Housecalls

Demonstrating CanMEDS–Family Medicine competencies during home visits

Most family physicians easily and readily provide feedback to learners on the CanMEDS roles of family medicine expert or communicator (eg, in field note format).⁶ Opportunities to assess a learner as an advocate or collaborator might be less common in a typical clinic setting. In contrast, a housecall is intrinsically rich in opportunities to provide feedback to learners. Before arriving at the patient’s home, the preceptor can prime the trainee to pay special attention to his or her role as the following.

Health advocate.

A home visit is a chance to truly see the patient as a part of his or her community. What do the neighbourhood, housing, and home environment tell the resident about the patient’s determinants of health (Figure 1)?

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Figure 1.

Thinking like a health advocate

Collaborator.

Nowhere is an interdisciplinary team approach more essential than when caring for a patient in the home. After an environmental scan in the patient’s residence, ask the learner whom he or she might connect the patient with to help address the health needs identified (Figure 2).

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Figure 2.

Thinking like a collaborator

Manager and leader.

Compared with an office visit, the patient’s home setting allows for a more contextualized evaluation of the effectiveness of the health care system in addressing his or her needs. Prompt the learner to think about health care organization, resources, and efficiencies; there are many examples of these concepts, especially in an urgent or a posthospitalization house-call (Figure 3).

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Figure 3.

Thinking like a manager

After the visit, use the family medicine expert role to guide a reflection on the experience of seeing the patient in his or her own home, and a debriefing about the learner’s experience. A simple prompt could be, “How would this visit have been different had we been in the office?”

Learner safety and supervision

Official policies related to safety during housecalls might vary depending on the educational institution or the learner’s representative advocacy group (eg, the Professional Association of Residents of Ontario). Safety is paramount, just as it is in office or hospital settings. If the patient is unknown to your practice, an important first step is establishing that the patient, his or her in-home support persons, and the geography and environment are reasonably safe. But many, if not most, patients will be well known by the family physician and stepping into their homes will hold the same risks as other community activities and encounters in the neighbourhood around the family practice do. In fact, in one survey of an academic housecalls program in Toronto, Ont, 94% of family medicine residents did not see safety as a barrier to looking after their patients at home.⁴

Experienced clinicians can model this common-sense approach to safety for the learner on a joint home visit. Reference tool kits contain practical advice on how to prepare for possible problems, from bedbugs and barking dogs to the risk of crime and personal safety.^7,8 Professional liability for home visits by physicians and interprofessional team members can be addressed through standard insurance, as outlined in A Canadian Provider’s Handbook to Home-Based Primary Care.⁷

Geriatric and palliative medicine at its best

To reiterate Dr McWhinney’s words from the beginning of this article, housecalls for geriatric and palliative patients are worth discussing, as they can be part of the long-term relationships physicians have with their patients. The importance of geriatric functional assessments, such as home safety checklists and fall risk questionnaires, becomes evident when keenly observing older adults in their own home environments, when they open the door to care providers, walk them into the living room or kitchen, or get up to find their pills. The importance of medication management is clear with one look at a tidy blister pack in an accessible location, compared with searching for and finding a bowl of mixed tablets, bottles, and empty puffers up in a cabinet. Encourage learners to “watch the patient in action” and follow up with prompts to translate their observations into a comprehensive and practical assessment of the patient.

Most Canadians, given the choice, want to be in their own homes at the end of life; only a small fraction actually have that option.⁹ Whatever the model of palliative care is in your local practice area or your own level of comfort in managing symptoms, the unique honour of participating in end-of-life care can start simply with a supportive housecall to your terminally ill patient and his or her family.¹⁰ Taking learners along will allow them to experience how natural and often spiritual the process of dying can be when witnessed outside the sterile hospital environment, in the midst of the person’s belongings, and (if so lucky) surrounded by a caring family. Many competencies as a family medicine expert and communicator can be reviewed and reflected on when caring for palliative patients in their homes.