When Donald Trump takes the oath of office in January, he will be the oldest president Americans have ever elected. That also makes him some doctor’s geriatric patient, joining 46 million Americans in the age 65 and older group. By 2060, that number will double, reaching a staggering 98 million people. Taking care of older patients can be a challenge. Some have multiple health conditions, and many are homebound, making a trip to see their primary care doctor almost impossible.
House calls will almost certainly become a way to improve the care of our geriatric patients and will become an essential piece of the provision of care in the future. In fact, legislation being discussed in Congress would help make home-based medical care a financial reality.
Making house calls sounds simple. But we worry that physicians-in-training aren’t learning the skills they need to care for their patients at home.
The American Board of Internal Medicine and the Council of Academic Family Medicine, two bodies that help certify doctors in fields likely to provide home care, have lists of procedures that they deem essential to the independent practice of their respective fields. The list for internal medicine graduates is surprisingly short, with knowledge of how to draw blood, insert a needle into a vein, and do a pap smear on a woman as the only essential skills required. The list for family medicine graduates is slightly longer, including some basic women’s health and obstetric skills. Glaringly missing are the procedural skills needed to provide quality, and arguably, crucial care to patients at home. These include management of urinary tubes, feeding tubes, breathing tubes, chest tubes, infected wounds and sores, and more.
Today’s — and undoubtedly tomorrow’s — medical technology makes it possible for patients with multiple medical conditions, such as diabetes and heart failure, to thrive in their own homes and be treated there. That means the scope of knowledge and technical skills required for a home care doctor has become increasingly complex.
When doing a house call, a doctor does not have the luxury of sending his or her patient to a specialist for immediate attention. The patient may be on a breathing machine or ventilator with a tracheostomy tube that needs to be changed. He or she may have a feeding tube that malfunctions, or arthritis so bad that an injection of steroid into a joint is needed.
In the past, such procedures were familiar to most young physicians in all fields of medicine largely because there had been a generalist, competency-based approach to medical education. However, as the scope of medicine has widened, those in today’s training programs often forego mastery of these basic procedural skills in favor of procedure-oriented services, such as interventional radiology. Young doctors must then rely on simulation centers or shadow specialty doctors to gain the out-of-hospital skills they weren’t able to master during their training.
If the house call is to truly make a comeback — and it should for both patient convenience and cost — training programs and the organizations that oversee them must revolutionize their curricula to help young physicians develop the skills necessary for home care medicine.
Training programs can easily do this. Many large academic medical centers already have simulation centers where residents could spend time working with experts to hone essential skills like removing fluid from a joint or draining it from the abdomen (abdominal paracentesis). Many physicians-in-training already spend time on rotations in which they learn to perform procedures, though these have traditionally been limited to ones needed for in-hospital practice. Simulation centers would give residents the ability to really practice with experts, without major disruptions to the current curriculum.
It might even be necessary for interns and residents to do three to six months of extra training to really master the complexities of taking care of patients at home.
Home visits can be an effective way of providing medical care to the burgeoning senior population in the US. But making home care a reality will require training programs to provide future doctors with the skills to provide proper home care. Once that happens, house calls may no longer be a part of your grandmother’s past but a viable solution for your new president’s health care, and yours.
Katherine T. O’Brien, MD, is a geriatric medicine fellow at Northwestern University’s McGaw Medical Center. June M. McKoy, MD, is associate professor of medicine and preventive medicine at Northwestern University Feinberg School of Medicine, where she directs the geriatric medicine fellowship program.
I think you will be pleased to know that since your article was published, the Home Centered Care Institute (HCCI), has opened 8 Centers of Excellence (Cleveland Clinic, Icahn School of Medicine at Mount Sinai, MedStar Health – Medical House Call Program, Northwestern University Feinberg School of Medicine, Perelman School of Medicine at the University of Pennsylvania, University of Arizona Center on Aging, University of Arkansas for Medical Sciences, University of California, San Francisco) at academic medical institutions across the US who will teach the essential elements and principles of Home-Based Primary Care.
Developed by national experts in the field, these courses are for those currently providing primary care in the home (MD, DO, PA, NP), as well as those who would like to take their career in this direction. For information on dates and location for attending a course, see our website http://www.hccinstitute.org/solutions/train/when/
I disagree that:
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It’s surprising to me that the authors fail to mention the role of nursing.
The trouble with procedures is that to be good at them, you have to do them a lot. (Many of us have experienced the difference between having an IV placed by an experienced nurse versus a new one.) The other problem, in terms of housecalls, is that you need to carry the right equipment and keep maintaining the travel kit supplied.
Given the shortage of geriatricians and of generalists with the (non-procedural) skills and inclination to visit older adults at home, I’m not sure we need to push for such physicians to get better at drawing blood.
Instead, we should be ensuring that most housecalls physicians are able to effectively partner with nurses, either because they are on a team together or because it’s straightforward to request nursing services. (We can currently order home health care services, but the coordination experience is variable.)
(BTW, I am a geriatrician.)
Excellent, well-written article. I wish more home-based care had been available when my mother-in-law was struggling with the beginning stages of Alzheimer’s. as challenging as it is to transport older patients, homebase care makes a ton of sense. I’m glad this is becoming a new reality.
Tom Cornwell at Chicago is giving house call trainings.
It is possible in many instances to avoid invasive procedures in the home:
1) topical ketoprofen gel 20 % instead of joint injection especially of steroids
2) low dose torsemide every hour for 4 to 5 hours will mobilize even malignant ascites.
3) topical soaks with aluminum acetate to remove proteinaceous debris and then chlorhexidine for anti staph coverage then keep wound surface serially moist plus use of negotiating to facilitate microvascular blood flow facilitates wound care in the home that secondary care givers can give
Most needed home based care skill needed is application of BioPychoSocialCognitiveCulturalMotivationalBehavioral assessment, diagnosis, intervention and continuity of care skills with the help of an individual with triple training in clinical medical assistance, community health work and psychiatric social work the training of which could start in the ninth grade with potential certification in all three community skills by the 13th grade of high school in an early college high school program as North Carolina has. Training practicums could occur with home visit team making the home visit integral to the initiation and propagation of medical training in the community.
Errata….
Keep wound Sterile with…
Use BENFOTIAMINE fat soluble derivative of thiamine that efficiently repletes intracellular thiamine pyrophosphate thereby serving as a cofactor to the enzyme Transketolase that facilitates microvascular blood flow integral to wound healing.