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A House Call



 

Arsheeya Mashaw, MD1

Perm J 2020;24:19.114 [Full Citation]

https://doi.org/10.7812/TPP/19.114
E-pub: 11/22/2019

Editor’s Note:

This is fictionalized retelling of this story. The characters’ names have been changed.

Nurses were talking in the background as I spoke over the phone with my patient’s niece. “Okay, Ms Pierce, can I come by around noon to do a home visit for your aunt? I should finish rounding on the patients here in the hospital by then.”

“Of course, Doctor,” she said, excitement in her voice. “We really appreciate it! I don’t think there’s any way I could get my aunt to your clinic.”

Ms Pierce gave me precise directions: “Turn left at the old McMillan chicken house, go over the one-lane bridge, pass the Baptist church on your right, and about a mile later I’ll be waiting for you at the bottom of our road.”

I was in a rush to finish rounding in the hospital, so I didn’t instantly catch her last statement. Huh? Waiting at the bottom of the road? I wasn’t sure why she would do that. Oh well, I thought, I’ll figure it out when I get there. I finished rounding on my hospital patients and got in my car.

As I drove down dusty roads, the chaos and anxiety of my small rural hospital disappeared behind me. I followed the directions past Ms Pierce’s landmarks. I’d never have recognized them if I hadn’t been living there for so many years. I am truly a local now, I thought proudly. I finally made it to the driveway and sure enough, her big pickup truck with oversized mud tires was waiting at the bottom. I parked on the side of the road and walked over to Ms Pierce.

“So why don’t I follow you up to your house?” I asked.

Her eyes grew wide with a horrified look. “Oh no,” she said, “your car would never make it up there.”

When I heard her words, I didn’t believe her. I had a brand-new Subaru WRX—the first car I could ever afford to buy. One reason I chose that model was because I’d seen it used in rally car racing on television. If my car was capable of tearing down a dusty dirt road at 90 miles an hour, then why couldn’t I make it over a few country back roads? But I didn’t want to start my home visit on the wrong foot and offend her by insisting that I drive.

“Okay,” I said hesitantly. I climbed up into her truck like a mountain explorer in a white coat, carrying my medical equipment as if it were climbing gear.

The truck roared as we moved forward, the sound of gravel crunching under massive truck tires. “My drive is about a mile long,” my guide said as the bumps became more intense.

I saw larger rocks in the road as we veered to the left. My car could easily do this, I thought. She must think I’m some sort of city guy. Just then, the road dipped and in front of us was a 15-foot-wide, 2-foot-deep creek, with even taller rocks protruding in spots.

My mouth dropped and my guide smiled. “This road got washed out a couple years ago,” she said, her voice vibrating with the bumpy road.

But that was just the beginning. As we moved on, I felt like I was in a truck commercial. We dipped into a 2-foot-deep crevice, and the rocks got bigger still. We bounced up and down as we climbed the big hill to her house. At one point I caught myself gripping the glove compartment in front of me in horror. Finally we pulled up to Ms Pierce’s house.

I can only say it was worth the near-death experience. Sitting at the top of a huge hill, the house had a view of the Shenandoah Mountains that was breathtaking. From this view, I could see the contrast between leafless forested mountains and the meandering Shenandoah River in the distance. I felt exhausted and exhilarated. And I hadn’t even seen my patient yet.

I first met Ms Pierce’s aunt a couple of years earlier. Lucy Karn was 87 years old and had just moved to our small town from Philadelphia, where she’d been living with her son so he could help her around the house. Unfortunately, Lucy’s son lost his job and couldn’t afford to help take care of her any longer, so her niece Patsy Pierce agreed to let her move in.

Lucy was a diminutive, kind lady. She was only 5 feet tall and weighed just 105 pounds. The first time Lucy came into my clinic, she sat in the corner of the room next to her niece, her white hair pulled back in a smooth ponytail. When she spoke, her words came out softly, and I had to sit next to her to hear her. At the same time, she was strong-willed and it was always difficult to get her to agree to my plans for her care.

“I don’t want some young doctor telling me what to do,” she would say whenever I made a suggestion.

But in time we became good at compromising with her medical care. I would suggest a new medication, and she would counter with a dietary supplement. We would finally agree with a handshake on a lower dose of medication. I grew to enjoy my visits with Lucy. We would joke about how exhausting my kids were, and she would share stories about her son.

