In the age of 15-minute patient visits and compressed scheduling, it almost seems inconceivable for a physician to entertain thoughts of seeing a patient in his or her home. Yet the lessons gleaned from just one such visit could affect the patient’s care for years to come. Seeing the realities of poverty, family dynamics, and environment could influence many recommendations or interventions a doctor prescribes.
During the General Internal Medicine residency program at Rhode Island Hospital, directed by Associate Professor of Medicine Kelly A. McGarry, MD, residents step outside the Medical Primary Care Unit where they see some 15,000 patient visits per year, most of them with the underserved. They choose one patient, usually someone whom they would describe as “challenging” or “psychiatrically complicated,” who has a hard time adhering to treatment or maintaining regular appointments. With the support of their team, the residents visit the patient in his or her home as a group.
The experience is profound, says Clinical Professor of Psychiatry and Human Behavior and Medicine Carol Landau, PhD. Landau is co-chair of the Psychiatry and Psychology in Primary Care Curriculum, and meets weekly with the residents. This is a key part of their training, since most people with psychiatric and behavioral medicine needs are seen by their primary care providers, not by mental health professionals. She oversees the process of selecting and setting up home visits. In groups, she and the residents have visited houses, apartment buildings, and public housing all over greater Providence, and even Rhode Island’s Adult Correctional Institution (ACI).
Division of General Internal Medicine Chief Angela Caliendo, MD, who is also vice chair of the Department of Medicine, says: “Our goal is to provide residents with a broad and meaningful experience in primary care during their training, with hopes of igniting their passion for clinical practice. The impact of house calls and other innovative programs is likely contributing to our success in having residents pursue careers in primary care.
To help the residents process the home visit experience, Landau and her co-chair, Associate Professor of Psychiatry and Human Behavior and Medicine (Clinical) Colin Harrington, MD, use a narrative medicine tool: reflective writing. Immediately after leaving the home, the residents write a short, stream-of-consciousness-type reflection that captures their observations and feelings about the visit.
Landau says the reflections help the residents accept what pediatrician Sayantani DasGupta, MD, MPH calls “narrative humility.” In an article in The Lancet in 2008, DasGupta wrote:
Narrative humility acknowledges that our patients’ stories are not objects that we can comprehend or master, but rather dynamic entities that we can approach and engage with, while simultaneously remaining open to their ambiguity and contradiction, and engaging in constant self-evaluation and self-critique about issues such as our own role in the story, our expectations of the story, our responsibilities to the story, and our identifications with the story …