House-calls, the Cure for the Common Doctor
I’ve been asked, repeatedly, by fellow doctors why I do house-calls. This is usually right after the wide-eyed exclamation, “You do house-calls?!?” It’s as though I’m admitting to being a unicorn, and claiming that, “Yes, there’s a spiraling horn right on my forehead, you just can’t see it. And also, I have rainbow-glitter flatus.” Flatus is a doctor-word for farts, but, as you know, doctors can’t use regular words when a longer, dead-language word will work. That’s just not done.
Neither, apparently, are house-calls.
So, to answer the question, “Why?” I’m going to tell a story. It’s a real story, about a real person. A real person really named Rick, who gave me permission to tell his story publically.
Rick is a normal guy, in his early 50’s, doing what normal guys do. He’s raising his kids, working as a computer programmer, all-around minding his business when he’s at work one day and decides to stand up. That’s when things go wrong. Really wrong.
Rick fell down. First, he stood up, no problem, then he fell down. Then he couldn’t get back up. The room was spinning pretty hard, and it was sudden. There was no pain. There was no weakness. There was no slurred speech.
This had happened before, about 15 years ago, and he got better after a few days, so Rick wasn’t too worried. But, this was worse than last time, so he called his fiancée to come help him, because he couldn’t really stand very well. Rick told her to call his new doctor—the one he got because he didn’t actually have medical insurance, and she is a Direct Primary Care doctor.
So the fiancée, Amanda, called me. This is where it got surprising to Amanda, because she called and I answered. That’s right, the doctor answered. She told me what was going on, and I said, “Bring him to the office.”
Fifteen minutes later, he was here. Except, there’s no elevator and it’s on the second floor. Amanda called me and told me she didn’t think he was going to make it up the stairs. So I went down. Weird moment number two, right? When does the doctor exit the office and go to the parking-lot to see the patient?
I tell you, though, that looking at a pale, sweating, Rick lying fully-reclined in the passenger seat of a Prius, it was pretty obvious that Rick wasn’t, in fact, going to make it up the stairs. It was pretty obvious we needed a new plan.
New Plan: it was time to make a house-call.
This wasn’t my first house-call, but it started down the road to giving me a great story demonstrating why I do house-calls—and why it’s a flat-out tragedy that we lost this amazing tool for caring for our patients somewhere along the way (I know exactly where, but that’s another article). That first house-call involved trying to interview and examine Rick while he was laying sideways on his futon, the room still spinning around him, nauseated and wanting to vomit. As I looked around, I found out something I didn’t know about Rick.
He plays the guitar. I’ll come back to this later. So just hold onto this little tidbit, you’ll need it then.
Apparently, Rick plays a lot of guitar, because there were guitars all over the place. Now, I play the guitar, too. I’m not great, or anything, but I understand having guitars all over the place, because I’m a hobbyist, who drops in and out of regular playing, and I have five guitars. Any guitarist worth their salt has at least five guitars. So, I made a comment on the number of guitars around, and Amanda rolled her eyes. Rick, because he is a funny guy even at this particular moment said, “I’m always suffering ridicule for my art.”
This is the thing. I do really extensive interviews of new patients. I find out as much as I can about them on our first appointment, and on every appointment to follow. Still, until that moment, in his house, there was something fundamental I didn’t know about Rick. He is a musician. A real, no kidding, musician. But I wasn’t done learning about Rick, right then, and I had other priorities, namely, figuring out whether Rick was having a stroke, or having something called “peripheral vertigo”.
Now, vertigo, or that spinning sensation, can be either peripheral (coming from the ears) or central (coming from the brain). Usually, as in the vast majority of the time, it’s peripheral, and it gets better on its own. There’s some ways to sort that out, but the most reliable way is to do an MRI of the brain. Thing is, if you don’t have insurance, it’s expensive. Even if you do have insurance, some people can’t get them, for lots of reasons, including the fact that some people can’t tolerate the 30 minutes in the long metal tube. Also, when you do studies you don’t need to do, you find out things you don’t need to find out, which can (and usually does) result in more testing and even surgeries you don’t need to have. All of that is bad, and rarely does it result in anything good, so, I try not to do that.
As I contemplated Rick’s situation, I asked myself first, if I really really needed an MRI. And the answer was, “No.” Everything in Rick’s situation looked like peripheral vertigo. Even if Rick had insurance, even if I had been seeing him in the Emergency Department and not in his home, I wouldn’t want an MRI for this situation.
So, easy. We’ll do symptom relief and see him again in a few days.
Except, not. Because the next day, Amanda calls me to tell me that now Rick has a tingling sensation in the fingers of his left hand, and he feels like his left arm doesn’t quite track the way it should. It’s not weak, it’s not numb, it’s just not, exactly, going easily where it’s supposed to go.
