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10,000 house calls and counting

Yale Medicine Magazine, 1999 - Fall / 2000 - Winter


There’s only one reason to treat patients at home: They need your care.

The familiar, rhythmic tones interrupted my pre-dawn reverie that early-spring morning. I rolled out of bed and made one long step to the dresser, where the beeper lay among the contents of pockets emptied the night before. It was 4:15 a.m. and Peggy Hooper wanted me to make a house call.

Ms. Hooper is a woman whose vague complaints have led us to try more than 15 prescription medicines over the years with very little measurable effect. I have treated her in the hospital, in the office and many times in her home. Going there was not a problem — I am a doctor who makes house calls — but, with 6 a.m. hospital rounds looming, there just wasn’t time.

Since I began my career in medicine in the early 1980s, I have made house calls for one simple reason: Patients need and want them. Historically, before the wide availability of acute-care hospital beds, the home was often the most appropriate venue for treatment. There were fewer physicians’ offices and clinics in the first half of this century, and, even today, getting to the doctor can be difficult for the bedridden or homebound patient. It costs society a lot less to transport a healthy physician to the bedside of an infirm patient than to transport that patient to a doctor’s office or hospital.

I told Ms. Hooper (as I will call her to protect her privacy) that I couldn’t come to her home just then because I would soon be on my way to the hospital. “I know that,” she barked. “That’s why I called you so early. Come now.”

With apologies, I offered to visit her that evening but she angrily declined. “I’ll take you to court,” she yelled into the phone as she hung up. I imagined the headline: “New York City doctor sued for failure to make 4:30 a.m. house call.”

* * *

Around 4 o’clock on a steamy Friday afternoon, I drove into Harlem and parked in front of the six-story, walk-up apartment building. The five young men who occupied the stoop continued their conversation as I collected my black bag and locked the rented Lincoln Town Car. I uttered a greeting as I maneuvered my way up the crowded steps, and a few of the men grunted back. I never saw their eyes.

In the dark apartment the old man was very ill, with an irregular heartbeat, difficulty breathing and profound weakness. His wife said that they would be returning to their home in South Africa soon. Adjusting his medications, I prescribed a large supply of pills that might be difficult to obtain overseas. As I hurried back to the car, I once again had to pass by the men on the stoop. This time they cleared a path and glanced up at me, revealing not only their eyes but the faintest of smiles as well. As my car door was about to close, I heard one of the men say, “Have a good day, Dr. Moore.”

I looked around in an attempt to identify the source that had revealed my name. All I could see was a small envelope, lying inconspicuously on the back seat, visible only to deeply inquiring eyes.

* * *

I walked up the icy wheelchair ramp of the house in Brooklyn and entered the small apartment on the first floor. The bedroom stank of necrotic tissue and urine.

The patient was a 23-year-old man who had been paralyzed by a bullet seven years earlier. Buster Black had adapted well to his medical disabilities but he was plagued by recurrent pressure ulcers that would not heal. He was very knowledgeable about his condition, and he and his wife managed the complications remarkably well.

The bedside tray table had been set up with gauze pads, saline, disinfectant and dressing tape by his wife, who for religious reasons did not show herself in my presence. Buster was particularly concerned about the condition of his wounds that day — and for good reason. One ulcer had penetrated down to the hipbone, making it necessary to hospitalize him immediately.

It was after 9 p.m. when I left. As I headed to Queens to see a 95-year-old woman with severe osteoporosis, it occurred to me that I might not get to my last call of the day in Manhattan before 11. As my old Jeep hugged the slippery Interboro Parkway, my thoughts drifted to why I was making house calls on a wintry Friday night after a week of more than 30 hospital bedside visits and 140 office visits. It occurred to me that, during my 15 years in medicine, I had made well over 10,000 house calls. Why? The answer came quickly: Practically no one else was doing it.

* * *

Buster Black died this year after a long hospitalization. He had spent an unhappy period before this in a nursing home — an option that he had opposed and resisted from the very beginning of his disability. He had done well at home but, in the end, this resourceful, spirited young man lost his will to live. Maybe he had lost faith in my ability to provide the necessary medical services that kept his fragile health intact.

As an alumnus of Yale, I sometimes feel that my contribution to medicine should be made on the pages of journals like The Lancet or The New England Journal of Medicine. But then I remember Francis Weld Peabody, who wrote that “the secret of the care of the patient is in caring for the patient.” We show patients and their families that we care when we go into their homes to heal.