“When he was young, he wanted to fly,” she once told me. “He opened his bedroom window on the second floor. Then he jumped out, holding an open umbrella like a cartoon character! He didn’t break anything, but was limping for a week.” She laughed as she spoke, the pride of a parent glowing on her face.

One day, after I’d been seeing Lucy for about a year, I noticed her weight had dropped significantly. Generally a woman her age should not be losing much weight. I made a note of it in the chart and asked her to return in a month for a recheck.

When she returned, her weight was down even more. I was concerned and brought it up with her. “Ms Karn, I wanted to talk to you about the weight you’ve been losing,” I said hesitantly. I knew she didn’t like it when we delved into anything that might end up with me suggesting she take medications or might need to be “worked-up.”

“I’m a little worried, and—”

“Dr Mashaw,” she interrupted, “I don’t think that’s necessary. You have to be the first doctor who’s ever been upset about a patient losing weight.”

I paused, realizing I needed to explain. “Well, when someone loses weight unintentionally, it’s sometimes a sign that something is not right. It can be something as simple as not eating nutritionally balanced foods, or depression, or sometimes it can be a sign of a more serious disease like cancer.”

She didn’t even flinch. “I don’t care, Doctor. I feel fine, and I don’t need a bunch of blood tests and x-rays to tell me so.”

I was convinced she was in denial, and I wanted to know why she didn’t want to know. “Ms Karn, I’m sure this isn’t something horrible,” I said. “But what if you had some sort of disease like cancer and it was treatable? Wouldn’t you want to at least know that?”

Again, Ms Karn didn’t even hesitate. “No, Doctor. I’m 88 years old. I’m so happy for the time I’ve had. If it’s my time to go, then it is.”

Our visit was over. She had made clear what her goals of care were. I thanked her for coming to see me and asked her to return in a couple of months to catch up on things. She smiled and walked slowly out of the room and down the hall, holding her niece’s hand for balance.

Months passed and I didn’t hear from Lucy. Then one day I got a frantic call from her niece. Aunt Lucy had pain in her abdomen and needed to be transported to the Emergency Room. She came in and we ran some tests; there were signs of cancer in her liver. True to herself, Lucy wanted no further workup. She accepted pain and nausea medications and went home.

In a follow-up call, Patsy told me Lucy was too weak to get out of bed. My first thought was that we should get hospice involved and help make Lucy as comfortable as possible. But Patsy was against it from the start. She and Lucy didn’t want some stranger coming over every day to check on things. “No one,” Patsy said, “will come to our house.”

That was the last time I heard from either of them until Patsy called to invite me out to their home.

I walked into the house and found Lucy sitting quietly in a rocking chair by a window that faced the beautiful Shenandoah Mountains. Her niece said she hadn’t told her I was coming, “because if I had, she would be fretting all day.” When I walked into the warm, bright room, Lucy’s face lit up as if the sparkling noonday sun had just shone on her. She smiled and even let out a little laugh.

I walked over, kneeled down, and gave her a gentle hug. Patsy pulled over a chair for me so I could sit next to Lucy’s rocking chair. At first, we talked about nothing medical at all. We chatted about the show she had just watched and what she was going to have for lunch. I was again reminded of how important living in the moment was to Lucy.

During our conversation, though, one thing kept nagging at me. I still wanted to know why she never wanted to be worked-up all those months ago for her weight loss. As her doctor, it bothered me so much that perhaps I could have caught her cancer early. What if it had been treatable? As our conversation progressed, I steered it more towards her disease and broached my question.

“Look Doctor,” she said in her collected, quiet voice, “it’s February and 60 degrees outside and sunny. This moment is what I want to enjoy.”

Just then I realized that she’d already answered my question once before. “I’m so happy for the time I’ve had,” she had said. “If it’s my time to go, then it is my time to go.” I just didn’t understand her reasoning before. And perhaps I would have never understood her if I hadn’t made that adventurous trek up Lucy’s mountain and looked out at her beautiful view.

Throughout that decade of my career in rural Virginia, I learned that knowing the nuances of my patients’ lives helped me understand the bigger picture of their health. It gave me context to their medical problems and allowed me to do a better job treating them. Eventually I would learn that this truth wasn’t limited to patients living in hard-to-reach mountain homes.

