House calls are not a core part of my practice as a specialist, although I have made many.
In doing a house call, I think of driving up a snowy road to a decaying-but-loved farmhouse and moving next to a window's light to look at what might be cancer. I am always struck by contrasting feelings of attachment with the patient and family and isolation from the medical environment. Without doubt, seeing my patients in their home amplifies understanding of their challenges. Deeper understanding of their cultural and personal roots is placed front and center. (And, of course, that understanding is a great help, even if it sometimes makes clinical detachment difficult.)
For a doctor, it's unusual to have this level of immersion in patients' contexts on a routine basis. But for people who deliver care in the home -- the caregiver, the aide, sometimes the family -- it is their "normal." They see a developing stroke manifest by a slow degradation in clarity of speech, although it's hard to describe and hard to communicate. They see subtle changes in the nature of a wound that portend massive sepsis. But they are not given the tools or the structure to communicate these observations, hunches, and context effectively.
Medical hierarchy is both very deep, very entrenched, and often with caregivers and home care aides, seen as being at the "bottom." Because of the hierarchy, providers like aides, who primarily give care at home, are expected to carry out orders, not influence the course of care. So they're left with checkboxes and protocols, not tools to share their insight. Often checkboxes and protocols are designed to avoid mistakes, but instead have the unanticipated consequence of communicating nothing because there are not enough boxes to check.
The hierarchy has value in that a chain of command makes orders clear and accountability strong. However, complex situations demand a more complex flow of information. Not just orders from top to bottom, but information "uphill," too. And when information needs to flow uphill, the orderliness of hierarchy makes a strong barrier to responsive and personal adjustment and modification as a vital response to changing condition.
Beyond communication, we need to rely on collaboration where we take the best of everyone in the hierarchy and build a team and a plan. Teams change. Plans change. We need to accommodate, embrace, and adjust to the change.
So, to return to the title of this post, probably the loneliest and most solated work in healthcare is home health care. Changes are observed but it can be an almost impossible job to communicate those changes in the context of the hierarchy. When home monitoring sends a signal of weight change to a central station, that is lauded as a great breakthrough and it is. Then what? The caregiver in the home probably saw a change first and even knows the intervention that is needed. We need to recognize this and empower the change while keeping the entire team involved.
One more reason for doing what we are working so hard to do: getting access for the patient, collaboration for the providers, and use the interactions to teach those who follow us.
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