house call physicians

One glance inside a diabetic’s refrigerator can tell me more about her diet than any in-office discussion or nutrition questionnaire. A peek in the medicine cabinet detects polypharmacy, and a quick pill count reveals medication noncompliance.

Inspection of the patient’s “den” may uncover safety hazards such as loose rugs, sharp corners, or the absence of night-lights. Accumulating mounds of household clutter may be an early warning of incipient dementia, as an old person falls behind in organizational capacity. The clues are all right there in the home environment.

For many patients, an office visit is Showtime. An old woman applies a little lipstick and makeup to conceal her pallor. She musters the fortitude

to get behind the wheel and drive to the doctor’s office, where she puts on a fifteen-minute grand performance of forced vitality. Later, back home

and out of my sight, she suffers a total collapse due to utter exhaustion and requires a full week to recover. A younger woman, sapped by chemotherapy

and radiation, does no better. More useful to me, as the patients’ physician, would be a more natural encounter at home, without the theatrics.

Does she get up to greet her guest? Can she navigate within her own home? Is she managing independently? Where is she on the variable but

relentlessly downward-sloping curve to frailty? What will her needs soon be? The home visit is anticipatory, not reactive.

As a sensitive functional assessment, for the elderly in particular, the

home visit offers screening for the four common geriatric syndromes that

herald a coming loss of independent living: risk of falls, dementia, depression,

and urinary incontinence (Ehrlich 2006, 38). These are the most

common culprits that lurk, ready to render a once functionally independent

older person into a sadly dependent and declining nursing home

resident.

the essential activities of daily living,

the personal and private achievements that preserve independence

and human dignity: walking, eating, dressing, grooming, bathing, and use

of the toilet.