House calls have long been associated with primary care providers (PCPs), the proverbial “black bag,” and days gone by. Unfortunately, house calls are often just a memory or something we watch in reruns on the television.
Those people that best remember the prevalence of house calls, the elderly, may be the same population whose needs will bring house calls back from the brink of extinction and return them to the mix of services offered by PCPs.
House calls should be a core offering of PCPs, since by nature we help patients from cradle to grave. Therefore, some of these patients may not be able to come to see us because they are too old or too sick or immobile.
Why then can’t PCPs go to these patients? We certainly can solve the majority of primary care problems where our patients want or need to be seen, including in their homes, whether these problems are run of the mill day-to-day issues; or those associated with chronic, continuous care diseases; or even many urgent care issues.
Unfortunately house calls are rarely offered because many PCPs view them as too time consuming and therefore too costly to conduct.
The need for house calls for these populations will not go away. The populations that house calls can help include:
• those that are bed bound, very old, who want to age at home rather than a nursing home;
• those suffering from dementia;
• those recently discharged from the hospital, and unable to be mobile short term or long term; and
• those that are receiving hospice care.
Many of these people cannot leave their home, or more importantly, should not leave the home, to go to the doctor’s office for an office visit. It is important to understand how very expensive this is for the caregiver, in terms of time, lost hours on the job, effort and transportation costs, all to actually get them to the medical provider’s office, because their loved ones have problems with mobility or other hindrances.
The result? There are many in need of medical care that cannot receive it. This increases medical problems and mortality. When healthcare is ignored or foregone for the most routine of problems, more expensive and much more serious healthcare issues arise in its place.
A recent article in the New York Times reported that keeping geriatric patients out of the hospital and getting them the care the need at home can result in a cost savings of between 30% and 60%. In addition, a house call program, piloted by Duke University, has reduced the number of hospital admissions for those patients unable to get to the doctors office by 68% and the number of emergency room admissions by 41%. These patients are thereby healthier, and even safer, working with a PCP that makes house calls.
Several organizations currently offer house calls as a core part of their services offerings, like Urban Medical in Boston, or the practice I am with, doctokr Family Medicine. Also there are beginnings of pilot programs for house calls, like the one at Duke’s Medical School which was mentioned earlier.
But these are only a few providers, and the movement needs to be widespread. Our aged population needs it and we as primary care providers should be listening to their needs and providing for these needs. Otherwise, we are falling short.
Several years ago, I was telling a patient about the importance of doing routine screening for skin cancer – by far the most common type of cancer in the U.S., affecting over a million people a year. She volunteered that she was covered, that she was seeing a dermatologist routinely for Botox injections. “Does he do a complete head-to-toe exam?” I asked. Her pause and sheepish expression told me all I needed to know. She wasn’t at all covered – because she was never uncovered.
Fortunately, the majority of skin cancers found each year are basal cell or squamous cell – the types that have a very high chance of being cured. The National Cancer Institute estimated that fewer than 1,000 people died from these “non-melanoma” cancers in 2008. Melanoma is another story, affecting over 62,000 Americans a year and causing over 8,400 deaths. The majority of melanomas occur in older patients but almost 1 percent are diagnosed under age 20 and almost 8 percent are found between ages 20 and 34. So you’re never too young to start thinking about ways to prevent skin cancer and ways to keep track of what’s happening with your skin.
Since I was in medical school in the mid-’70s, the number of yearly cases in the U.S. has more than doubled. Early detection is likely one reason for the increase but nobody is exactly sure what has been causing the dramatic rise. What is clear, however, is that early detection is the name of the game when it comes to curing melanoma. The earlier a lesion is found, the better the chance of cure – which brings us to the main point of this blog. Everybody should be getting routine head-to-toe skin exams. This means looking from head to toe at every millimeter of your body, including where the sun doesn’t shine. Skin cancers can occur in any location of the body, including the armpits, scalp, between the toes, in the groin or anogenital area – anywhere! Routine self-exam should be part of your screening regimen. If a partner is available who can examine hard to see areas such as the small of the back – all the better.
