Yes, They Make House Calls : S.D. Doctor, Dentist Bring High-Tech Service Home

Radio was still king, television just a dream, and space flight only happened in comic strips in the days when the family doctor who made house calls vanished from the American scene.

But maybe not forever. Medical care providers who will actually come to your house, rather than answering your telephone call with the advice to take two aspirins and drop around the office the next day, are back in San Diego, at least in a small way.

A San Diego doctor and a dentist have centered their practices on making house calls. But if you want to see them, don’t expect a couple of horse-and-buggy drivers to show up on your doorstep.

Both are throughly modern medical men--and one uses the latest in computer age equipment.

Here’s a look at what they’re doing.

The boyish face of 40-year-old Dr. Gresham Bayne pops around the front door of Juanita Younie’s condo on a sunny street in Point Loma.

“How’s the chest?” he asks breezily.

“The chest” has brought Bayne around to this door many times, not all on sunny mornings at convenient hours. Younie has respiratory problems. Most people in her situation face the prospect of regular midnight trips to the emergency room. The trips are about $220 each by ambulance--according to Hartson Ambulance Service--probably rising to $250 later this year. Then there are the hospital fees.

Since coming under Bayne’s wing 14 months ago, she hasn’t been to a hospital once. He has done several tests on her without her having to leave home--for $150 per visit.

“I was thrilled,” said Younie’s mother, 80-year-old Grace Cates, who is visiting her daughter from Texas. “When Juanita was born, our doctor came seven miles from town by horse and buggy to our farm. I remember when your little brother was born, Juanita. That was a hard birth, and Dr. McCulloch came from town in the very first car I had ever seen.

“Now, here’s a doctor coming home again. After all these years! It makes me feel so secure for my daughter.”

“I don’t do home births,” Bayne said, “just because of that 2% risk of problems that really do need hospital facilities. But coming to the patient’s home helps me, too. This way, Juanita is much more relaxed. She knows she can call me anytime, and coming here I can get much more input than in the clinic. Plus seeing her mother gives me an insight to her family background. Their longevity, and so on.

“What’s more, it saves everybody a lot of money. Sometimes, even saves lives. Not long ago I was checking up on a patient. He had angina. I asked him how it was. ‘OK,’ he said. But his wife called out from the kitchen, ‘Honey, that’s not true!’ And from that remark I decided to investigate further.

“He had crescendo angina--and the result was five-vessel coronary artery bypass surgery. He now has a pacemaker, but without his wife’s remark--which I wouldn’t have heard in my office--he would be dead, for sure.”

He leans down to listen to Juanita’s chest.

“You’re honkin’ and squeakin,’ ” he says, “but your theophylline level last week was 12. That’ll give us a window for your next crisis in spring.”

Up on slightly less-fashionable El Cajon Boulevard, Philip Lepor, 38, dentist, is setting out in his elderly car with a few little boxes, some wax, paper face masks, a burring drill and protective glasses. Oh, and rubber gloves. He just about forgot those. He sets off for University Avenue and the first of today’s four patients.

She is Pearl Davis. Lepor is standing with his electric grinder, glasses and gloves in hand, knocking at her door.

“Hello, Mrs. Davis,” he says. “Any problems with the plate? Can you eat yet?”

He’s leaning over a frail little old lady lying on her bed in a blue dress with red stripes, long stick legs in brown stockings, and rosy cheeks.

“It still rubs on this side,” she says.

“I’m going to set up in your kitchen, OK?” Lepor says.

“Go right ahead. You will anyway.”

This is a refinement visit. He has fitted her, had her plate made, and last week he brought her her new set of teeth. Now, he wants to make sure they are just right.

He feels in and out of her mouth, talking all the way. He has her bite on a sort of napkin to find where pressure points are.

“I like bacon,” she says. “I can’t eat it unless you take that rise off.”

Lepor takes the plate to the kitchen, and starts whirring his grinder.

“I’ll be 89 soon,” she says, “and this is the best dentist I ever had. Before him, I couldn’t eat! In the nursing home, they only cooked for people with teeth. All I had was soup that I sucked through a straw. I was starving to death! I went down to 65 pounds.

“I’ve seen four dentists. Paid over $1,000 to the last one. No good. No good! Just getting there to his office, with my broken hip, wheelchair, car--that laid me out for two days. They made all sorts of promises.

“But now, Dr. Lepor, he comes in, and he cares. I can chew! And he did it all here. He keeps coming back till it’s right. He’s taken so much worry away. Before I just prayed for God to take me. Now, my big ambition is to go and have a hamburger with my son for my 89th birthday. I’d gladly pay Dr. Lepor, but he’s free. Now I weigh 79 pounds, thanks to him. I love him!

Lepor washes her new-ground plate under the kitchen tap. He brings it back.

“Here, my dear, try this.”

He works the plate gently in.

“You see why I’m a happy man again?” he asks. “You feel you’re getting someplace.”

“I just started off this whole idea with a feeling,” Bayne says later. “I never realized that everything would start making it almost inevitable. The cost of medicine, the federal government financial squeeze, a real need to find more efficient ways of conducting medicine.”

