There’s no place like home

I have always been passionate about caring for patients at home. Among all medical disciplines, it is almost exclusively family doctors who offer housecalls. It is our territory. It is our history. It helps define us. We are the physicians who care for people across all geographic settings—not just in the office or hospital. It is the intimacy of treating patients and their families in the home environment that symbolizes for me the closeness of the personal relationship that exists between us and our patients. Caring for people at home is a core professional task of family physicians.¹ The cost and health benefits of keeping patients in their homes have been well documented.² The personal rewards help some physicians reconnect to the reasons they studied medicine in the first place. The appreciation of patients and their families for this care is usually beyond words.

Much of my clinical practice involves caring for patients near the end of life in their homes. I love what I do and it is a privilege to be able to provide this kind of care. I recently reflected back to my residency, during which I undertook a study of “home birthing.” I concluded that it wasn’t a safe practice in Canada, but on a deeper level, it made intuitive sense to me. And now I’m helping people with “home dying.” Most Canadians would choose to be at home at the end of life,³ but very few get the chance. And only about 10% to 18% of Canadians older than 65 years, depending on the province in which they live, receive any home care during their later years.⁴

Unfortunately, fewer and fewer family doctors are offering housecalls or providing a liaison to home care services as part of their scope of practice.⁵ Overall, in 2010, 42.4% of family physicians offered housecalls, down from 48.3% in 2007. The most worrisome downward trend is among younger physicians. In 2010, only 30.8% of family physicians younger than 35 years offered housecalls (32.3% in 2007). Of our second-year residents, only 34.1% intended to offer housecalls (43.6% in 2007), and even more concerning, only 10.0% intended to be liaisons for home care (40.4% in 2007).

What’s going on? Education in aspects of home care is a part of the family medicine residency curriculum as found in Standards for Accreditation of Residency Training Programs,⁶ but the experience seems to vary from program to program. In 2010, only 66.8% of residents reported that housecall training was available and only 26.0% reported learning about how to be a liaison for home care.

There is a disconnect here that requires investigation. As fewer family physicians undertake home-based care, fewer learners are exposed to the role modeling, the necessary skill sets, and the experience of the rewards that are inherent in this type of practice. Provincial governments across the country are beginning to call for increased home care services as a cost-effective and safer alternative to hospitalization and institutionalization, especially as our population ages. But who do they expect will provide the medical aspect of these services in the future? Community-based health professionals require the support of physicians to manage their patients at home.

There is no doubt that in this day and age it is a challenge for family doctors to provide home care. Busy office practices, hospital care, emergency department shifts, teaching, administrative work, difficult weather, and for some, large geographic distances or traffic all contribute to the barriers that lead to fewer housecalls being performed. Financial disincentives might also exist in some provinces. The housecall appears to be a dying art and its demise should concern us all. It is truly an issue of access to health care for many Canadians.

Does technology provide some partial solutions? A shared electronic medical record between the family doctor and home care team can be a huge asset. These days one can use Skype to communicate with patients and the team. Smartphone electrocardiograms, and remote blood pressure measurements, blood gas measurements, and chest and cardiac auscultations are all possible. Will technology be the great equalizer in facilitating access for poor, disabled, fragile elderly, and dying individuals?

Perhaps. But the richness of the personal housecall visit for the patient, family, doctor, and student can never be replaced by technology—not in our specialty. As a discipline, our responsibility to society is to provide a service for which we are so aptly suited. For those who still practise and teach this art, please continue. For those who don’t, please reconsider. Canadians deserve it. We’re enriched by it. The future demands it. Truly, there’s no place like home.

• Copyright© the College of Family Physicians of Canada