In addition, I feel that routine screening should include a well-trained health professional who is interested in performing a careful skin exam. This is where it can get tricky. We live in a time when sub-specialists abound – even among dermatologists. A patient may see a cosmetic dermatologist several times a year for Botox injections. The dermatologist may glance at areas of exposed skin but the patient should not feel that a full screening skin exam is being routinely performed. The patient I described at the top of this blog had magical thinking – somehow reasoning that she’d received skin cancer screening just because she’d seen a dermatologist, even though she hadn’t taken her clothes off! Trust me: no doctor is good enough to detect skin cancer without examining the skin.
When the CBS Doc Dot Com team was brainstorming for segment ideas recently, producer Jessica Goldman came up with the idea of following her through a complete evaluation with a dermatologist. That brings us to today’s episode with New York City dermatologist Dr. Francesca Fusco, who covers a wide range of skin issues, from cancer prevention to cosmetic dermatology.
I met a patient today in the emergency department and had what is becoming a common interaction. Despite feeling quite ill, the woman had taken the time to prepare for her visit. When I first spoke with her, she enumerated her symptoms and how frequently she had suffered them. Then she reached into her purse, pulled out a stack of printed pages derived from several medical Internet sites – all of them names you would recognize. The pages covered her specific symptoms, a wide range of possible conditions, and a myriad of treatments. Some of the information was good, and some of it was not so good. But, the information was better than it would have been a year ago, or even six months ago.
This patient’s preparedness pointed out to me how well-informed many consumers are becoming as they attempt to manage own health. The fact that she may have been influenced by some misinformation merely underscores how much responsibility there is for information quality control, and how much of the assurance process is being delegated by default to the individual patients.
My take on this is that certain aspects of healthcare are increasingly shifting to self-care. Between the increased strain on healthcare resources (when was the last time that a doctor in a busy practice could expect to spend more than ten minutes with a patient) and increase in specialization, patients are forced to encounter numerous clinicians and coordinate their responses, in effect becoming navigators of the health care system.
Rather than resent it, I appreciate it when a patient is well informed, particularly if they have the ability to understand some of the basics of disease and disease management. The Internet has vastly changed the landscape of possibilities for understanding and confusion. The sheer quantity of health information that is easily and rapidly available to consumers via the Internet is staggering, and far exceeds what was formerly available to trained medical professionals.
If the reader is not overwhelmed and can apply practical filters to what is presented, then he or she becomes an educated patient. An educated patient makes smarter decisions and tends to be a strong partner in the treatment decision process.
The caveat is that every patient must recognize his or her limitations, and not attempt to self-treat beyond prudent boundaries, which will be determined over time. Of course, if one acts on incorrect information, that is a formula for failure, or worse. But what about good information? The downside of the increasing ubiquity of information occurs when any patient becomes overly convinced of particular facts of his or her diagnosis or treatment in the absence of proper clinical oversight.
I’ve heard colleagues tell stories of patients that were so completely convinced of a self-diagnosis based on articles they read online that they ended up opting not to pursue the treatment path recommended by their providers. These patients inevitably ended up back in the doctors’ offices, having lost precious time. What this points out is that doctors have the greatest advantage to put everything in context. My advice is simply to be cautious. Even if the source is a trusted medical encyclopedia, “good information” misunderstood or misapplied can slow down the process. The goal is to apply superb information to make a layperson better informed, not overconfident.
As far as getting reliable information into a patient’s hands, in my relationship with Healthline Networks, I’ve advised on and reviewed Healthline Treatment Search, a product that creates customized, medically-guided pathways to inform and empower consumers on important health decisions. Whereas most treatment information is embedded deep within articles on health websites, Healthline Treatment Search surfaces a semantically-generated, stand-alone list of possible treatment options for diseases and conditions. The current release covers nearly 1000 health conditions, and includes 4,500 treatment options and 1,200 over-the-counter and prescription medications, with content from ADAM, Cerner Multum, Gale Cengage, Natural Standard, and others. It is Healthline’s policy that feedback from users, both consumer and professional, will allow their experience and observations to improve the product.
