The End of House Calls

We think the reason doctors rarely make house calls is money.   Doctors can charge, but it is hard to charge enough to justify the time it takes to drive door-to-door, fill the tank and attend lengthy visits. Thus, the house call has faded into history.  However, I have another theory about the end of this valuable service; perhaps it is increased emotional distance between patients and their doctors.

I watched an entertaining movie the other night, the 2006 French farce, The Valet. A comedy about a porter who pretends to be the lover of a supermodel, in order to fool the wife of the model’s real lover, it is fun and confusing in a European way.  The character I most enjoyed was a physician who makes brief appearances during the film, each time during a house call. 

Played by French actor Michel Aumont, the elderly doctor has a home visit practice and is driven on rounds by his daughter.  The twist is that the doctor is apparently more ill than most of his patients.  Therefore, wherever he goes, his ”patients” need to take care of him.  At one home he is having chest pain, so the gentleman whom he is visiting, who has bronchitis or even pneumonia, must get out of bed, so that the doctor can lie down.  

Another time the doctor is so weak that his patient has to give him some sort of an injection.  The doctor complains the patient has no skill in giving injections and causes him great pain.  Fortunately, the doctor knows that at the next house on his list, “that woman really knows how to give a shot.“  The doctor is also upset that the patient keeps coughing and thereby may get the doctor more ill.  Finally, at each home, after being nursed back to life, the doctor is careful to show his appropriate appreciation to each “patient” for their kindness.  He charges them 200 franks.

I very much enjoyed Aumont’s character, not to mention each patient’s acceptance of this backward system.  They are happy to reimburse the doc, simply for his presence and for the honor of giving him care. The insight in this parody is about the balance and exchange that happens when a doctor enters a patient’s home.  At some level, both are healed.  It occurs to me that perhaps part of the reason for the loss of this intimate relationship…the doctor at the personal bedside, is that the closeness, openness and honest interaction which comes from meeting a patient in their home has become too personal, too intimate, too honest for the modern physician. 

Think about the patient – physician encounter.  Check in through the front desk bureaucrats, charge card in hand.  Vital signs taken.  Locked in cold sterile room, decorated with pharmaceutical ads above gauze containers, strip of identifying garments and rap in disposable blue paper gown, either too small or too large.  The doctor rushes in, 25 minutes late, to collect symptoms like stamps, make diagnoses like trophies, record in his laptop, dispense therapeutics and rush out.  The complex real person, who is the doctor, never enters the room.  The complex person, who is the patient, is not allowed. 

Contrast this with the warmth, mess, smells, pictures, dreams, family and hope which fill a home and therefore a house call, and the result is a different type of doctor – patient interaction. 

“Doctor, it is really cold out tonight, can I get you a cup of Earl Grey?  How about a scotch?” 

“No thanks to the scotch, I have more houses to visit, but the tea sounds good.”  “Cookie?  I baked them myself.” 

“I didn’t know you cooked.”

“There is a lot you don’t know about me. See that ribbon over the fireplace…?"   

A relationship of mutual caring and respect, perhaps more focused on working together in the battles of life, than in being an on-time customer or rendering a service product.

I doubt that the house call will make a come back any time soon.  Too much is invested in the efficiency of the clinic, and the sophistication of medicine practiced around high tech equipment.  Nonetheless, I will strive to remember that each patient comes from a special place, their home, and each is special in that place.  However, if house calls do make a rebound, I am gong to start bringing my laundry.  The only question is how much I can charge my patients for each load.

As published in Sunrise Rounds. 

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