The thought of the family doctor, of taking medicine back into the home, occurred to him as he worked his specialty, emergency care, month after month in Navy Hospital’s emergency room. He realized so many coming in could be cared for by their family doctor, if only they had one. The emergency room had become the first, not the last, line of defense. The time and money being wasted were enormous, he thought.

A study confirmed it. From 80% to 85% of the 300 who came in each day to the Navy Hospital emergency room didn’t actually need emergency facilities. And with the time he had for each patient--average eight minutes--he didn’t feel he was doing a good job on them, either.

If nothing else, there was no warmth in relationships any more. It was a factory. He found he wanted longer with his patients--a traditional family physician relationship. He knew the patients missed it, too. And he suspected that better, cheaper medicine could accompany such a change.

The result, six years later, sits in the driveway of Bayne’s Point Loma house. A Ford van. White, with plates that read “CALL DOC.”

“It’s horse-and-buggy days again, but it is only possible because I’ve made use of the cutting edge of computerized technology,” he says. “If I’m to maintain today’s medical standards, and treat people at home, I have to have the most important diagnostic equipment aboard, and I have to stay connected to a data base--clinic, hospital--via lap-top on-board computer and cellular telephone, to send and receive a patient’s details instantly.”

What he has done is to spend $250,000 on outfitting his van with an X-ray machine you can wheel into the home; on-spot film processing; centrifuges for 22 different blood tests; a wound closure bag for knife wounds; a sort of tool box with things for getting foreign bodies out of ears, noses, and throats; and 110 of the most commonly prescribed medicines--the result of his own yearlong survey--already put into prescription bottles.

This is a rolling mini-hospital and pharmacy. If Bayne’s master plan comes to fruition, the van is going to take the place of hospital and surgery for maybe eight out of 10 would-be emergency room patients. He believes it will cut the the stay in hospital of people like gallbladder or hip-fracture patients to two days from 10 after the operation.

It is going to save patients and insurance companies and the country literally thousands and millions of dollars. Today, Point Loma, tomorrow the world! Well, at least, San Diego. That alone is going to be a major challenge to the medical status quo.

Davis and today’s three remaining patients are a far cry from the 30 a day Lepor was averaging when he was part of a general practice. The money was good then, but it went against his grain. The pressure was turning him into a nervous wreck. Besides, from his post-grad hospital work he knew there were people out there who needed him more, who could only reach him by surrendering to the hospitals for dental treatment.

One day in 1985, he came home from working on 30 more mouths and realized what it was doing to him. He spoke with his wife. She brought up a suggestion she and his mother had talked of through the years. Why not set up a house-call service?

It would be aimed at the elderly especially, and post-stroke victims. Anyone who had difficulty leaving home.

He had always liked old people. Respected them. Partly because of what turned out to be a momentous decision to study under specialists treating “compromised patients” at the VA hospital in Palo Alto, rather than going on to pursue a research doctorate.

That period spurred his interest in dentures, and the special treatment of older mouths. And the problems and joys of dealing with the slower, more painful, more genial world of the aged.

“The first thing I came to realize was that eating and talking are two of the few pleasures left for many old people. If they can’t do that, they have very little.”

So Lepor started talking with people like the San Diego Home Health Nursing Agency, the Agency on Aging, social workers at hospitals like Grossmont where he also became a consultant. He started constructing a new kind of practice in consultation with the California State Board of Dental Examiners.

As things have turned out, he has no shortage of customers, about half on some form of government aid program. He is paid through the dental service agency of Medi-Cal.

Ask colleagues in the medical and dental professions for their reactions to all this, and mostly you get that “rather them than me” look.

“Chances of survival?” replied Dr. Vernon White when asked about Bayne’s mobile clinic. “Not too good. Others have tried and gone broke. Basically, you’re wasting time getting to patients. You see far fewer patients. You’re charging more than double the average fee. You have that quarter-of-a-million-dollar investment you’ve got to recoup.”

“Dr. Lepor has always worked outside of organized dentistry,” says David Donnelly, secretary of the San Diego Dental Society, but he thinks Lepor’s idea “generally good,” especially in view of a population that’s steadily getting older.”

Dentist Ron Hurley agrees. “There is a desperate need for dental help for old people,” says Hurley, who is involved in a state-sponsored pilot project to find out how bad the dental condition of the aged in San Diego nursing homes is.

“The number of people wrongly labeled ‘not capable of tolerating dentures’ . . . is outrageous. But who can see them? Most dentists just can’t afford to get out. Not in the last five years. So there’s no lack of customers for Dr. Lepor. But he’ll have difficulty making it, financially. Strictly speaking, under the law he should have a fully equipped office to practice, but if he has to support that, he’d never survive home visiting.”

And yet Bayne and Lepor are not alone. A nascent outfit called “Doctor on Call” is about to launch a doctor service for the 30 million tourists and businessmen who annually invade San Diego, guaranteeing a doctor at any hotel within 30 minutes day or night. AMI Valley Hospital has started a mobile clinic that visits sites on the edge of town as a community service--and a way of building customers through good will.