I’m already at work, and now Rick can—more or less—make it up the stairs, so I see him in the office. I re-examine Rick. It’s actually still a completely normal exam. I phone a colleague who is a neurologist to ask what he thinks. We debate back and forth, I discuss it with Rick, and finally, we all decide to do an MRI. Fortunately, because I do Direct Primary Care, and I have a fair number of non-insured or Liberty Share patients, I have an arrangement with a radiology group, San Diego Imaging, to do reasonably priced studies for cash prices.
I tell Rick I think there’s a 2% chance we’ll find something on the MRI. Rick gets the MRI. I get the results from the radiologist about 15 minutes after they finish the study.
Rick has had a rare type of stroke.
Here’s the thing. I like Rick. I think he’s a really cool guy. I never want to have to give bad news to my patients, but this one is even worse than usual, because I feel like we have a bond. I’ve been in his house. I know his kids, his fiancée, his cats. Even though I know this is a type of stroke he’s going to get excellent recovery from, at that moment, thinking about Rick and his family and everything I’ve learned about him, I just feel plain bad. I really wanted that MRI to be negative.
But, it isn’t. And that’s how it is.
And this is where it gets really weird for Amanda, and anyone else who was expecting the usual Primary Care dump into the Emergency Department. Because, that’s not what happened. I talked to the ED doctor about the MRI result. I showed up in the Emergency Department. I talked to the admitting doctor. The next day, I went to see Rick in the hospital to find out how he was doing. I made sure that the nurse had my information to ensure follow-up.
I didn’t do any of this because I like Rick—I do, he’s a cool guy, remember—I did it because that’s what being a Direct Primary Care is all about. It allows me to be a “Country Doctor”, to take care of my patients throughout all the stages of their illness. That includes understanding what happens to them in the hospital.
In the hospital, I found out that Rick’s vertigo was getting better. His feeling of difficulty controlling his arm was improving. Unfortunately, he started having a lot of hiccoughs.
Hiccoughs can be a huge problem.
Most people don’t realize how debilitating intractable hiccoughs can be. Even I was about to get a real education in just that issue.
That’s where the second house-call comes in.
Rick got out of the hospital on a Friday. I made arrangements with Amanda to see him on Monday, in their home.
Meanwhile, via text and phone over the weekend, Amanda kept me updated on Rick’s condition, and asked me for help with his hiccoughs. We tried different medications, but nothing was working very well.
On Monday I found out how not-well the medications were working.
Rick was sitting in his bed upstairs, looking pale. I started asking him how he was doing. He answered, staccato-fashion, between harsh, sharp, hiccoughs. A few minutes after we started talking, he lurched up out of bed and rushed to kneel over his trash-can, with prolonged retching. He was retching because he had nothing left to vomit.
He looked miserable. Amanda is pretty funny herself. All throughout this ordeal, in the hospital, in my office, at their home, she kept cracking jokes, giving him a hard time, making him laugh. Yet, I caught her looking at him when she knew he wasn’t watching her, and she looked heart-broken. There she was, staring at the man she loved deeply, wanting for all-the-world to make this better—but she couldn’t.
Looking away from this moment, I noticed something else. In addition to guitars, there was also a drum-set in the room. So, I asked him about that. It turns out, Rick played the drums even before he played guitar, and he’s played the guitar for over thirty years. Then, in between hiccoughs, and retching, he told me that he’s been playing the drums since he was 7, and started playing guitar in his teens. He also told me that just before he had his stroke, he finally had put together the opportunity to record an album, which was supposed to have started in the near future.
Then he started lamenting that he would never be able to play at that level, again. That he didn’t even want to try to pick up the guitar because he was afraid of how bad it would be, after all those years of effort and practice and hard-earned skill.
Well. Fecal-material ("fecal" is Latin for "poo").
Up until that very moment, staring at those drums, and back at Amanda staring at Rick, and back to Rick leaning over a trash-can, retching, even I didn’t understand why I do house-calls.
Now I do.
I do house-calls because that is the only way to really understand why my patients need me, and what they need from me. I do house-calls because that is the only way to learn what is truly important to my patients. I do house-calls because that is the only way to see the real people behind the façade behind the people sitting on my couch, telling yet another doctor their “social history”, yet leaving out ninety-nine percent of what is actually important to them.
I have never been so motivated to help a patient get better as I was watching Rick retch into a trash-can only to resume hiccoughing so hard he could barely speak—and watching Amanda look on, helplessly. I have never understood, so deeply, that you can “recover” from a life-changing illness, and yet still be unable to return to doing what you really love, because of the fear of never being able to do it right. I have never realized how much I was missing, in the office.
I never would have known any of that, had I not seen Rick at his house, and seen—for myself—that Rick is a musician, and this stroke could take that away from him if I don’t figure out how to prevent that.
Doing house-calls makes me a better doctor.
That’s why I do house-calls.