House calls: what doctors get when they give

Iris Gorfinkel; Mark Bernstein

doi:10.1503/cmaj.191474

Submit a Response to This Article

Compose Response

Title *

References

Author Information

Contributors

First Name and Middle Initial *

First or given name, e.g. 'Peter'.

Last Name *

Your last, or family, name, e.g. 'MacMoody'.

Degrees

Email Address *

Your email address, e.g. higgs-boson@gmail.com

Occupation *

Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Minimum 7 characters.

Affiliation *

Your organization or institution (if applicable), e.g. 'Royal Free Hospital'. Minimum 12 characters.

Address

Your organization, institution's or residential address.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

Vertical Tabs

Jump to comment:

‘Care in Reverse’: Home Visits as a (partial) Antidote to Burnout
Marc Clark [MD]

Posted on: 19 December 2020
RE: "HOUSE CALLS".... for 30 years
James KRAHN [MD/CCFP/FCFP]

Posted on: 12 December 2020

Posted on: (19 December 2020)

‘Care in Reverse’: Home Visits as a (partial) Antidote to Burnout
Marc Clark [MD], Family Physician, No affiliation given
As family physicians who do home visits we heartily endorse Gorfinkel and Bernstein’s conclusion that a visit to a patient at home can comfort the physician as much as the patient. And at a time when many talk of physician burnout, we join them in asking if we, as a profession, have discarded a simple practice that once protected us: “the very real potential solace found in the humble house call”.

A recently published survey of members of the Canadian Society of Palliative Care Physicians and the Société Québécoise des Médecins de Soins Palliatifs concluded that a third of Canadian palliative care physicians suffer from burnout [1]. Wang et al note two factors that appear to protect against burnout: higher scores on personal accomplishment and lower scores on depersonalization.

These are precisely the benefits of home visits. As Bernstein and Gorfinkel wrote, and as we can attest, physicians will never feel closer to patients than when they sit with them in their own homes. The sense of personal accomplishment can be palpable, restorative, intensely satisfying.

Yet institutional structures continue to disincentivize home visits. Our research, presented at the 2017 CSPCP annual meeting [2], demonstrated that, compared to hospice care, physicians see home visits as harder work and lower paid. Our research was limited to one city, Edmonton, but physicians from elsewhere confirm anecdotally that structural disincentives are widespread.

Until this ch...
Show More

As family physicians who do home visits we heartily endorse Gorfinkel and Bernstein’s conclusion that a visit to a patient at home can comfort the physician as much as the patient. And at a time when many talk of physician burnout, we join them in asking if we, as a profession, have discarded a simple practice that once protected us: “the very real potential solace found in the humble house call”.

A recently published survey of members of the Canadian Society of Palliative Care Physicians and the Société Québécoise des Médecins de Soins Palliatifs concluded that a third of Canadian palliative care physicians suffer from burnout [1]. Wang et al note two factors that appear to protect against burnout: higher scores on personal accomplishment and lower scores on depersonalization.

These are precisely the benefits of home visits. As Bernstein and Gorfinkel wrote, and as we can attest, physicians will never feel closer to patients than when they sit with them in their own homes. The sense of personal accomplishment can be palpable, restorative, intensely satisfying.

Yet institutional structures continue to disincentivize home visits. Our research, presented at the 2017 CSPCP annual meeting [2], demonstrated that, compared to hospice care, physicians see home visits as harder work and lower paid. Our research was limited to one city, Edmonton, but physicians from elsewhere confirm anecdotally that structural disincentives are widespread.

Until this changes, physician home visits will continue to be dismissed as a quaint anachronism. The drawbacks to home visits — the travel time, the extra effort to communicate with the care team, the potential for sudden crises — are obvious. But the restorative benefits are subtle. It takes time to recognize and value them.

A deeper understanding and appreciation of home visits can be modelled and taught. Our survey of Edmonton physicians showed that, of the ten family doctors accepting orphaned palliative home patients, seven taught or studied in one University of Alberta family medicine teaching site, and two others were educated in the United Kingdom in a medical culture that still values home visits.

Canada’s medical schools could do much more. Health care managers could reassess their focus on institutions and their devotion to sub-specialism. Patients would embrace a return to “the humble house call”, and we as physicians would be healthier for it.

