House calls vital to Northeast Florida patients, doctors
By Teresa Stepzinski
Just days from surgery to repair a leaking heart valve, Norma Andrews was surrounded by all the comforts of home as her doctors checked her blood pressure and the circulation in her legs.
Andrews, 76, relaxed in her favorite recliner.
Seated on a sofa close by, her 86-year-old husband, Fred, a diabetic, waited and watched patiently. Photos of their children filled the walls around them. A talk show host dispensed advice in muted tones from a television in another room.
Teaching physician Helena Karnani and resident Meredith Riddle of the St. Vincent’s Family Medicine Residency Program chatted easily with the couple while examining them in the living room of their Jacksonville home.
The exam was a house call. Once standard practice of doctors nationwide, house calls virtually vanished from the landscape of modern medicine. But the old-school custom is making a comeback, and three Jacksonville medical centers are at the forefront of that resurgence.
In 1930, house calls accounted for about 40 percent of doctor-patient visits nationwide, but by 1980, they bottomed out at about 1 percent. More doctors now make house calls but not as many as in the 1930s, indicates a 2013 American Academy of Family Physicians survey of its 115,900 members nationwide.
About 10 percent said they make one or two house calls a week, while 3 percent make more than two a week. The remainder said they don’t do home visits, the survey shows.
The biggest obstacle is travel time. House calls reduce the number of patients a doctor can see in a day.
Under the current fee-for-service, pay-for-volume process, fewer patients means less money coming in to pay the overhead costs of a practice, said academy President Reid Blackwelder, a physician for 30 years.
However, the need and demand for home visits will rise as the population ages. By 2030, about 70 million Americans will be 65 or older. Many will live at home and have disabilities hampering their ability to get to a doctor’s office.
“Anything you can do to take care of patients outside of the emergency room in the hospital is a good thing. I think home visits really have a place in that …” said Blackwelder, predicting that the payment model will become more conducive to home visits over the next five years.
Many doctors likely to be making those future house calls are being trained in Jacksonville, which boasts three of the 11 family medicine residency programs in the state.
St. Vincent’s Healthcare, Jacksonville Naval Hospital and Mayo Clinic in Jacksonville offer the residency. House calls are at the core of the three-year family medicine residency as well as a national requirement for those training in that specialty. Riddle and the other residents must do at least two home visits during the program, but many do more.
Their patients come from all social and economic backgrounds, and live throughout Duval and neighboring counties. They include retirees, new mothers and young children, adults with diabetes, heart disease and other chronic conditions, and those at the end of their life.
House calls offer more insight than often can be gleaned from a typical 10- to 15-minute office visit.
“You can get to know the patient as a whole person,” Riddle said.
A glance inside the refrigerator or pantry can reveal if patients are eating right, which is crucial for diabetics. Checking prescription and over-the-counter medicines can prevent dangerous interactions. Securing a loose rug or clearing obstacles near stairs can prevent a fall. And seeing who’s at the home with them speaks volumes about their support network, Karnani said.
The rapport, the doctors say, is everything. It betters the patient’s care.
It’s a bit worn from 16 years of house calls, but U.S. Navy Cmdr. James Keck still carries the same medical bag he was issued in medical school.
Along with his stethoscope, blood pressure cuff and other tools of his profession, the bag holds memories of his patients and their families.
“You become friends with your patients. … You know their family. You know what is going on in their life. You spend time talking about those things that are important to them,” said Keck, director of Jacksonville Naval Hospital’s Family Medicine Residency Program.
Established in 1971, that program is the oldest in the Navy. Its doctors and residents serve patients from all branches of the military: active duty, retirees, reservists and family members. The hospital as well as its primary care clinics, research and scholarly programs have earned national recognition for excellence in patient-focused care, health care quality and safety.
Travis Bridges and his oldest daughter, Cheryl, rely on Keck as their primary care physician and consider him a friend. Keck’s house calls have been a godsend, said the 77-year-old retired Air Force technical sergeant, who has a serious heart condition and diabetes.
When his wife, Patricia, passed away at Easter, Bridges became the sole caregiver for their 52-year-old daughter, who has Down syndrome, heart problems and uses a wheelchair. It can be tough for them, Bridges said, to get to the hospital’s clinic for appointments. Keck, who’s been their doctor about eight years, regularly comes to their home north of the Trout River Bridge.
“Even if it’s the middle of the night, and we needed him, I know that he would come,” Bridges said. “Because of the Down syndrome, Cheryl doesn’t always understand things. But she knows Dr. Keck and she welcomes him and cooperates with him. I really think she loves him.”
While it’s not required, the physicians overseeing and teaching the family medicine residents at the three medical centers also make house calls for some of their patients.
Walter Taylor remembers as a child the doctor “would come to the house when you had measles, chickenpox or whatever.” It’s not like that anymore, said Taylor, director of the Family Medicine Residency at Mayo Clinic in Jacksonville.
“Usually, we choose more patients who tend to be home-bound … patients that are struggling to get in to be seen, or may have a progressive disease that is getting worse and impairs their ability to be able to get in here,” Taylor said.
Riddle hopes to continue making house calls once she completes her residency.
About 20 percent of the St. Vincent’s family medicine graduates still make some occasional house calls after they go into practice, said David McInnes, director of the Family Medicine Residency Program.
Meanwhile, applications pour into the three hospitals’ family medicine residency programs.
Each typically receives 1,000 to nearly 2,000 applications a year from throughout the United States and countries around the world. Space is limited because of the nature and rigors of the training.
Mayo accepts six residents annually. Jacksonville Naval Hospital averages a dozen each year, while St. Vincent’s accepts 10 a year into its program. The directors say they look for the best and the brightest. Their academic credentials are important but the applicants also must have the heart and passion for family medicine, they said.
House calls are an essential part of the residents’ training, but it’s also crucial to patients like Norma and Fred Andrews, Travis and Cheryl Bridges and others.
“They have been really good to us, very nice, and done everything that I think a doctor ought to do,” Norma Andrews said.