Eventually, I moved from rural Virginia to the big city and joined Kaiser Permanente as a hospitalist. There, we initiated a novel way for our patients to transition back home from the hospital with the aid of virtual technology. For some of our patients, after they were discharged home, I was able to talk to them over a video conference and check in on them. Patients would connect a video chat software on their computer to my computer terminal, and we could discuss their care face-to-face.

Around this time I met Jennifer Filch. Jennifer was a perpetually smiling lady in her late 60s with blond hair that was slowly turning white. Whenever she came to the hospital she would place a bright red blanket over her hospital blanket. “It makes me feel more at home,” she would explain in her soft, composed voice.

Jennifer was in the hospital for the third time in 5 months to be treated for a congestive heart failure (CHF) exacerbation. CHF can happen when there is a weakness of the heart that leads to a buildup of fluid in the legs and lungs. There are medications to treat the adverse effects of CHF, but it can be very difficult to treat an exacerbation. Often CHF patients have to come into the hospital to treat the excess fluid buildup more aggressively.

Jennifer responded well to the treatment, and I discharged her. I wanted to check in with her for a few days after she’d gone home, to ensure she was transitioning okay. The video visit was the perfect way.

The first time I called her, my equipment connected with Jennifer and her bright face filled the screen.

“Hey, Mrs Filch, you look great,” I said.

“Doc, you have to stop calling me Mrs Filch!” she responded abruptly. “Call me Jennifer.”

“I’m so sorry, Jennifer. I spent a long time living in the South, and it’s kind of hard to change.”

We laughed and I asked, “So how are you doing at home?”

Her eyes lit up and she smiled. “It is so good to be normal again, Doctor. I just got back from the grocery store. The place is a mess because I haven’t been able to put the groceries away,” she apologized. To demonstrate, she lifted the camera on her computer and turned it around to scan her surroundings. I could see her kitchen counter covered with cans of food, some stacked 3 to 4 cans high.

As the camera turned back to her, I caught a glimpse of my own face in the corner of the screen, my eyes wide and mouth open in horror. I quickly composed myself. “Mrs Filch, I mean Jennifer, why are there so many cans there?”

“Well, I just can’t drive a car anymore and so I convince my neighbor to take me to the grocery store once a month. If I only go once a month I can really only buy canned foods and frozen dinners.”

The realization hit me: This is why Jennifer had been to the hospital 3 times in 5 months. This is why she wasn’t getting better. When patients with CHF eat too much salt, the fluid in their body and lungs increases. With all those canned foods and frozen dinners—both of which are famously high in sodium—her return visits were no longer a mystery.

I took a breath to compose how I could address her diet without offending her. “Jennifer,” I said, “I love how you solved your grocery problem, but I’m worried that all the salt in your canned food and frozen dinners is causing you to come back to the hospital over and over again.” I went on to explain about the salt in her diet causing excessive fluid retention and that I thought we could help her get more fresh and healthy foods regularly.

When the video visit was over I was able to work with our social workers to help Jennifer Filch get funding for transportation and food vouchers. She was ecstatic and, because of the dietary changes, never had a further admission to the hospital again.

As science and technology change and become more complex, so too do our treatments and medical knowledge. These changes have forced us as medical practitioners to evolve and to become more specialized to keep up with these changes. But as we specialize, there become fewer providers for our patients. And with our growing population, it becomes increasingly difficult to account for the small details that contribute to our patients’ health.

In response, we must somehow resolve the massive amount of information we need to know about our patients while there are fewer medical practitioners to go around. It is telling what physicians know at their core: That no matter how advanced we get, good treatment still requires a nuanced, personalized examination of a patient. I believe my video checkup with Jennifer reflects real progress in this new medical reality. Was this video visit a virtual house call? What is the essence of a house call? As a physician there are ineffable details that I gain by being near my patients, and even more when I can see what their lives are like. By speaking to them and seeing them in their element, I can learn things that contribute to their care. I can ask specific questions and read into their body language. We already have the technology that can improve these visits by enabling us to virtually listen to our patients hearts or lungs. But I find it ironic that we have leveraged such complex technology and science only to recreate an electronic and virtual version of our beloved rural doctor.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

How to Cite this Article

Mashaw A. A house call. Perm J 2020;24:19.114. DOI: https://doi.org/10.7812/TPP/19.114

Author Affiliations

1 Department of Hospital Medicine, Westside Medical Center, Hillsboro, OR

Corresponding Author

Arsheeya Mashaw, MD (arsheeya.mashaw@kp.org)

Keywords: hospitalist, house call, rural doctor

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