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.
System integration
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.
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What a crazy story. I’ll probably share this with some of my friends. Thanks again for posting it.
With all due respect to the years of training and internship, as well as to the financial hardship incurred by ALL medical doctors go through in order to attain their medical degree.
The following is my humble (if harsh) opinion regarding what should be family physicians duty and responsibility to do house calls, based on my own experience as a working self employed woman, mother and wife, paying and aging citizen and occasional patient of Ontario’s health system, Canada. It does NOT refer to the “specialty” medical practitioners, not to ALL practicing physicians (as a very small minority still exists that practice out of compassion and their highest desire to aid and/or heal pain and suffering), but to the largest percentage, as of the situation presenting today (and for the past 10 years).
Admission to the faculty of medicine shall have, besides the academic prerequisites, the MANDATORY stipulation/requirement that the student be driven to practice medicine for the highest scope of “serving and aiding” the population at large, REGARDLESS of location of practice. That being said, practitioners be allowed to practice ONLY if their highest goal is to SERVE and AID, based on a culture of compassion for entire society. Once in practice, they shall serve their community based on the ability of the patients to travel to a so called “selected clinic location”. Especially all patients with impaired mobility capability outside of their residence of choice due to either age or illness. Becoming a physician shall be based firstly on a personal, social, moral and ethical consideration, born of the individual’s compassion and highest desire to “serve and aid” the humanity, and only after that shall the personal monetary compensation consideration should come into play.
These days, seemingly, the only reasoning behind individuals entering the medical field (other than the specialty medicine that is still based on the doctors highest desire to heal), most entering students AND practicing physicians highest motivation for this profession is, unfortunately, monetary in nature.
And this is the kind of medicine we, the population of Canada, do NOT need, or want to finance. We also feel that the doctors current remuneration or compensation for the potential “house calls” is more than adequate, but not enough to make someone rich in a short time. A physician has the liberty to perform these either within the normal eight hours daily shift or outside the eight hours shift, at his option. But if the choice is based on monetary considerations first and foremost, instead of a physician’s ethical role, duty and responsibility, then, regardless of how much higher compensation is provided, there will also be room for even more.
When we go to the physician’s office, we DO NOT want to:
1. be treated with disregard and contempt by the medical office staff (as more often than not happens);
2. be seen by the physician “in a rush, less than 5 minutes visit”, as she/he shows impatience due to “volume” of patients; we are still paying them by “units”, meaning at least 20 minutes/unit/person; if volume too high, the practice should bring more staff on board;
3. be told that the “only emergency” is being represented by either infants or injuries;
4. be told, when we call for a patient that can hardly move due to recent illness/fever/injury that the “family physician does NOT perform HOUSE CALLS!
5. Most importantly: the “right” of ANY physician to perform ANY medical acts (ex.: annual genital physical exams by opposing sex doctors, or euthanasia), based on an individual physician “chosen religion and/or personal beliefs” shall be prohibited in its entirety; as long as the school of medicine includes in its curriculum mandatory training of a particular kind pertaining to the specialty, the physician shall have the professional OBLIGATION and be bind by the medical association and Ministry of Health/Training to improve his/her knowledge by way of continuous and up-to-date training, as well as to practice to its FULL SCOPE of PRACTICE, REGARDLESS of his/her religious beliefs. Going into the medical profession IS A CHOICE; practicing the chosen medical field WITHOUT PRECONCEPTIONS and to its FULL SCOPE becomes a social obligation, responsibility and accountability.
** Religion or Personal Religious or Monetary Considerations/Beliefs shall have NO PLACE in the MEDICAL practice! PERIOD!!!!
To that regard, my heartfelt thanks go to ALL physicians and medical specialty doctors who, like Dr. Sandy Buchman and many other physicians like her (see her blog above on 17August2011), practice ONLY based on compassion first and foremost, putting her patients needs and well-being first.
These considerations shall be MANDATORY physician DUTY by training “and” medical PROFESSION ACT!!! No one shall be allowed to practice this profession based on anything else that human compassion! No exception!
Thank you!
I am a recently graduated MD. My first house call, I was awakened at midnight to check on a bedridden patient. It was not an emergency consultation. After seeing the patient, the family then said that they don’t have the money at present & would forward it to my clinic instead. That was 3 months ago, but still no payment. In my heart, I just decided to consider this as a charity case. However, because of this incident I have decreased my interest to accept future house calls
Is the government responsible for paying doctors for house calls? Can’t you send you patient intake form to government to get compensated?
Home visits are extremely valuable to the old and the frail. That house calls are falling out of favour among physicians has a lot to do with supply and demand. We just don’t have enough medical specialists and both logistically and economically, clinical practice makes more sense. It is convenient for doctors to go to a limited number of locations, hospitals and clinics and have people come to them. It also allows them to see more patients and earn more, overall.
Financially incentivising home visits while good in the short term, would burden a lot of elderly retirees, who generally have a lot of medical expenses. Indeed, it would probably make this service unaffordable to those who need it most. Training and mentoring medical students in house calls, though essential, would not incentivise many to make visits for purely reasons of convenience and economics, as commented upon earlier. However, sensitisation amongst physicians, especially while dealing with the elderly is a part of medical education that really shouldn’t be ignored. While medical leadership should glamorise family practice, particularly house calls, dare I say it, a medical soap would probably do more to make primary physicians doing house calls more respected.
