Thursday, 21 June 2007

No visits please, we're British

I delayed writing this blog entry until today because I was a bit ashamed of myself yesterday. It is on a subject that I find difficult to deal with - visiting patients at home. It's not the visiting that's the problem, it's whether or not a visit is justified. The frequency of home visits varies from country to country. In the United States they are almost unheard of but in continental Europe they are more common than here, where the number of home visits has decreased over the years. It is true that “the past is a foreign country, they do things differently there”. Half a century ago the doctor would do a morning surgery of five minute consultations, drink his tea and then set out “on his rounds” to see many patients at home. Most of these visits would be brief, hardly more than a quick chat before he was on his way again. When I started practising about a quarter of a century ago I would regularly do up to four visits a day, now I do just one a day or less.

Our workload has changed vastly since the 1950s. We now have many powerful drugs at our disposal and can do a lot more for our patients, but all this treatment has to be monitored carefully. We are looking after a lot more chronic disease that used to be managed by hospital services, and we still have to deal with all the new problems that our patients bring to us. Our consultations have lengthened to ten minutes and beyond. So there is much less time in the day to spend on “rounds”, and we rely increasingly on the facilities available at the surgery to look after our patients. At the surgery we have proper examination facilities (with chaperones if necessary), we can take blood, analyse urine, do ECGs and lung function tests, and we have access to the computers that contain the patient's full record and medical reference sources. Compared to this, the GP visiting at home with little more than a stethoscope and a prescription pad is practising under primitive conditions.

Because of all this I am quite happy to agree in theory that patients should only be visited at home if they are truly housebound or are terminally ill. That is certainly the view of our keen young partner. But in practice I am inclined to be a bit more accommodating about visit requests, perhaps thinking back to how things used to be. Some of my other partners feel this even more strongly than I do, and this is one of the sources of discord within the partnership.

A case in point occurred yesterday. The daughter of an elderly lady rang us from Spain (where she now lives) to say that she was worried that her mother was getting more confused and would we please visit? My partner took the call and put the elderly lady's name down for a visit yesterday. The lot fell to me. I toddled off and found that she was indeed a bit confused but had no sign of acute illness and seemed to be coping well enough at home. She told me that she had recently been to see a nurse to have her ears syringed. When I got back to the surgery I found that her brother had taken her to the surgery to see the nurse on the same day that her daughter had rung from Spain. The nurse had noticed that she needs some routine bloods doing and has arranged for her brother to take her to the surgery again to have these taken next week. Now clearly there was a communication problem, but also a difference of approach. The anxious absent daughter had rung one of my partners who is happy to visit the elderly even when not housebound, whereas our practice nurse was doing things correctly. I think that we will be giving this lady the benefits of a proper assessment in surgery from now on.

Then, half way through yesterday's evening surgery, I received a phone call from a junior doctor at our local hospital. One of my patients had been admitted a week ago with a perforated bowel, he had needed a sigmoid colectomy and then treatment on the High Dependency Unit for two days. Once back on the ward he was making good progress, but he is someone who gets a bit stressy and agitated at times and that afternoon he had insisted on taking his own discharge. The doctor rang to let me know and also to ask if I would “pop round” to see if he was alright. I didn't think there was much point in seeing him that day as he had only just been seen by a doctor before leaving hospital. I also felt that if he was well enough to leave hospital then he was well enough to be brought to the surgery, so I rang him and arranged for him to be seen at surgery this morning. That was the point at which I felt uncomfortable about my actions, so first thing this morning I rang his house to tell him that I would visit him this afternoon. His wife told me that he had got anxious again last night and had gone back to the ward, where he was re-admitted.

In retrospect I probably did him a favour by not visiting him last night because the reassurance would have encouraged him to stay at home, which is not a safe place to be when you are just three days out of HDU.


Anonymous said...

The single greatest advantage to a home visit (and I'm speaking as someone who's not a doctor) that I see is that it gives the doctor an opportunity to see the patient in context. Even when you know the patients well from many years of seeing them in surgery, you really are only seeing the public face, and you're much more likely (I'd think) to see the 'real' face in a home visit.

The Shrink said...

Janeway, indeed. Even the simple process of them making you a cup of tea lets you glimpse their sequencing of tasks, the order or disarray of their environment, the contents of their (often empty) fridge, all giving a rich impression of how life is for them and how they're coping, or not, which is critical context to guide on optimal management plans in the community. No point getting out the FP10 if they're in dire need of social care, voluntary support, financial benefits, carer respite, talking therapies, explanation/diagnosis/formulation and framing of problems or any of a host of interventions that can facilitate coping.

I'm in the habit of doing home visits most days (often with a nurse sometimes with a social worker) since I really value them. Most medics do, and ironically it's the GPs in the community who have little time now to do so!

When I was in GP land I had one colleague who'd see everyone asking for a DV "just to be safe" and one who'd never ever go since it wasn't in the red book as a must do (an appropriate consultation must be offered, there's no requirement for DVs, he offered a consultation in the surgery) and "either they're well enough to see me in surgery or they should call an ambulance!"

I'd see it coming down to having to balance the limited and precious GPs time to maximally impact on clinical need (and not necessarily patients wants). Domiciliary visits are then important but not universally so.

A. said...

And then there are the people, mainly I would say elderly, who don't want to cause a fuss. In any major crisis during the decline of my in-laws' health, their first port of call was invariably us (my husband was an only child), so we were often seen rushing out because someone had fallen, couldn't be roused, all sorts. Ambulances were out of the question, a doctor's visit only marginally less so. Part of the problem was that my father in law was trying to hide his wife's progressing dementia, but also not wanting the neighbours to know what was going on.

julie said...

The whole popping round thing is what I always found most amusing as a district nurse. Like our jobs out here in the community involved a more leisurely pace of life where we could just pop to see a patient, have a chat, cup of tea and pass the time of day. My own obstetrician even said to me when I was in hospital prior to the birth of my son "we'll soon have you back out on your bike"!!

Dr Andrew Brown said...

Thanks everyone for your interesting comments.