Old Practice Revived : Doctors Making House Calls Again

The doctor’s house call, once nearly as extinct as the horse and buggy, appears to be making a comeback.

Increasing competition among doctors, new technology and the aging population have combined to help resurrect the once-common practice.

“There was a time when everyone said the house call was dead,” said Dr. Samuel Warburton, an associate professor of community and family medicine at Duke University Medical Center. “But house calls in many respects are making a comeback.”

Relegated to Nostalgia

The house call was relegated to nostalgia during the 1960s by a combination of several factors.

Advances in technology that required the use of non-portable equipment for diagnosis and treatment made many doctors feel unable to provide adequate care in the home.

“There was a time when virtually everything you needed was in your little black bag,” Warburton said. “The technology is now in the office and the hospital.”

And a shortage of doctors prompted physicians to open centrally located offices that offered easy access to large numbers of patients. By staying in the office instead of spending time traveling, a doctor could serve more patients.

Undersupply of Doctors

“Medicine went through a period when the physician was real busy,” Warburton said. “There was an undersupply of doctors. A physician could see four or five patients in an hour in his office, but if he went out on house calls he could only see one or two.”

As medicine became specialized, fewer patients depended solely on one general practitioner. The sick would often be referred to specialists they did not know who practiced only in their offices.

Several new trends, however, have begun to make the house call more popular again.

An increase in the number of doctors, especially in urban areas, is forcing physicians to be more competitive. Young doctors trying to establish new practices offer house calls as a marketing tool to attract patients.

‘Marketing Edge’

“Wise physicians are realizing that the house call may give them a marketing edge,” said Dr. Jay Siwek, a family physician who teaches at Georgetown University in Washington and has researched the use of house calls.

People are also living longer. Many of the increasing numbers of the elderly are housebound with chronic or terminal illnesses. Without a house call, they would either have no care or have to ride an expensive ambulance to an emergency room.

“The woman I made a house call on today is an 88-year-old woman who would be in a nursing home if I didn’t see her at home,” Warburton said.

Government efforts to cut the cost of medical care encourage shorter hospital stays. After discharge, many patients require follow-up care and may be unable to leave their homes easily.

Encouraged by HMOs

The increasingly popular prepaid medical service programs known as health maintenance organizations, or HMOs, also encourage short hospital stays in favor of less expensive home care.

“There’s an awareness on the part of physicians that the medical-political forces are shifting out of the hospital and into the homes,” Siwek said.

And just as advances in technology first worked against house calls, more recent innovations have allowed doctors to take technology back into the home.

“What we can do in the home in 1986 is much greater than five years ago,” Warburton said.

Intravenous Treatments

In the past, for example, patients had to check into a hospital to receive intravenous antibiotic treatments. Such treatment can now be safely administered in the home.

Portable X-ray machines can serve as preliminary diagnostic tools. Simple blood analysis can also be done bedside. Most physical therapy, including traction for back injuries, can now be done at home.

Visiting nurses, nurse practitioners and many family physicians never completely stopped doing house calls.

But Bill Delay of the American Academy of Family Physicians said more family doctors have begun offering the service and most training programs for family physicians now include instruction on how to conduct a “home visit.”

Specialists Offer Calls

Doctors in other specialties, such as pediatrics and internal medicine, have increasingly begun offering house calls, and others may follow.

“I’d love to see psychiatrists and orthopedists start making house calls,” Warburton said, adding that the elderly especially could benefit from orthopedic treatment at home.

No one is quite sure exactly how many doctors are performing house calls. But the demand for the service has spurred the establishment of special house-call services nationwide.

Mobile Medical Care Inc. in Portland, Ore., has been dispatching doctors to homes for eight years, serving primarily elderly housebound patients.

“For these patients, if it weren’t for our service many wouldn’t get any kind of medical care,” said Cele Jameson, who coordinates the service.

Called Last Resort

Jameson said she considers the house call a last resort. If patients can go to the office, they are encouraged to do so.

“Whenever we find a patient who is ambulatory and it would be better for them to get out, we will refer them to a regular doctor,” she said.

The house-call service, which usually responds to about 10 calls a day, is also careful not to take business away from doctors in regular practice.

“It’s a very political type of service,” Jameson said. “There are a lot of physicians in the United States today. There are not enough patients for the number of doctors. That’s one of the reasons we are very careful not to steal patients, so to speak.”

3,500 Calls a Month

In New York, Doctors On Call answers about 3,500 calls a month from a much more varied clientele.

“It’s a mixture of everything,” said office manager Elizabeth Delvalle. “We have a lot of elderly, but we also have the young professional who doesn’t want to take time off of work to go to the doctor and parents with children at home. Or maybe someone who just doesn’t feel like going out.”

Delvalle said her service does not make judgments and also works with doctors, who give their patients the service’s number to call in case they cannot be reached.

“A lot of people today also don’t have a family doctor. They don’t feel they have a need for a family doctor and then all of a sudden they get sick and call us,” she said.

Fees Average $50

The average fee for a house call is $50, compared to an average office visit fee of $35 or close to $100 for emergency room treatment, she said.

While the cost of a house call is lower than a hospital visit, it is higher than a regular office visit. And while Medicare and some private insurance reimburse doctors for house calls, the amount is usually the same as for an office visit.

“For many private practitioners, funding is still a big issue in whether or not they can afford to make house calls,” said Dr. Patricia Barry, who teaches at Boston University School of Medicine and makes house calls to elderly housebound patients.

Other doctors also caution that house calls can be abused.

‘Particular Purpose’

“There is no question that the house call has a particular purpose and should not be abused by the physician or the patient,” said Delay of the family physicians’ group. “There is no question that when the patient is in a position to come into the office, it is much more effective as a patient encounter because the doctor has at his fingertips the diagnostic equipment and support personnel that make for a more effective visit.”

Dr. Irving Newman, a pediatrician in Chelmsford, Mass., said he sees little use for house calls in his specialty.

“I think house calls basically put medicine back into the 1940s. The doctor is seeing the child in that person’s house. The lighting is no good. He only has a fraction of his equipment. It’s better, I think, for a doctor to see the patient on his turf where he is more relaxed,” he said.

“If the child is that sick that he can’t be moved, then he should be in the hospital,” he said.

Several Benefits Seen

But many contend that there are several benefits of treating patients at home, especially for patients who otherwise might go without treatment.

“For the person who needs the house call, it’s indispensable,” said Michael Rooney of the People’s Medical Society, a consumer group. “Anything that helps the consumer get a service they need is good.”

The house call also gives doctors information they might not get in the office.

“You just get a totally different impression of a person when you see them in their own home,” Barry said. “It really gives you a much better ability to see what’s going on with the patient in terms of how they function in the home setting and how much support they get from the family.”

And in these days of tension between doctors and patients that some say lead to malpractice charges, the house call can help restore the good feelings once common between doctors and their patients.

“One big advantage is that people like it,” Siwek said. “The people you go to see are very appreciative. That helps.”