E N C O U N T E R
Tectonic plate movement is underway in healthcare and it’s long overdue. Thank you Mr. Sars-COV2. Here’s something no one is talking about – house calls. My associate just retired to his lake house to do telemedicine full-time. Every day I get emails telling me how to shrink my brick and mortar through tech’. Literally, in my email inbox right now I have propaganda from companies doing virtual front desk; supplement fulfillment; and even laboratory fulfillment specifically for doctors. And Amazon Pharmacy is ramping up. Where does that leave us?
Hospitals and insurances will continue to disown primary care; micro-practices will share office space and be mostly tele-med’; new holistic-style urgent care centers will evolve; medi-spas will start to include laboratory testing, and… house calls.
Swap the black bag for a smartphone and the horse and buggy for a Tesla and it feels like a case of the new old. Which is, or will be I should say, a good thing. A learning curve is on the horizon for the uninitiated. Before COVID hit I was already doing home visits (and job visits), and I can tell you first-hand that moving the doctor appointment into the patient’s field of play makes the experience much more than an “encounter.” House calls will shift us from treating a patient to treating a life. But, it’s not for the timid, as I learned in a pre-COVID house call a few years back.
His wife was holding the flashlight over my right shoulder as I removed the last of my patient’s bandages. I could feel her trembling as fear, insomnia, and disbelief pushed and pulled the light beam in and out of the target zone – in this case, her husband’s inflamed buttocks.
Their home’s small first-floor bathroom was clearly not designed for this type of activity, but that’s where JM’s wife had set up what felt like a third-world proctology clinic. God bless her. I mean it. Can we give a healing high-five to all the dedicated wives out there…
Staring me in the face was the slow healing rectal abscess of my “medically humbled” patient, JM. JM’s right hand was handling his right rear cheek while my left, gloved, handheld his left buttock cheek open far enough for me – aided by a dance-floor-esque moving beam of light – to examine the man’s wound.
“Misses JM, move the light to the left please…Mr. JM, let me know if this starts to hurt.”
“OKAY,” they said in surrendered unison. This couple was in it together. There was something oddly endearing about the moment. As it goes for parents, this tender moment was fleeting. One of the kids tapped on the door and wanted momma bear. “Sweetie, mommy is busy right now – go ask your sister for help.”
JM’s left forearm was propped atop his toilet seat in violent contrast to his usual orientation on the Thunder Mug (my college roommate’s term). Someone reading this is thinking, “see that’s why I do yoga. You never know.”
No it isn’t.
You and I do yoga in a bubble of denial about our backside being for anything other than to look sexy in a LuLu outfit. How do I know this? Because every once in a while someone in my yoga class leaks out a down-dog fart and the whole class giggles and acts surprised. (See Will Smith Farts on YouTube for a laugh).
My guy, JM was in a modified down dog – yes. But, this was no happy, playful pup’ doing his morning stretch. My man felt like a dirty mutt. He was being forced into a state of sub-human punishment. And all three of us were sharing his pain.
Around his ankles, my patient had the following telescoped layers serving as shackles:
Gym shorts, tighty-whities, diaper (you heard me), gauze, and medicated, ie- slimy, packing gauze. I started cleansing the wound with my right, gloved, hand.
Outside, slumped over in the passenger seat of his 1986 VW Vanagon, my friend lay sleeping – with hoodie tight around his head and beach blanket hugging his body. The VW – white on white no less, looking the role of a modern alt.-ambulance, sat idle on a quiet Vancouver street just 10 minutes from the city’s iconic harbor.
This is the spectrum of a man’s life that I must keep in view at all times. One moment a man is grabbing his ankles and the next is sleeping like a baby without a care in the world the next. We are not monks in this life. We are surfers. We are weather systems. We are rhythmic through-lines of good and bad, testing and recovery. We never stop learning to walk.
And I get to help hold patients together as they traverse the expanse of being human in the modern world. Along the way, I’ve trained myself to see people simultaneously in health and in moments of profoundly humbling, rectal abscess-type vulnerability. Because I know that no matter how healthy or sick an individual is today, things will change.
JM will eventually be in his Transit Van, sleeping like a baby on a camping trip to the Okanagan Valley with his family. My buddy, slash, alt-ambulance driver will – and did – end up unexpectedly a week later in the ER with an anaphylactic reaction to peanuts. I am committed to seeing, and preparing for, the dirty dog and the playful down dog at every “encounter” with a patient. Expect the best, but prepare for the worst? Yes, that’s my calling, even if my patient is in yoga-mat denial about how life really goes. This is doctoring. And I think this is love.