But for Bayne and Lepor, one hi-tech, the other lo-tech, getting back to the basics has already developed a deep well of good feeling that, if their instincts are right, will prove harbingers of the future. The genie might well be out of the bottle already.

But in the end, isn’t it sort of, well, demeaning being a doctor who drives a van around like a fruit merchant? Is that the image doctors want? Don’t they like to be the smooth technocrat specialists surrounded by gargantuan machines that scare the hell out of their patients?

Bayne acknowledges that it will be perhaps difficult for some. Not for him.

“This is turning medicine back into a service industry rather than a business. The solution is a return to local, mobile doctors with a van. It’s just as hi-tech, but it becomes a service again.”

Bayne himself need have no trouble with image. He has been an assistant professor of medical surgery at UC San Diego Medical Center and has served three years as physician on LifeFlight helicopters.

He is so committed to his revolution that he has four more vans in the design stage. He is in the final stages of achieving the admittedly large financial backing required. He went East recently to talk to people looking to supply “comprehensive mobile units of primary care” for China and Third World world countries including India and Pakistan.

He has applied to the Health Care Finance Administration, the governing body of Medicare and MediCal, for a $400,000 grant to study how much a home-call doctor service would save the administration.

Yet surely, this trend he wants to start runs counter to the ever-increasing pressure toward specialization?

“No way,” he says. “You can have orthopedic equipment in here, urology . . . Each van can be specialized as much as you want. It can have modules you just put in and take out, so one van could be geared to any of a dozen specialties. But the main thing is this is the front line. This is where the triage should take place. The screening of patients so only those who truly need hospital care have to go to hospital.

“With the use of these vans, people can get the post-operative recuperative care at home without taking up expensive beds. They can spend two days in hospital instead of 10. It will be possible to provide the specialists . . . all the post-op information they need via computer, so that they won’t have to spend half their time making the rounds of wards. They’ll be able to spend a far greater time doing their specialty, in the operating room. That will make them richer.

“Of course, it also will mean fewer of them are needed. Save money for the hospital. But with us emptying hospital beds, this is going to mean fewer hospitals. I think it is inevitable that some of the smaller ones here in San Diego are going to close anyway. The industry has to trim down.

“They’re talking about more catastrophic health care funds going to nursing homes. I think it should be directed towards families who are prepared to help their loved ones at home. That’s where people want to be. With their families. That’s what I want to encourage. Believe me, the genie is about to come out of the bottle.”

Bayne is back home. A couple of people have knocked on his door with medical problems. Two men have come to talk about the fitting up of the next vans. Now, he’s sitting under a crewel work of a yacht he sewed for his wife. And he is talking of the future.

“Technology is letting us out on a rope. To take the hospital to the customer. Which is good because we can start breaking down this mystique--the passive, uncomprehending patient giving complete trust to the all-knowing doctors. We are supposed to be a service industry. But do you realize how far we have gotten from that? We have fallen from grace! Five years ago, the medical profession was Number 1 in public esteem. Now, the clergy are Number 1 and--this really hurts--we are third behind dentists!”

He is writing a book called “How to Avoid the Doctor” so people can take a more active role in their own health care. He is trying to get Medicare to accept his flat $150 fee instead of itemizing, a move he says will save Medicare money. He is patenting a miniaturized breathing machine which frees up an extra person at the scene of an accident. He is an admitted workaholic.

Lepor goes to a trailer park in El Cajon. A 56-year-old ex-biker is in a wheelchair. He is about to be kicked out of this home. Lepor has been trailing his wavering fortunes since he left the hospital, waited for Medi-Cal to come through with help and welfare to help out with housing.

Mysterious fevers have kept the man in and out of the hospital ever since he was seriously injured in a construction accident. It was Lepor who confirmed they came from teeth abscesses.

“Can I use your kitchen?” asks Lepor in his now-familiar routine.

Lepor takes the new set of teeth he’s just brought from the lab. He leans over the patient’s black Harley Davidson T-shirt and puts the teeth gingerly in the man’s mouth. He hands him a mirror.

“Maybe you could draw them in a bit,” the patient says, “so I don’t look like a piano keyboard.”

Lepor backs out of the pot-hole-pitted mud driveway. He shakes his head. Nobody knows where this patient will be next.

“But that’s the thing. I did catch him. And he will have a little better time of it because of what we did this afternoon. I have only done four people today, but each I’ve spent time with. We’ve got things right. Not half-right, right. Plus I’ve saved them a lot on lost time and transportation.

“One person might save between $200 and $500 all told, including lost time, traveling, waiting in the office line. There’s a lot of Dr. Kildare in this job. I like it. It’s what I used to dream of when I watched it as a kid. Actually changing lives.

“Of course at this pace in a regular set-up, I’d go under financially, never stand a chance. But here, I’ve got no overheads. A regular dentist has to put out $6,000, sometimes up to $35,000, a month in fixed overheads for rent, office staff. So it works from all points of view.

“As a matter of fact, I’ve got more work than I can handle. I’m thinking of taking on a couple of dentists to work for me. That’s the great thing. I can do what I believe in, have a great family life--and make some success at it. I’m happy!”