House Calls -- the Newest Thing in Medicine

October 31, 1994|By DANIEL S. GREENBERG

WASHINGTON — Washington.--It's mainly old-timers who remember the house call, a humane arrangement in which doctors attended the bedridden at home, rather than having them stagger to their offices. House calls started to fade in the early postwar years, yielding to increasingly high-priced doctor time and medicine's reliance on X-rays and other diagnostic tools too weighty for travel.

Today there's good reason to revive the house call, and especially to acquaint medical students with the problems and virtues of treating patients in their own beds. But in characteristic fashion, most medical schools remain a few decades behind when it comes to preparing the next generation of doctors for the needs of the patients of today and tomorrow. There's an old saying in academe that it's easier to move a cemetery than it is to change the curriculum. This is especially so in tradition-bound medical education.

Because of less-invasive surgical techniques and other treatment methods, more patients are now treated on an ambulatory basis or sent home after a brief hospitalization. The trend is pushed by advances in technology and cost-conscious insurers eager to avoid hospital-room charges that dwarf the rates for luxury suites in classy hotels. It is common now for mothers to be discharged a day or two after uncomplicated births. Appendectomy patients are likely to go home the day after surgery.

Because of these cost-saving changes, hospitals are suffering from a surplus of beds, which has led to the closing of wards and a wave of hospital consolidations. The patient load is shifting homeward.

It might be assumed that medical education is tuning in to this development and preparing students for an era in which home-based recuperation -- even for serious cases -- will be an important part of medical care. Unfortunately, but predictably, most medical schools are continuing in tradition-bound fashion, according to a survey reported in the New England Journal of Medicine.

With replies from all but three of the nation's 126 medical schools, the survey found that 66 offered ''some kind of home-care training,'' but in most instances it was pretty skimpy. Only 18 schools offered lectures on home care. Fifteen required students to ''have a home-care experience'' in the first two years of medical school, and 27 in the last two years, which are devoted to clinical training.

The numbers, however, are more impressive than the reality. The survey report notes, ''In some programs the experience consists of a single home visit. In only three schools do all students make six or more home visits in the clinical years.''

As much as it would be desirable to give medical students more than a hurried acquaintanceship with home care, there's little likelihood of curriculum revision in that direction. Entrenched departments in medical schools are forever squabbling over shares of the crowded curriculum time. Home care, if it has a foothold in any medical school, is not a notably strong competitor for time on the overloaded schedule, nor can it compete financially with the high-fee specialties.

But home care is not a lost cause. As the medical economy runs into spending restraints from insurers, employers and hard-pressed patients, incentives will increase for doctors to go where the patients and the payments are. And, increasingly, patients are at home, fresh from treatments that would previously have landed them in hospital beds.

Though it might not be profitable at present for doctors to travel about town visiting house-bound patients, the new economic reality is that fees are to be found for service in the patient's home. The problem of toting around weighty diagnostic tools remains, but it has been considerably lessened by more compact equipment, such as easily portable electrocardiogram devices and electronic hookups to hospital-based diagnostics.

Finally, there's a looming competitive factor. If doctors won't attend to the medical needs of house-bound patients, nurse practitioners and other health-care providers will -- as they already are in many communities.

The failure of medical schools to do their job is lamentable. But in one way or another, help is on the way for patients who must recuperate at home. Whether or not doctors make them, house calls are coming back.

Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.

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