There was a lot of love in that first-floor bathroom during my memorable house call. I don’t think my patient’s wife had that scene in mind when she first imagined the two of them lingering in the sheets. I mean, guys talk about whether or not they will – want to, can stomach – being in the room when their daughter is born. Women don’t talk over cappuccinos about “think you would hold the flashlight when he needs his rectal abscess drained over your Italian tile bathroom floor?” Do they?
This is love for a patient. What the hell was I doing at JM’s home at 10 pm on what was supposed to be the first night of a ski trip to Whistler? I was there because my patient was frightened. He’d been kicked around various doctor’s offices for weeks without any improvement. The socialized medical systems punt their nuisance cases to the back of the bus. I’ve seen this in Malaysia, The UK, and Canada. I have extensive wound care training and most importantly, he’s my patient and I care.
This is love for a friend. My buddy, prior to counting sheep in the Medical Mystery Machine (See Scoobie-Doo for the uninitiated), drove 45 minutes across town to fetch me at the airport with the expectation that we were going directly to Whistler to ski some fresh powder. But, no. I told him at baggage claim that I first needed to go see a dude about his infected buttocks. My friend shrugged his shoulders as only a great friend can, and played Tender Tissue Taxi without a single question.
In the end (I couldn’t help myself), my patient needed an incision and drainage and rinse, but the biggest issue was something rather minor. He wasn’t putting enough ointment on the gauze. Sitting in his diaper and shorts once again and sipping a hot, “it’s all going to be okay” cup of tea, my patient nodded like a boy who had just been rescued from a well.
“If you don’t want this to happen again, this is what you need to do,” I explained. His wife sprayed down the bathroom, lit a Potpourri candle, and started taking notes on improving wound care.
“You two were doing it mostly right. But, every time you were changing the bandage it was pulling away the delicate new tissue and the healing had to start all over again. Double the frequency and amount of ointment and I’ll show you a better-medicated gauze to use. I will also point you toward an amino acid supplement and get you started on a stool softener.” They were beyond grateful and I barely noticed that an hour had gone by.
When I slid the side door of the Vanagon open my buddy jumped from his nap –
“All good? Whose next doc’?”
Ski time bro.
Rolling down the Sea-to-Sky Highway my buddy asked me “what are you charging that patient?”
I looked at him – he at me. The wheels hummed on the pavement. The question filled the van.
I stared at the empty road…
“I have no clue. There’s no fee schedule for home rectal abscess drainage with wife assisting performed by a surgical sub-specialist with training in cosmetic surgery.”
My buddy laughed, “yeah, but you need to charge something, right?”
“A big bill feels insensitive, like pouring salt on his wound. It feels like telling the boy rescued from the well to immediately go mow the lawn.”
We drove on and eventually shifted our focus to white, fluffy snow. A week later I sent the patient an email, “glad to hear you are doing better. We pinged your card for $175 – you bought us dinner and put gas in the Vanagon.”
JM sent back the, “ah, that doesn’t seem like enough doc’…” type email. We played the game. He went on to leave a glowing review online – a bonus from the boss to the Doctor.
What’s ideal for care?
What’s ideal for business?
This is a tension that is not going away in the new era of medicine.
I watch hospital commercials and think, “man, they make it seem as if they would drive to your home to drain your abscess.” But, that’s far from true. That business model isn’t very attractive.
What I know from my time in the Borneo jungle is that the Medicine Man in the village never goes hungry; never is without shelter and can always call in a favor when needed. He has dignity and esteem in the community. But, he should get a nice paycheck right?
It’s about the money, sure. But, it’s about impact and ultimately about being part of the human experience. It’s more than an encounter. I encounter the mailman. I encounter a squirrel on the bike trail. But, every time I open my electronic medical record (EMR) and click new encounter I think to myself “it’s much more than that.” A doctor’s appointment, especially a home visit, is an investment in a patient’s life. And the kickback is the privilege of co-authoring unique moments and a memorable story.
Adam Miller, DDS, MD is a surgeon, integrative medicine expert, dentist, and husband who has trekked the globe looking for the heart of the matter.