Finally, in my opinion, it is essential to up the supply of doctors all over the world. I find it hard to believe that medical education is still as expensive as it is considering the rapidly lowering cost of diagnostics and availability of patients. It is time that medical education is actually revamped and the artificial doctor deficit stemmed. There is a glut of life scientists. A bridge course to cover the clinical aspects of medicine and residency/internships would stem the oversupply of life sciences graduates/PhDs and help millions of people access healthcare at home.
Disclaimer: I write from the Indian perspective, though I imagine that the methodology of healthcare and medical practice is similar world wide.
I also think it is vitally important to recognize the role of the inter professional team members such as Nurses and Nurse practitioners who are also doing and can continue to provide care in pateintst whomes along with Family doctors.
So in addition to the above suggestion we need to foster health leaders who want to change the culture of primary health care as well as medicine
I am a Licensed Clinical Social Worker and Medicare Provider who exclusively provides Home-Based Therapy. The benefits to the patient, family and to me are unlimited except for the financial in terms of reimbursement rates. I am saddened that I felt I had to choose changing the fee schedule to create financial incentives but that is unfortunately what will motivate more practitioners to provide housecall services. I have a continual waiting list and the need continues to be growing. I love what I do and there is no turning back.
I look forward and believe that more Health Care Providers who take this step will never want to return to the office.
I had a total hip replacement surgery last Tuesday. Not being 100% mentally with it because of the drugs I’m on before they released me we never went over the medication I had and I thought I had what I needed for me to last until I have my stitches removed in another week. I am now out of the Fentanyl patches I’ve been using to control the severe pain I was / am in.. This Dr. has known me for years and when I realized I was going to be out I called to see if there was anyway he could make a house call because I have great difficulty getting into and out of our car and into and out of his office. Although I’m able with a walker to go small distances I would be putting myself and new hip in jeopardy because of the distance I must walk and coordinating the in / out contortions I must do to get into and out of the car without over exerting my new hip . I was just released from the hospital 3 days ago. He is not allowed by law to prescribe Fentanyl without my visit and won’t make a house call. So I’ll be in agony for 6 days ( I see Dr then to have stiches removed ) until I get more medication if I still need it at that time.
I am a family physician in Toronto whose practice involves solely providing home based palliative and end-of-life care. A good deal of my practice also involves looking after many with severe chronic disease such as COPD who are unable to leave their homes. The appreciation and gratitude of patients and their familes who receive this care is overwhelming. The meaning and fulfilment that Family Physicians can achieve by including this kind of care in their practices cannot be emphasized enough. It often re-connects them to why they went into medicine in the first place. The home is the ideal environment for students and residents to counteract the effect of the “hidden curriculum” in our medical schools. However, at workshops that I have offered on teaching home based care for academic faculty in family medicine, there is little Interest from physicians (while there is huge interest from other health professionals). I came to realize that since very few offered house calls as part of their practice, very few were interested in teaching this essential skill – a core comptency of every family doc in my humble opinion. As the article states, mentorship is key, as is leadership. To me, it is actually an issue of social accountability of family medicine to society.
Hi Sandy, I could not agree with you more! I was unable to chose any of the four options as I believe that even though the third choice (which received a paltry 5%, 23 Votes) preferable, it will take “fostering health care leaders leaders who want to change the culture of the health care system“ is a more appropriate response-action that may result in any change. You noted there is little interest from physicians and “ there is huge interest from other health professionals“. Respectfully, feel physicians are one part of our health care system and this issue needs “leadership from the highest levels“ as the article states, in order to effect any change in our health care system and especially in how we provide care to the most vulnerable in their own homes.
Most family docs likely recognize the value of home visits but feel this is impractical given the decreased number of appointments one can cover in the same amount of time. However, this is likely mostly due to our fee-for-service system that forces family docs to think in terms of visits rather than patients. Working at a community health centre, I’ve had the pleasure of doing many home visits and providing care for very frail patients. This, however, is supported by the salary-based model in community health centres. While culture definitely plays a part, the solution on a wider policy level is financial – adding a way to bill home visits that appropriately compensate docs for their time or overhauling the fee-for-service system.
Home care visits for incapacitated immobile patients is a valuable service. Those patients should have strict eligibility criteria and be registered with the Ministry of Health or LHIN. Supplemental funding could then be directed to support the physicians providing home visits. That would also differentiate these selected patients from others who call physician replacement services for home visits as a matter of convenience but who otherwise are able to attend a physician’s office.
Some retirement homes have ‘house doctors’ but their lists are quite long. My parents moved to a retirement home 20 months ago and their long- time physician (who is otherwise truly excellent) would like them to move into one of the two practices associated w their retirement home. On one level this makes sense; however if they do, they will lose continuity with this excellent doctor who has a very good rapport with both of my parents and knows their somewhat complicated medical history. Are you aware of any new remuneration schemes operating in these types of settings as (to an outsider) it seems that should be feasible to set this up to be efficient for both docs and patients?