LOS ANGELES STAFF WRITER LINELL SMITH CONTRIBUTED TO THIS ARTICLE. — Marion Eastlake answered the knock at her door and welcomed the gray-haired visitor into her tiny suburban California apartment.
With a small brown medical bag and briefcase in hand, Dr. Arthur Samuels entered and took a seat in the center of the room. Ms. Eastlake doesn't drive and is limited in her movements. So the doctor comes to see her.
After a few questions about diet and exercise, the internist took the blood pressure of his 69-year-old patient.
"Still high," Dr. Samuels, 74, said pensively in his deep voice.
He then checked her heart rate and listened to her lungs and heart with his stethoscope.
After a few more questions, he recommended that the patient stay on her diet and then called in a request for blood work and an electrocardiogram test.
Medical technicians would arrive at her home to take the tests in two days, and he told her he would be back to see her in a week.
House calls are making a comeback. The rationale is to reduce costly and unappealing hospital stays, according to the American Medical Association (AMA). And an aging population and medical improvements warrant the changes.
Due to higher life expectancy rates, an increasing number of patients are elderly, AMA reports indicate. And more elderly and chronically ill people are homebound. At the same time, hospital space is becoming more limited.
The result is a need for more home visits, according to Dr. Joanne Schwartzberg, director of the AMA's Department of Geriatric Health.
"We are just so successful with modern medicine up to a point," she said. "But the fact is, there is an increasing population of dependent people who need health care but can't get it because they can't get to a doctor's office."
Francis Scott Key Hospital in East Baltimore, for instance, runs -- an elder house call program that serves about 200 patients in the neighborhoods surrounding the hospital. Begun in 1979 by Dr. John Burton and Dr. Susan Denham, the program's staff contains 12 physicians who make regular house calls to patients with such chronic illnesses as heart disease and diabetes.
Financially, it is a losing proposition.
"Medicare reimburses a home health aide more for making a home visit than it does a physician," said Sarah Whalen, coordinator of the program. "We lose money doing home visits, but we are supported by the institution. Physicians in private practice have to limit home visits because they are not lucrative."
"I'm not going to make a house call for anyone who's 22 years old and has a car," said Dr. William Howard, a surgeon at Union Memorial Hospital and director of the hospital's department of -- sports medicine.
"I see older patients at home," he said. "And I only do it about once a month, for patients I know . . . and if it's on my way home or near the hospital.
"From the point of view of doing good medicine, it isn't all that rewarding. You can only carry along a stethoscope and a pair of eyes. . . . Especially in today's litigious society, people are a little nervous about calling on a patient who has a new problem, say, someone who you have been treating for a heart problem who suddenly has a pain in the abdomen."
Some pediatricians routinely make house calls for newborn babies, said Daniel Levy, a pediatrician in Owings Mills and spokesman for the American Academy of Pediatrics.
"In my career, some of the most memorable experiences I've had were house calls because they bond you to the family. Unfortunately, it's increasingly difficult to make house calls because of the volume of patients we have to see."
Dr. Marion Friedman, chairwoman of the manpower advisory committee of the Maryland Academy of Family Physicians, said more doctorsrealize that home visits can supply vital information about patients.
"There's no substitute for knowing the patient completely, and you don't know the patient completely unless you know the environment in which they live," she said. "You go into a house, for instance, and you find factors that militate against the patient's being able to follow the instructions you've given -- and many things that you won't even think of by just asking questions in your office."
A national survey of 1,100 family physicians and internists that Dr. Schwartzberg of the AMA conducted in 1990 showed that more than 50 percent made some house calls. Follow-up research indicates that the number has not declined in three years.
Several smaller state surveys taken in the early 1980s showed that only 20 percent to 30 percent of family doctors and internists made house calls.
In California, about 20 percent of the 3,203 doctors on the Los Angeles County Medical Association's referral list -- doctors still looking for patients -- make house calls, a rate that has not increased in five years. However, agency spokesman Bob Calverley said the list is based on information volunteered by physicians, not scientific survey, and it does not include all area physicians.