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http://www.nytimes.com/2002/06/04/health/policy/04HOUS.html

House Calls: How Physicians Heal Themselves

By RANDI HUTTER EPSTEIN

hat a difference a few house calls can make. Sometimes even the doctors feel better.

There was a time, before physicians started seeing Rosalia Morales at her home, when this very ill 66-year-old widow was not getting any medical care at all. Mrs. Morales suffers from Alzheimer's disease and has had several strokes. She is bedridden and cannot feed herself.

"It was only me," said Milagros Morales, her 30-year-old daughter.

"In the beginning, my mother would walk around pacing the floor, taking off her diaper. She would get real angry and try to run away. She'd scratch me when I tried to give her a bath and spit out the food when I fed her. Sometimes I would get so overwhelmed I would scream, but that would only get her more agitated."

The two women live in a rose-painted apartment in East Harlem, cluttered with family photographs and souvenirs. For a while, Mrs. Morales went to a clinic, but as she got sicker, she refused to go.

"After what my mother did for me, raising me, I thought I could never leave her side," said Ms. Morales, who scrapped plans to go to college to stay with her mother.

But the constant demands of caring for a deteriorating patient became overwhelming, even for a highly dedicated daughter.

One telephone call changed the lives of both women, and also lifted the morale of the doctors who now treat Mrs. Morales.

About three years ago, Mrs. Morales was selected from a list of clinic no-shows to receive checkups at her bedside.

The doctors cannot cure her disease, but they have treated her bedsores and prescribed medicine to ease her agitation and lower her blood pressure. They have also arranged for nursing aides, paid for by Medicaid. The extra help has enabled Ms. Morales to attend Touro College, earn money as a cleaner in a hospital on weekends, and even resume dating her boyfriend.

And while the Moraleses have benefited, so too have her doctors. Dr. Sonni Mun, her current physician, clearly likes her job.

She enjoys the leisurely time chatting with the family and says it adds a new dimension to practicing medicine in New York City.

The Moraleses are part of a five-year-old program of the Mount Sinai Hospital and Mount Sinai School of Medicine that was started primarily as a teaching strategy. The program, called Visiting Doctors, was founded by Dr. Jeremy Boal, Dr. David Muller and Dr. Laurent Adler, three former residents here, who worried that the grueling demands of residency training were creating a breed of callous, angry physicians.

The three brainstormed for solutions and decided on a month of house calls in the training program to remind residents that their patients are people, not biochemical analyses.

Several residency programs across the country are now incorporating low-tech methods to instill compassion into weary and disheartened trainees. The Mount Sinai course was modeled after a Boston University program, directed by Dr. Sharon Levine. Other strategies include seminars in ethics and role-playing classes to teach bedside manner. But the house-call program is one of the most intensive additions.

"As far as I can see this is a trend that is starting to sweep training programs in our field," said Dr. William Hall, past president of the American College of Physicians-American Society of Internal Medicine.

"The whole idea of getting away from training primarily in hospitals and seeing where people actually spend their lives opens their eyes to the healthy side of medicine," Dr. Hall said. "We have spent the past three decades coping with the knowledge explosion, which has been phenomenal in internal medicine, and to some extent might have been done at the expense of spending less time learning communication skills."

There are no data to prove that a few weeks of home visits will make for happier doctors, but those who teach residents have a hunch the experience, however brief, is rejuvenating.

"You can lecture to death about how important these things are, but you have to be surrounded by it," said Dr. Margaret Bia, professor of medicine at Yale.

"You have to see that your patients may have kids running around handing pills to their dolls, and that may be why the patient keeps forgetting to take her medicine. In this day and age, when every doctor is burning out and questioning why they went into medicine, you realize the importance of these things."

Every resident in internal medicine at Mount Sinai is required to spend one month making house calls. In addition, they attend two seminars a week, one on palliative care and the other on literature. At the end of the month, residents complete projects — essays, poems or artworks — reflecting their experiences.

In the house calls, residents learn to take care of all sorts of nonmedical yet crucial components of healthy living. For instance, they help weed through the confusing mass of insurance forms; they check food supplies; they double-check to make sure prescribed medicines are really taken.

"You come to the home visits right after a rotation in the intensive care unit, where you take care of incredibly sick people who you never knew and many of them die," said Dr. Joanna Sheinfeld, a second-year resident in internal medicine at Mount Sinai.

"The I.C.U. is incredibly hard and there are nights when you think, `What am I doing here? Who am I helping?' You are too busy to feel like you are helping anyone. And then you start these home visits and it's like a breath of fresh air."

On a warm Tuesday morning in October, Dr. Mun, Mrs. Morales's home physician and an attending physician at Mount Sinai, lugged a canvas backpack filled with medical records, a stethoscope, prescription pads and other medical necessities. In tow were three second-year residents, including Dr. Sheinfeld.

First stop was the Morales home. Next was a woman in Harlem with severe multiple sclerosis, and last was an elderly woman on the Upper West Side of Manhattan. Dr. Sheinfeld said the month solidified her decision to go into geriatric medicine and to continue to make house calls.

"I really think even one house call is powerful," said Dr. Levine, an associate professor of medicine at Boston University, who helps coordinate house call programs. "You learn to understand your patient in a holistic way; I mean that in the real sense of the word.`

Almost all the residents say the house call segment is their favorite part of their rotation, Dr. Sheinfeld said, adding, "This is the kind of medicine you imagined before you started medical school."


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