By Douglas B. Flora, MD, LSSBB
My first house call started with my patient easing cautiously into his favorite armchair, and I was struck by how they matched—the chair and patient—both tired and worn. After a year of chemotherapy, his decline was accelerating, and it was apparent. This cholangiocarcinoma had originally just been a visitor here too, but had now made its home in his life. Where once his cheeks had a healthy glow, now his face appeared hollow and shadowed, and baggy pajamas, which only a few months ago would have fit him well, now hung loosely on his frame. Half-empty pill bottles littered the kitchen counter. Beside him, a newspaper sat folded upon a television tray; I could see he had solved the daily crossword (I never knew he did crosswords...)
I found myself reflecting on this man in his own space, and found myself leaning in. It felt easier to hold space in this place, and a more comfortable and natural conversation emerged between doctor and patient. We covered all the essential cancer-related topics, but as a guest in his home, it somehow seemed more personal and absorbing. We talked about his life before his cancer, about his best memories, and some of his worst. We even laughed, hard, when surprised by a few cameos by his family cat. We were able to relax and engage sans stethoscope and our conversation carried us to quieter topics like end-of-life care and hospice enrollment. We both knew that death was whispering to him. The patient was now ready to listen, and we had a real talk about dying, and fears, and time. We both knew he’d had his last dose of chemotherapy and it was time to care for the person instead of the tumor and involve hospice care. When we reached this destination, both of us were comfortable with these decisions, and I personally felt a familiar relief, knowing this was a talk that had been overdue. When the end of our visit drew close, we said our goodbyes. I closed my patient's chart, and I knew I would likely never see him again in person.
The twist for this house call: he was on video, and I was seated at my desk 20 miles away. Our virtual visit had happened over wi-fi on a hastily purchased iPad I'd ordered as the coronavirus first invaded our lives and clinic schedules. My patient was immunosuppressed and receiving chemotherapy, and we were now practicing in the brave new COVID-19 world. I looked around my own office, surrounded by modern medical talismans: framed degrees, neatly pressed white lab coats on hangers, stethoscope draped on a chair, and couldn’t help but reflect on how this setting contrasted with the messy living room I’d just (virtually) visited. I thought these tools were critical to my patient’s care, but in reflection, what this patient needed in the end had been an honest and compassionate conversation with his cancer doctor. Our most personal discussion in a year included none of these more conventional tools of my trade. When removed from the sterile exam room and the harsh glare of hospital fluorescents, I had been able to see the man rather than the sharply dressed character he played during our appointments. The new understanding I gained about my patient from this visit had so much more resolution than the picture of him I'd had before. When this new house call ended, I logged off and texted a friend and colleague: "We are never going back to the way things were."
The post-COVID world of medicine is a place of nuance at the new, tech-driven intersection of love and science, and allows us the opportunity to revisit the doctor-patient relationship with this lens. Just as, initially, the doctor's house call was born out of necessity, so now this type of digital house call is required so that we can care for those patients who cannot or should not come to us in person. An unexpected silver lining of this pandemic is that, by forcing us to learn to be alone together, we can bring back a powerful tool to our medicine bags that we may have lost along the way: seeing the patient as he lives. In the last few weeks, I have seen patients who deny having pain but who then grimace as they shuffle around their kitchens. I've seen a patient's apartment in disarray and was able to point out dangers that pose a risk of injury, like loose throw rugs and sharp-cornered coffee tables. I'd have missed that in my office. This burning platform of COVID-19 pushed telehealth for our own medical practice from completing only 250 video visits in the entirety of last year, to nearly 130,000 since emergency self-distancing measures were introduced almost 6 months ago. Most expect telehealth to persist in some fashion post-COVID, and I’d argue this represents a real opportunity for physicians and other providers to meet our patients where they are and to realize that our old conventions were built around our schedules rather than those of the patients we serve. That alone merits some consideration on our part. Ironically, these virtual visits can absolutely bring us closer to our patients, despite the physical distance between us.
Now, with many more virtual visits under my belt, I have come to love this new version of the house call. Through this lens, I've been able to view the grace and daily heroism of the caretakers, husbands, wives, sons, and daughters caring for their loved ones. I've seen how tirelessly they work to keep my patients afloat. I've been a guest in their home. I’ve met more family cats. I am finding that I am learning to be a better listener. Seeing the patient in their home makes me pause and allows me to soak more deeply into their lives. I recently read a note from a respected psychiatry colleague that articulated this well for me, as she described “sitting in the depths of their caves” with her patients. That is what these new house calls do--we can now see the worn chairs, the baggy pajamas, and learn more about our patients in the shadows of their own caves. When I move to the next non-video visit on my office schedule, it now can seem almost sterile to have those same conversations with a patient on an exam table, gowned and vulnerable under the fluorescent lights again. I realize with some guilt that, for many of my patients, just getting dressed for the public and traveling 45 minutes to my office adds hardship to their already difficult lives. As a result, we’ve started to alternate in-person and video visits for those patients for whom a careful physical examination isn’t absolutely required. The patients and the providers have fully embraced this change in our practice.
This new house call allows both the doctor and the patient to sit together like in those celebrated oils by Norman Rockwell that graced the Saturday Evening Post, but a router has now replaced the well-worn black bag, and an LCD screen, the stethoscope. During these visits, it doesn't matter to either of us that we aren't together in person. Our conversations cover all the things we need to say to each other, with a healthy dose of laughs and tears thrown in, and hopefully, we both leave with a deeper, more human understanding of each other. In this weird way, separated by two screens and miles of internet cable, we can learn to really see our patients again, allowing our care to be more personal despite the distance between us.
My patient with cholangiocarcinoma did pass away shortly after that first virtual visit, but I felt heartened as I reflected on our last appointment. I remembered him well, with his life and death now seen more vividly after our deep and affecting conversation. I reflected on how he’d looked in in his baggy pajamas sagging into his favorite armchair. Mostly, I remembered the quiet space we had created in his messy living room, and I felt content that at the end of our journey together, this new virtual house call had placed me exactly where my patient had needed me to be.