Marc Clark MD CCFP FCFP
Rebekah Gilbert MBBS MRCP DPM
Paul Humphries MD CCFP FCFP, Professor, Department of Family Medicine, University of Alberta
David Moores MD CCFP FCFP, Professor, Department of Family Medicine, University of Alberta
Show Less
Competing Interests: None declared.
References
Iris Gorfinkel, Mark Bernstein. House calls: what doctors get when they give. CMAJ 2020;192:E561-E562.
[1] Wang et al, Burnout and resilience among Canadian palliative care physicians, BMC Palliative Care (2020) 19:169, https://doi.org/10.1186/s12904-020-00677-z
[2] Available from the authors on request.
Posted on: (12 December 2020)

RE: "HOUSE CALLS".... for 30 years
James KRAHN [MD/CCFP/FCFP], Primary Care Physician, ENVOY MEDICAL DISPATCH & Doctor HouseCalls
Thank you Iris and Mark for this wonderful piece. What a surprise to see your name twice in this same week, on national news in relation to COVID-19 and then with a subject dear to me:House Calls. Thirty years ago this September I started working as a house call physician in Winnipeg, largely in the core area, but at points in all suburban areas as well. I began part time while also studying addiction assessment and treatment in an Indigenous circle of learners at the Nechi Institute near Edmonton in 1990. At various times I have worked house calls in a full time or part time capacity while also doing private practice at Wellspring Healthcare.
Thank you for sharing the learning experiences and connectivity we can realize and benefit from on the patient's home turf. In the Indigenous training circle, the teaching value of story and shared life experience was poignantly evident, a beautiful and powerful balance to the top-down training we as physicians so typically have experienced. A house call, as you and Mark Bernstein have shared, always has that same potential, showing us the light and life in each person. We come away challenged and enriched. I've been to the most deprived places and to the fine hotel rooms of visitors to Winnipeg in this house call capacity. It might come as a surprise that there are some very tidy homes and apartments in the core area, and some very messy ones outside that core. I'm most at home with the inner city calls where...
Show More

Thank you Iris and Mark for this wonderful piece. What a surprise to see your name twice in this same week, on national news in relation to COVID-19 and then with a subject dear to me:House Calls. Thirty years ago this September I started working as a house call physician in Winnipeg, largely in the core area, but at points in all suburban areas as well. I began part time while also studying addiction assessment and treatment in an Indigenous circle of learners at the Nechi Institute near Edmonton in 1990. At various times I have worked house calls in a full time or part time capacity while also doing private practice at Wellspring Healthcare.
Thank you for sharing the learning experiences and connectivity we can realize and benefit from on the patient's home turf. In the Indigenous training circle, the teaching value of story and shared life experience was poignantly evident, a beautiful and powerful balance to the top-down training we as physicians so typically have experienced. A house call, as you and Mark Bernstein have shared, always has that same potential, showing us the light and life in each person. We come away challenged and enriched. I've been to the most deprived places and to the fine hotel rooms of visitors to Winnipeg in this house call capacity. It might come as a surprise that there are some very tidy homes and apartments in the core area, and some very messy ones outside that core. I'm most at home with the inner city calls where I also practised for years as a young physician at Hope Centre Health Care. I've seen the tiniest babies and the centenarians, the movie director and rock band concert assistant, the lonely, the patient surrounded by loving family, and even visited in a situation where the patient had passed away. The range of experience is almost incalculable.The opportunities for advocacy and for levelling the playing field of health care are likewise. There is so much gratitude and appreciation, and that is a blessing and gives sustaining energy for the work. Making a diagnostic call on pretty much a purely clinical basis, and which sometimes saves someone's life, is very satisfying. While COVID puts me more or less on phone visits these code red weeks, the communication and connection over the years pays off with mutual understanding, even from this sometimes awkward domain. Gordon Neufeld has said that none of us do separation well, it's how we are built even from before we are born, created for joy and to return to joy as Jim Wilder has taught me. The house call is full of opportunities to convey and receive signals
of, as Wilder puts it: I'm happy to be with you.
Show Less
Competing Interests: None declared.
References
Iris Gorfinkel, Mark Bernstein. House calls: what doctors get when they give. CMAJ 2020;192:E561-E562.