PHILADELPHIA - The house call is staging a comeback.
But the doctor visit won't be as your grandmother or mother or even you might remember it. The physician appearing at the door with a black bag to check on a sore throat or fever is a vestige of an era before most Americans had TV sets.
The new vision involves a doctor working with a medical team to give routine care to an expanding legion of elderly patients whose illnesses can make it impossible to go downstairs, let alone to a physician's office.
Going back to the future, though, will be foreign territory for today's generation of doctors. Making house calls was rarely part of their training. Many doctors would be baffled if they had to do one.
Anticipating a growing need for the nearly lost skill, medical schools are beefing up their home-care curriculum. A national group of home-care doctors has expanded from five to more than 1,000 in the last 10 years. At the same time, the federal government is raising the amount it pays doctors for house calls.
No one is suggesting house calls will surge to the volume before World War II, when a patient's encounter with his or her doctor occurred at home 40 percent of the time. But with a burgeoning homebound population and shorter hospital stays, a resurgence seems inevitable, experts say.
'The need is there'
"The need is there and is growing," said Dr. Risa Lavizzo-Mourey, who makes house calls and is director of the Institute on Aging at the University of Pennsylvania Health System. "If you never see how patients are functioning in their homes, you are in many ways treating them in the dark."
Her program is one of three in the Philadelphia region that recently got $70,000 apiece through the John A. Hartford Foundation to improve the teaching of home care to medical students.
The others are the Philadelphia College of Osteopathic Medicine, and the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in Camden.
Although the cash at stake was relatively small, 57 medical schools applied for the 10 grants available nationally.
The response shows a demand for better training, said Dr. Knight Steel, a professor of geriatrics at the University of Medicine and Dentistry of New Jersey who oversees the project for the Hartford Foundation, which focuses on aging and health-care issues.
Steel did a survey in 1994 and discovered only half of medical schools offered some kind of home-care training during a student's four-year education. Students can graduate without learning how to adapt their expertise to a rowhouse or efficiency apartment. Taking a patient's weight at home, for example, might perplex a doctor who usually relies on a scale in the exam room.
"In an acute situation like a hospital or a clinic, a doctor is accustomed to having certain backups on the spot," Lavizzo-Mourey said. "If the doctor goes into the home, and they don't have the ability to order a chest X-ray or get the lab exam at that moment, that can be very disconcerting to them."
Learning the art of house calls can also give doctors insight into the obstacles that patients face when they leave the hospital but still can't fend for themselves. Even a simple task like going to the bathroom could be a challenge.
About 7.4 million Americans receive home care each year and doctors are in charge of ordering for them all sorts of medical services, drugs and tests. But physicians often make the requests without the benefit of seeing their patients for months. They rely on reports from the nurses, social workers, aides and others who provide the direct care.
"It's amazing how little physicians know about home care," said Steel, who also is director of the Homecare Institute at Hackensack University Medical Center.
While Steel is an advocate of home-care nurses, he thinks physicians need to be more involved. "The physician who doesn't know what services are provided, what the needs are, can't provide first-class care," he said.
Lynn Rinke, chief operating officer for the Visiting Nurses Association, said she, too, would welcome more hands-on care from doctors, especially when a face-to-face encounter could help determine if a patient needs hospital care or can be treated just as well at home. But she doesn't think the current arrangement leaves patients at risk.
"For the most part, physicians trust the agencies they work with," Rinke said. "They are willing to let the nurse be the expert."
Until recently, house calls paid so little it hardly seemed worth the effort. In the time it took for a doctor to go to someone's house, four or more patients could be seen in the office. In many cases, the Medicare reimbursement for home-care nurse visits was higher than for doctors making house calls.