Saturday, April 10, 2010

House Calls: Paid in Full Plus Tips

I just made a house call which was, as usual, very satisfying. I can't mention more since I'm being followed on Twitter by HIPPA, as of 4/06/2010. (Should I be flattered?). Old house calls come to mind that won't create problems with my HIPPA friends, so I'll flash back a bit for you.

My first holiday weekend on call in a small Ohio town over thirty years ago included my first house call. Someone exacerbated a herniated disc, was bedfast and called for relief. I accommodated with an examination, a differential diagnosis, a diagnosis and an injection of Demerol (meperidine) and a prescription, a treatment plan and a time for follow up visit in the office. He paid me with a check (He asked about the charges and was provided with the fee amount of $75, including injection, which he gladly paid from his sick bed). He then asked his wife to provide me with some of his homegrown fresh tomatoes, which she selected from a freshly picked array on the kitchen table. I gathered up my black bag and my tomatoes which added a nice touch to their gratitude. The intense pain was relieved, as was the patient (of my partner). I felt good about being able to help someone in pain, which I perceived to be part of my calling to family medicine.
Later I discovered that the man in pain was a millionaire which added to my sense of how human we all are. Human to human we're all human. First house call, first tomatoes, first millionaire. Paid in Full. The tomatoes were great.

On a cold early winter nite, a patient with pre-terminal congestive heart failure called with SOB and edema. I examined her, clarified the situation (dying at home, pre-home hospice, not interested in hospitalization), injected furosemide and chatted about her church and family. She showed me the photos on the walls and told a few stories about her deceased husband. She was teaching me about meaning at the end of life. She then sought to pay for my services and wrote a check for the home visit (100% of the Medicare allowed charge- that's how long ago this was) and then surprised my by insisting on giving me another check for me personally, as a sort of Tip. I quickly rejected on the grounds that Medicare didn't allow physicians to take more than the approved medical fee. She became visibly short of breath as I became firm in my "no tips for me" posture. I stopped my protesting and she stopped her further CHF exacerbation, breathing more comfortably. I accepted the $10 tip (but with federal paranoia about Medicare, I endorsed it over to her church the next day and washed my hands of potential banishment by Medicare or prison- maybe that's why HIPPA is following me- they found out about the Tip).
First teaching by a home-bound dying patient, first Tip. Paid in Full.

Many house calls and years later, I agreed to care for a home delivery newborn. The family called me one hour after delivery to see their 9lb 4oz son. I was greeted at the door by a smiling new (second time) father and taken into the family room where a smiling mother was breast feeding a one hour old infant. The older brother was eating a bowl of ice cream on the floor and two neighbors knocked and entered with supper and cake. They chatted with the resilient looking new (second time) mother while the smiling and nursing continued. No nurses. No needles. No circumcision.
I examined the baby, shared my perspective with the parents, chatted with the older boy and partook of a piece of cake when it was offered. What a natural process. They taught me another perspective on childbirth. They bubbled with wholeness and love and shared it with me. First home birth house call, first family expansion natural on site education, first house call cake. Paid in Full.

I also examined an elderly patient with an arrhythmia and CHF flare up while the Fourth of July Parade went by her front door. Heart sounds hard to hear through the bands, but we figured it out. Many house calls were to people with terminal cancer, initially without the benefit of home hospice. Initial home visits also were before emergency squads were commonly available. Families, neighbors and friends provided a lot of the care to these folks. The doctor was always prepared with one or two injectable medications. Incision and drainage of abscesses was another challenge on home visits, but doable and necessary at times. Overall, I still learn something new at each home visit, especially about life in America and life in families. People know a lot and share a lot with their family physician.
Many are surprised when I initiate a home visit. A friend and patient called one night with severe low back pain. I asked if he had any coffee in the house. He asked with confusion, "Am I supposed to put coffee on my back?" I said, "No, put on the coffee, I'm coming over to treat you." He was pleasantly surprised and I was Paid in Full.

The kindness of the individuals and families I've seen on house calls has been impressive. The learning has been touching and meaningful for me personally and professionally. I consider myself Paid in Full.


  1. That brought tears to my eyes. You are missing your calling, NOVELETTE BY JONAS.......remember I always said you are the Agatha Christie of medicine.

  2. Welcome to the blogosphere. What great stories! I'm looking forward to more of your writing.