September 24th, 2007

They make house calls—for a price

When I was very young, safe in bed with the usual flu or the occasional chicken pox or other standard childhood disease, I would dread the doctor’s tread on the stairs and the opening of his little black bag, which seemed vast to me. It was made of thick black leather and smelled of medicine and disinfectant—just like his office did, the one with the transom window above the door, the tiny uncomfortable wooden chairs, and the table with a map of fairyland on it that looked ancient even then.

He was a small man, our pediatrician. But I was even smaller, and he was scary, without the jovial bedside manner common to the genre nowadays. He had a tiny, trim mustache, and when he gave shots—and he gave them quite readily—they hurt.

But he made house calls. Any time my brother or I were sick enough to stay home from school, we knew we could not avoid his visit.

By the time I was the mother of a young child the house call was a thing of the distant past. When my son had a fever of a hundred and four, it was necessary to haul him, bleary-eyed and runny-nosed, coughing up a storm— often out into a storm—to sit in a waiting room with other sick children in the sick section, separated from the “well child” group by only a few feet, to endure the glares of the mothers sitting there.

But now, according to the NY Times, the house call has been revived—at least, that is, for the rich. Catering to the traveler and business customer, but available to all who can pay the very substantial out-of-pocket fee, there are those who have filled what is now a specialty niche in the medical service world.

There may not be continuity of care, but for most people that’s long gone, anyway. Just as people are willing to pay big bucks for personal trainers and other sorts of TLC, they are eager to pay for a doctor who will come when called, the black bag (metaphorical at this point?) sometimes supplemented by modern devices such as portable ultrasound machines.

Most of us, of course, can hardly afford the service that was standard in my youth. In those days, the main reason it was so commonplace is the same reason medical care in general was affordable: it was all paid out of pocket, and it consisted of very low-tech care. Immunizations were key, but they weren’t very expensive. For the rest, mostly the doctor came, looked at the patient, dispensed a few pills or maybe the (usually quite useless) antibiotic shot, and waited for the sick to get better.

Which usually occurred. When it didn’t, the doctor came to monitor the progress towards death. Every now and then there was an operation—the appendectomy or the hysterectomy or other ectomy. But mostly it was watchful waiting, which didn’t cost all that much.

Now we have MRIs for every sprain; CAT scans that can visualize our insides; and advanced cancer therapy undreamt of in my youth, when the words “you have cancer” meant “you will die soon,” and therefore were usually not even uttered in front of the patient.

Some of this represents an advance, but some does not. Some of it merely extends the length of life at the end of life, when there’s hardly any quality left and even the patient would rather go gentle into that good night, but isn’t allowed to.

We pay for the privilege of high-tech care, and in most cases we don’t want to give it up. But it’s the reason the health insurance crisis is not really fixable, and the house call is a privilege for the very rich.

15 Responses to “They make house calls—for a price”

  1. gcotharn Says:

    Our health care system is the worst in the world, except for every other health care system in existance.

  2. nyomythus Says:

    The writing is wonderfully detailed and descriptive; good post!

  3. snowonpine Says:

    My first memory of our family doctor was of me crouched under the kitchen table with a fork in my hand, fending him off so I wouldn’t get a shot.

    I was born at the end of WWII and in my early childhood had perhaps every disease there was it seemed, serious ear infections each year which mandated several trips to the hospital for surgery and a major accident. Reading your piece, Neo, made me suddenly realize that were it not for our family physician, whose $4.00 house calls—day or night, weekday or weekend– shots and homemade pills continued up through my early teen years—I could very easily have not made it. They certainly don’t make them like that anymore. He is long gone and I wish I had told him before he passed how grateful I was for his care, which I just took for granted.

  4. soonergooner Says:

    —-Some of it merely extends the length of life at the end of life, when there’s hardly any quality left and even the patient would rather go gentle into that good night, but isn’t allowed to——

    My 83 yr old dad was diagnosed w/small cell lung cancer this past month. He was having probs breathing(imagine that, after smoking for 67yrs) so we took him to emer room on a w/e. While he was there, they took a chest scan and found the shadowy mass. The doc took me to an anjoining room and showed me the “film.” Amazing. Dad has since begun a course of chemo, which before he was TOTALLY AGAINST. The good news, the oncologist words have rung true as crystal because he is feeling better and is quite fine, even with the O2 tube following him everywhere. Hopefully, more good news to follow… HAPPY THOUGHTS!!!

  5. Jimmy J. Says:

    I lived in a small town. (800 or so population) We had two Doctors. They both did house calls although one of them was quite elderly (probably in his 50s). It was my impression that they charged people pretty much what they knew they could afford. There was also quite a lot of barter and payment in kind. My mother had a beauty shop and often traded permanent waves for the younger doctor’s wife for medical care for my brothers and I.

