Doctor is out

Vivian Dennis hadn’t seen a doctor in two years. But that changed last week, when a woman in blue scrubs with a big black duffel bag showed up at her door. “Hello, I’m Dr. Ashley,” the doctor said, bending toward Dennis’ wheelchair to take her hand. “How are you?” Truth is, Dennis isn’t so great.

The 87-year-old Valley woman broke her knee moving from her chair to her bed two years ago. Since then, she hasn’t been able to walk or get into the car to see a doctor. She’s most concerned about several suspicious spots on her face and body. But she also has high blood pressure, a flagging appetite and a fungal infection on her foot.

Fortunately for Dennis, Dr. Susan Ashley is reviving a medical tradition: The house call.

“I decided this would be a good idea, something I could do as more of a service,” says Ashley, who started making house calls about six weeks ago.

Ashley still spends the bulk of her time in the office, practicing at Spokane Valley Family Medicine. The Liberty Lake resident saves house calls for her off-hours and says she has no plans to cut back on office time.

To limit traveling, Ashley will only see patients in the Spokane Valley, Liberty Lake, Otis Orchards and Greenacres.

Currently, she’s the lone area doctor offering home visits, one of a small but growing number of physicians around the country trying to bring back this once-common way of practicing medicine.

In 1930, house calls made up 40 percent of all doctor’s visits, according to a 1997 article in the New England Journal of Medicine. By 1950, that number dropped to 10 percent. And by 1980, house calls made up just a fraction of one percent of all visits.

But Connie Row, executive director of the Maryland-based American Academy of Home Care Physicians, is hoping to reverse that trend.

Row’s group works to smooth the way for doctors to start making house calls. The group has fought to increase insurance reimbursement rates and has created curriculum to teach young doctors about making home visits.

The Academy, which has about 700 members, keeps a list of at least one doctor or nurse practitioner making house calls in 40 states on its Web site at www.aahcp.org.

“We certainly hope it is a growing movement,” Row says. “But it is certainly small.”

About 2 million house calls are made in this country each year, Row says, citing Medicare reimbursement statistics. However, to serve just the elderly, homebound population, doctors would need to make 10 million house calls a year, she says.

“There is a huge and growing need,” she says.

Instead, those patients simply never get medical care. That is, until they become so sick they wind up in the emergency room.

“The federal government is going to have to get serious about chronic-care management,” Row says. “We are going to bankrupt this country if the only way we manage people is through emergency room.”

You don’t have to look too hard at the way medicine is practiced today to see why house calls fell out of favor. Who has time to drive to peoples’ homes when managed-care pushes doctors to see as many patients as they can each day?

But, thanks to recent increases in Medicare reimbursement rates, doctors are now being paid about the same amount for seeing patients at home as they would in the office. And many private insurers will pay for home visits as well.

“We’re hoping that gradually more and more doctors would at least try to make house calls part of their practice,” Row says. “It’s slow-going, it’s not easy and there are lots of barriers.”

Ashley admits that some of her colleagues think she’s crazy for taking her practice on the road.

But the 44-year-old doctor has always had a bit of an adventurous spirit. She served as a flight surgeon in the Air Force, and has practiced medicine in Kenya and Ukraine.

So far, she’s been struck by the things she has learned about her patients while in their homes, things she would never pick up on in an office visit.

She can scan medicine cabinets and help people toss out old drugs. She can spot hazards in the home that might cause an elderly person to trip. She can survey the kitchen or bathroom to see if poor hygiene is a health issue.

Before visiting patients at home, Ashley talks with them on the phone to find out what health concerns they have. That way, she knows what to add to the blood-pressure cuff, stethoscope, otoscope and other items in her bag.

She is able to perform simple procedures, such as draining a cyst or testing a urine sample, in peoples’ homes.

So far, about half of her patients have been like Dennis – elderly and unable to get out of the house. Most of the others have been parents with young children who liked the convenience of having the doctor come to them.

“The size of this city, I think it could support a practice that is doing solely house calls,” Ashley says.

Back at Dennis’ home, the doctor sits in an armchair and begins her examination. She takes a close look at Dennis’ skin, feeling the growths on her lip and head.

“These all look suspicious for skin cancer,” she says.

Ashley says she will arrange for someone to come to Dennis’ home to draw blood and that she will look into ways of transporting Dennis to the hospital to have the growths removed.

“I can come by and take the stitches out here,” Ashley tells her.

In the end, Ashley winds up spending about 45 minutes with Dennis, significantly longer than a typical office visit.

They discuss Dennis’ health concerns. But in the relaxed atmosphere, they are able to talk about other things, too.

Dennis tells the doctor about her wonderful daughter. She talks about her living will, her interest in religion, how she practiced yoga when she was younger.

“It’s wonderful you’re doing this,” Dennis says, her eyes welling with tears, as the doctor prepares to leave. “You’re exceptional.”