Sunday, May 1, 2011

Bringing It All Back Home

In the scope of history, medicine has a definite tendency towards cyclical trends through generations. Recently, I've been considering the moves to incentivize preventative medicine, as well as those to reduce admissions and lengths of hospital stay. These factors are driving health care out of the hospital, and into the home. But looking though the lens of the past – we've been there before.

For the overwhelming majority of American history, health care delivery was centered around the home. Only recently, with the rise of the hospital system, have we witnessed an explosion of inpatient care. Far from this, the only care done outside the house was in charitable centers for the destitute. Further, physicians rarely maintained private offices. Early American medicine was a diminutive practice, and professional physicians viewed as a whole, were considered inconsistent at best.

Throughout the 18th and 19th centuries, the center of health care delivery was definitively the home. It was considered a familial responsibility to care for the sick of the household, and it was often beyond thought to send an ill family member outside for care. There was great tradition in caring for one's own family and considerable comfort and dignity in dying in one's home. In rare or advanced circumstances, a doctor could be summoned to the house to offer guidance. But, by and large, patients remained in bed and the extent of care was entirely within the confines of the family house.

The rise of the professional hospital system and the association of physician licensing to health facilities did much to initiate the movement of medicine outside of the home. Increased urbanization and longer work hours also limited the ability for families to care for themselves. The final blow was cast by the rise of individual health insurance, and the co-committal necessity to seek professional care. By the 1930s and 1940s, the public perception had shifted and American expectations aligned with hospital and office-based care. Since that time, health care delivery has become overwhelmingly associated with these entities.

Modern medicine is now seeing a rejuvenation in health care in the home, and a movement away from the hospital and office. Equipping patients with home blood pressure cuffs, glucose monitors, and sensitive scales allow regular monitoring of health. Many large health systems have developed integrated patient tracking programs, in which these devices automatically transmit information into the system database for that patient. Red flags are recognized by the system, and a phone call to the patient allows immediate evaluation and intervention. Further, the rise of direct care physicians has seen a sharp return to “house calls”. In the near future, a continued increased emphasis on preventative care will keep patients out of waiting rooms and tele-medicine will allow many to confer with doctors from the comfort of own living rooms.

Looking at the cyclical nature of American health care, I am reminded of the importance of remembering our roots. With the current debates and projections in health reform, perhaps it would be prudent to more fully consider the past as a means of plotting the trajectory of the future?

Another thought, which may be somewhat tangential, is no less important for the future of family medicine. As we move into this increasing technological world of health care delivery, it becomes ever more paramount that we stick tightly to our foundations. We must be resolute in our commitment to our patients and present in our compassion. We must practice a delicate and humanistic bedside manner. For that is the one thing that computers and precision medicine can never replicate – a comforting hand, a warm heart, and the dedication and trust of a life-long family physician.

1. For an extensive and enjoyable review on this subject, I would encourage EVERY medical student to read Paul Starr's The Social Transformation of American Medicine. If we understand where we are coming from, we can better be prepared for where we are going.

2. Quality of care and patient satisfaction seem to be hot topics in medicine at present. Certainly, the importance of a bedside manner cannot be underestimated. However, I find it intriguing that we are still striving for perfection in this area in the 21st century. After all, the basics of bedside manner were outlined 2000 years ago in the works of Hippocrates. Nearly 400 years ago, Thomas Sydenham wrote extensively on the details and the art of patient care. Again, with the cyclical nature of health care – before so eagerly looking toward the future and waiting for new solutions to arise, perhaps we should more often delve into the past.

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