Alfred E. Stillman, MD, MACP
Home Visit Doctors
"I can better understand relationships between the patient and the caregivers by visiting a home. You get to know patients intimately at home. They let you into their homes—even knowing that you’ll see everything—because they really need you."
Alfred E. Stillman, MD, has a modest proposal for easing the nationwide shortage of geriatricians: Recruit retired physicians into geriatrics, and help them get the training and support they need to make house calls to homebound older adults.
Geriatrics is a particularly good match for experienced physicians, Dr. Stillman argues, and demand for geriatricians who make home visits is great, and growing.
He should know. In 1994, after practicing gastroenterology for nearly 30 years and garnering accolades along the way—he published prolifically, held academic and leadership positions in medical schools and hospitals, and was named a Master of the American College of Physicians—he, like many subspecialists, lost his job as overcrowded subspecialty departments began contracting. Then 57, he decided to make a change. Well aware of the coming Age Boom, he enrolled in a geriatrics fellowship program at Albert Einstein Medical Center in Philadelphia. After finishing the program he and another geriatrician, Alan Berg, MD, co-founded Home Visit Doctors. Their Philadelphia-based practice focuses exclusively on providing home visits to the homebound elderly.
"I'd always enjoyed working with and getting to know older patients—they have a lifetime of experiences to share—and I found during my fellowship that I liked home visits most of all," says Dr. Stillman, who recently published Home Visits: A Return to the Classical Role of the Physician. "When you make home visits, you develop a very intimate relationship with your patients, and your work brings great relief to people in very difficult situations. Among other things, appropriately timed home visits can circumvent and prevent nursing home placements, visits to the ER, hospitalizations and all those expensive things Medicare is trying to avoid."
Older patients tend to have multiple, chronic health problems, and homebound seniors typically have the greatest burden of chronic disease of all. Most of the patients Drs. Stillman and Berg see are homebound due to disability resulting from strokes, lung or heart disease, hearing or vision loss, cognitive or emotional problems like dementia or depression, or, most often, a combination of several of these.
Caring for older patients often requires a holistic approach, one that considers not only their physical, cognitive and emotional health, but also their living arrangements, ability to manage daily activities, financial circumstances, and family and other social supports—or lack thereof. And this is particularly true for homebound older patients, whose circumstances, like their health problems, tend to be particularly complex.
"Not only do they have a much longer list of chronic disabilities, their social needs and their economic problems are also far more serious," says Dr. Stillman. The nature of the home visit, he adds, makes it easier to both discern these problems—and to find appropriate solutions.
"If you're seeing someone in office, often you don't fully understand—unless you're marvelously perceptive—all that's happening with that patient," he explains. "It's different with a home visit. When I go into a home, I can see what kind of food a patient subsists on—I can see the canned foods and boxes of cereal. I might see alcohol in the cupboard. Despite their efforts to keep things clean, I may see vermin running across the floor and clutter near the stairs. I might find that the only light is in the middle of the ceiling and needs to be screwed in to be turned on. I can better understand relationships between the patient and the caregivers by visiting a home. You get to know patients intimately at home. They let you into their homes—even knowing that you'll see everything—because they really need you."
Though the vast majority of the 600 patients Home Visit Doctors sees are poor, they've lived rich and varied lives -- through world wars, the Depression, the civil rights and women's movements, and the advent of the air and electronic ages, Dr. Stillman notes. Despite their strained circumstances, they have so much to share, he adds, recounting a conversation he had one day with a 93-year-old patient with renal failure. "I started to recite the opening lines of Robert Browning's "Rabbi Ben Ezra," which begins, "Grow old along with me," when she turned to me and said, "That's beautiful—and I also love Elizabeth Barrett Browning's poems."
In addition to doing exams, taking complete histories, and making environmental assessments, home visit doctors do virtually everything in a patient's home that's done in a doctor's office. They can arrange for on-site visits from laboratories, and respiratory, electrocardiographic and imaging companies, for physical and occupational therapy evaluations, and for audiology and eye exams. Working with social service agencies and other healthcare providers, they can also arrange for a wide array of home services, including Meals on Wheels, and in-home PT, and OT, for rental of medical equipment, and visiting nurse and legal services. They can also evaluate the circumstances of and arrange for services and support for patients' caregivers.
"It's very important to support the caregiver in these cases," says Dr. Stillman. "Otherwise, the entire fabric of support for the patient can rend."
Not surprisingly, home visits are time consuming. At most, Drs. Stillman and Berg can each manage to see between five and eight patients a day. In addition to the visits themselves, there's also considerable time spent on the phone, arranging for diagnostic and other services for patients, and coordinating care with nurses, other healthcare and equipment providers, and family members. Home Visit Doctors employs three full time secretaries, a social worker, and two physician assistants to help with the workload. Though 600 patients would be a small patient load for an office-based practice, Dr. Stillman notes, it's quite large for a home visit-based practice, given the work and time involved.
While Medicare pays somewhat more for home than for office visits, it's doesn't pay enough to make up for the added investment of time and resources, he adds. While a doctor making house calls might see up to eight patients daily, an office-based physician might see 30, he points out.
And that, in part, is why he's convinced that retired physicians would be ideal candidates to care for the homebound elderly. "New physicians just starting out and loaded with debt aren't going to be drawn to home visits," because they just don't pay enough, he says. But retired doctors, who've long ago paid off their medical school loans, would be in an entirely different position. Because the cost of a completing a fellowship in geriatrics could be an obstacle, however, it would be essential to offer these physicians a shorter, subsidized course of training, says Dr. Stillman, who notes that he and his wife wouldn't have been able to cover the cost of his geriatrics fellowship, and their two sons' medical school expenses, had it not been for her well-paying job. His wife, Paula Stillman, MD, has been a leader in medical education in the US and is presently a senior vice president for a large healthcare delivery organization.
A short, intensive course covering the medical and social problems of older homebound patients, and assistance with malpractice insurance costs, would make a second career in geriatrics viable for retied physicians, he says.
"If you talk to retired physicians one thing you hear over and over is that they miss patient contact and the feeling of being useful to patients," Dr. Stillman adds. "These physicians, trained before high tech diagnostic tools were commonplace, relied primarily on a thorough understanding of diseases and on spending time with patients, getting to know their histories well, and examining them thoroughly. These assets would be particularly valuable when caring for older homebound patients."
