The soft, yellow light reflects off the glistening face of the physician as he sits beside the dying child. The lines in his face show the impotent angst he feels as the pale child inches closer to death. When this scene was painted by Sir Luke Fildes in 1887 (pictured left), the presence of the physician in the patient’s home was the norm. The authors of this month’s SOPT Monthly Feature argue that we should consider a return to home visits for trainees in pediatrics. (10.1542/peds.2016-2015)
As recently as 50 years ago, 40% of physician-patient encounters took place in the home, similar to Fildes’ painting. Over time, the authors’ point out, this percentage has dropped precipitously. As of 2001, only 0.6% of physician-patient encounters occurred in the home. While there have been many benefits of transitioning care into hospitals and clinics, the authors argue that pediatricians have lost something in this process.
First, trainees have lost an opportunity to better understand their patients’ home life. At the beginning of the article, the authors describe a visit to the home of Mia, “the fearless two-year-old.” Sitting on the mother’s well-used couch, the mother relaxed and spoke more candidly about her struggles. As they surveyed the apartment, they noticed several safety hazards that would have evaded their notice in an office setting. As the authors note, “studies show pediatric residents participating in a home visiting curriculum become more empathetic regarding their patients’ communities, barriers to care, and family dynamics.”
Furthermore, the authors point out that the ACGME currently requires family medicine residents to participate in home visits as part of their training. There is no similar mandate in pediatrics, yet the ACGME has encouraged pediatric programs to “formally introduce social determinants of health in graduate medical education.” Perhaps home visits can help to fill this void.
Despite the possible benefits of home visits in pediatric training, the authors identify many of the challenges to implementing this change. First, reimbursement structures do not currently support home visits as a financially-viable option for most physicians, especially when compared to high-volume outpatient clinics. Second, few pediatric faculty members will be skilled in providing home-centered healthcare, and role modeling may have some growing pains. One possible solution is to incorporate the residents into interdisciplinary teams that already focus on home visits. Another challenge is determining which families would most benefit from these home visits, and how to best target these populations.
Home-centered healthcare in pediatrics carries much promise, but implementing home visit curricula during pediatric training will confront significant obstacles and inertia. For such a program to be effective, it will require the right faculty, the right resident, the right families, and the right goals. Certainly something to strive towards.
