a family doctor who chaired a committee examining home-based primary care for the Toronto Central LHIN says that “the key to improving the efficiency of this kind of home-based care is integration, both within primary care as well as across transitions of care.” According to Pariser, the first step in this process is “to determine who these home-bound, high-risk elderly patients are, and who are the doctors and other providers who are presently doing this work.” She feels that once we know all of the players, “advances in information technology that facilitate exchange of information between these people will be a big part of how we make progress.”
The uncertain future
Sabrina Akhtar hopes to devise a training model that would be replicable at many other family medicine practices like hers across the country. While recognizing the challenges ahead of her, she is optimistic that “change can happen despite barriers if there are enough family doctors who are champions of house calls to lead the way.” But will the enthusiasm of physicians like Pariser, Akhtar and Nowaczynski be enough? Most physician organizations and universities have yet to weigh in on the house calls issue, and without leadership from the highest levels, changing the culture of family medicine will be a challenging endeavour.