    Serious problems that required surgery were evacuated by station wagon to the nearest hospital some 25 miles away. Cash was required, but people were able to work out a payment plan. Hospitals were usually sponsored by Churches, or other philanthropical groups that helped keep costs down.

    It seemed to work pretty well. Both doctors were among the wealthier citizens in town and everyone got treatment. The doctors knew the community well and the community trusted them.

    My stepfather contracted lung cancer from smoking cigarettes. They did everything for him that they knew how at the time (1953) but he died a slow agonizing death. Certainly convinced me that smoking was a bad thing for one’s health.

    Many things about medicine are better today, but the costs have gotten way out of line. We need to go back to having patients and doctors in control like it was years ago. Insurance companies and the government are calling the shots today. I read recently that government pays for 47% of healthcare today through Medicare, Medicaid, the new Medicare drug plan, and military medical care. We’re getting closer to socialized medicine. I think Health Savings Accounts would put patients and doctors back in charge.

  6. camojack Says:

    Actually, I have a friend who’s a medical doctor…she makes house calls.

    Sometimes I have to go to her house, though…

  7. sergey Says:

    May be, this is a symptom of backwardness, but we still have house calls in Russia as an everyday norm, and it is completely free! With all of my five children, for every cold sufficiently severe the child to be out of school, the doctor came to see the patient and make recomendation. Of course, we soon got known these recomendations by heart, but were urged to call a doctor to get a bulletin, so that my wife can have her leave to stay at home several days for child care (she was working and upbringing children at the same time).

  8. sergey Says:

    The treatment, thouh, was very simple, and diagnostics did not include any equipment or tests, only temperature measurment and visual examination. But doctors insisted that we called them every time, so that any serious illness like diphteria can be properly diagnosed.

  9. sergey Says:

    Socialised health care makes sense in a very poor country with mainly illiterate population, like Russia or Cuba; the more wealthy and educated population is, the less sense left in it. In such countries as Britain or Canada it inevitably became ramshackle, with long waiting lists and too few doctors that agree to work in such conditions. Another requirement for viability of socialised health care is the same as viability of socialism itself – closed borders, as in Cuba, or absence of international recognition of medical diploma, so that doctors have to agree with very poor salary.

  10. Tom Says:

    Neo, I have come to expect good sense from you, but this post profoundly disappoints. “MRIs for every sprain”; “merely extends the length of life at the end of life”; “But it’s the reason the health insurance crisis is not really fixable”. Really, Neo, on health care you remain a liberal.

    As a physician, I can’t even begin to tell you how wrong, how sadly wrong, you are. Health care makes incremental progress, and over my professional lifetime the progress has been truly extraordinary. There is no “merely” about extending the length of life.

  11. Kevin Says:

    House calls may sound charming, but that must have been an outrageously unproductive way for someone as valuable as a doctor to spend his time — spending half his day driving from one house to the next? I reckon people expected and consumed a lot less health care back in the day.

    I also strongly suspect my poor ancestors in small town Arkansas didn’t actually get house calls, as you did.

  12. Tom Says:

    There was a lot less health care to “consume” then, Kevin. How long have we had antibiotics? The answer may surprise you. And when did the average household go from a one-car household?
    Housecalls made a lot of sense when transport of the ill was limited and non-surgical remedies were few. Even in AR, even for the poor, even in small towns. In the 1950s, the average doctor earned about three-fold the average worker’s income, and it didn’t cost a zillion $ to attend medical school.

  13. Karen Says:

    Amazingly, there are still a few doctors in Australia who make house calls, just like I remember from the 1950′s in New England when I lived there. It is not unusual for your GP ring up to ask how little Johnny is doing a few days after you’ve had him in to the office to have Grandma’s diagnosis of chicken pox confirmed. But for caring, good service you can’t go past our local vets: they do follow up telephone calls on any pet which has had surgery or serious illness, especially if they’ve prescribed relatively new medication.

  14. jeve Says:

    I am a solo practice internist. I just returned from a housecall, to a patient who is quadriplegic. I have done housecalls for my entire career 16 years. Problem for me, an HMO wouldn’t pay me for the housecall unless I got prior authorization to go see my own patient. Medicare hasn’t paid me for this patient in the last two years, so now I have to spend half a day on the telephone begging them to tell me why. Its the endless problems with doing simple things that beat a struggling physician to give it up. But yes some of us do consider a part of our job and will do it for those who truly need it. Jeve

  15. Oscar Turner Says:

    Chicken Pox can cause massive scarring of the skin that may not clear, that’s bad-;’

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.


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