Not everyone is in agreement that the Internet is the best place for a consumer to begin his or her search to diagnosis or for treatment. But I would doubt whether this trend will be curtailed, because as the tools improve, we are witnessing increased demand for information. No other information source with the breadth and reach of the Internet looms on the horizon.
What do you think? If not with information from the Internet, how might we as professionals help empower consumers as they take control of their healthcare decisions? Perhaps another way would be to truly empower practitioners to use the Internet and electronic medical records for decision support, for we are also in need of assistance. Let me know.
Walgreens made some headlines with their program to give free acute care services to those who are unemployed.
Before you think that they’re doing this out of the goodness of their hearts, Jaan Sidorov gives a more practical reason.
Doctors rarely would drop patients who have recently gone on Medicaid, or worse, lost their health insurance altogether. Why? As Dr. Sidorov writes, “Today’s patients with no or non-remunerative insurance were not only yesterday’s richly insured but tomorrow’s also. These providers know that when the economy eventually turns around, these patients are going to join the ranks of the employed/insured.”
Walgreens is applying the same principle. Today’s uninsured patients will, more likely that not, have insurance in the future, and will repay Walgreens back for helping them out during these tough times.
So, rather than patting Walgreens on the back for their kindness, you should be noting their business shrewdness instead.
I just got back from a blog workshop at the Canyon Ranch Institute in Tucson, co-led by yours truly and the lovely and charming Kerri Morrone Sparling of SixUntilMe. We had a wonderful time with the locals, acquainting them with social media terminology, and teaching them how to blog and Tweet. We were also immersed in their culture, which largely meant that I lectured (for the first time in my physician career) in yoga pants, and enjoyed small portions of food rich in fruits and vegetables.
A Javelina
Despite the arid, inhospitable environment, the Arizona desert is teeming with life. Quail, rabbits, lizards, javelinas, humming birds and woodpeckers, bob cats and coyotes – all roam around freely near adobe homes nestled between flowering cacti. The extraordinary liveliness of the desert takes the casual visitor by surprise, and the variety of scrubby plants, aloes, and cacti of every imaginable shape, size, and pricklyness is a horticulturalist’s dream.
Since I was on east coast time, I was willing to participate in the 6:30am speed walks in the desert each morning. The lovely landscape inspired reflectiveness in the walkers, though I was somewhat distracted by the roaming hoard of javelinas (very large peccaries who resemble wild boars, smell like skunks, are virtually blind, and live to eat flowering plants). The javelinas had new babies with them – described by one Canyon Rancher as “footballs with legs.”
In between workshop lectures, Kerri and I were treated to some spa services – (regular readers know that I’m a huge fan of massages) which were welcome respites from our very busy work lives. But best of all, we got to spend some time with Dr. Richard Carmona (who attended our workshop), and we discussed how social media could be the key to inspiring behavior modification in Americans who need to eat more healthily and get more exercise.
As beautiful as the Canyon Ranch is, the healthy lifestyle it promotes won’t reach beyond its own walls if they don’t engage people in ways that fit their budgets and time constraints. Now that 70% of Internet users are engaged in social media, and Facebook, Twitter, blogs, and online support groups are growing exponentially, there’s never been a better time to find ways to reach people with disease prevention messages and strategies. As Washington gears up to support preventive health initiatives as part of healthcare reform, innovative non-profits like the Canyon Ranch Institute can play an important role in helping us get America back on track in terms of weight management and fitness. Online communities like SparkPeople or the Canyon Ranch Institute could be one avenue for change.
Of course, if you can afford to vacation in Arizona, the place itself has a calming, therapeutic effect. If that’s not in the cards for you, you can still emulate the lifestyle in your own javelina-free environment. As I take my regular walks back in DC, I’ll be sure to remember those cute little footballs with legs, and wear yoga pants as often as possible during future lectures (if the NIH looks at me quizzically next month during my NLM presentation, I’ll just blame Rich Carmona).
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