On Thursdays, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.
This week I am returning to some essays that were written last fall by second-year residents about home visits. I always enjoy these writings as they remind me to get back to doing home visits where we learn so much about our patients, their lives, their families and their communities. Kimberly Bombaci, MD, now chief resident at Hahnemann Family Health Center, has captured the rewards of home visits well in her reflection.—Hugh Silk, MD
A home visit for context
MF is a very kind and talkative woman in her early 80s. When I asked about coming to her home, she was very excited. She had a medical student visit her in the past and had a good experience. If you were seeing her in clinic, the first line of your note is likely to read “pleasant non-smoking female with a past medical history of non-insulin dependent diabetes and hypertension.” As hard as I try, it can be challenging not to first think about the person as a “problem list” that you need to address but rather think about them as a person. We think about their illness and how their life affects their adherence. When you see someone in her home, you think about the person and how the illness is affecting her life. During a home visit, you can learn so much about a patient you otherwise would not know. You may take a great family and social history, but it is so much easier to understand a patient when you can put them in the context of her own life and surroundings.
You start to learn new things about your patient as soon as you head to their house. You see the neighborhood they live in. You learn who lives in the neighborhood. Does it make you feel happy or a little uneasy? MF lived in a nice section of the city. On the way to MF’s house I saw the streets where MF’s children probably rode their bikes. The area was a little older and it seemed as though most of the residents were too. They, like MF, had probably raised their families there and stayed for retirement. It felt safe and inviting. I could picture what this place would have been like 40 years earlier.
MF’s house was well maintained. As soon as I entered the home, I was taken aback by the amount of knick-knacks on the walls and in shelves. Her home is filled with things she had collected throughout the years. She points to mementos she got while vacationing with her husband who had passed away eight years earlier. I instantly learned how sentimental she was just by being in her home. It made me understand why she was so resistant to leave this place. She had fallen two years ago and since then had been getting pressure from family to look into moving.
After showing me the house, we discussed her health. She showed me her medicines in a collection of bottles on the microwave. She had been given a pill dispenser in the past but had never really taken to it. She agreed to try it again as she sometimes forget which of her pills she has taken. We filled the container and also labeled her bottle caps with the time of day they should be taken so she could refill her dispenser the next week. I think helping organize her medicines was a success as it can prevent possible errors. I imagine her children had likely urged her to do this in the past but maybe having the doctor do it with her will motivate her.
MF had expressed in the health center how important it was for her to stay in her home. I think her motivation to stay there allowed her to let me walk through the home and discuss safety. She had a mechanical fall in the past and her balance was not great when it had been tested in the health center. We were able to get rid of some area rugs that she may trip on and moved some end tables that stuck out. Of all the things I could have done for this patient, this is likely to be the most useful. I can check her A1C, but preventing a fall is what will help her with her goal, which is to be in her home.
After seeing this patient in a context of her home, it made it easier to understand her point of view. When we are in the clinic things often seem very black and white. The patient is supposed to take these medicines for this condition. We determine if they are or are not safe in their home. We don’t think about everything else that is involved in this patient’s life. My visit with MF will encourage me to care for all my geriatric patients differently. It can be overwhelming seeing all the different medical conditions an older or sicker patient may have and knowing you have 15 minutes to address them. First on the list should be understanding the patient’s goals so you can work on their goals as well as the ones you may have on the computer screen. I also found that understanding the person can help you learn how best to motivate them as well.