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.