Building back better by addressing a major missing link

Build back better. I’m hearing this phrase more and more lately. Last week, there was a call from my provincial government for family doctors to pivot back to ‘face-to-face’ care. But what if this isn’t the only missing link?

I’m lucky. I’ve been making home palliative care visits for years. So, when the COVID-19 pandemic hit, the pivot to virtual home visits was challenging for me, but it was entirely conceivable.  

I struggled trying to navigate the various virtual platforms so I could keep myself safe and continue to care for patients ‘in’ their homes. Technology is not my strong suit. It got to the point where I felt like my home office had turned into ‘Control Central’ without a skilled technician at the helm. 

 

Eventually, I became savvier and before I knew it, I was providing 100% virtual care.  At first, I thought it was fantastic. This would make it possible to see more patients without the travel time.  I could add people to a virtual visit when needed – sometimes I had more than six family joining from all over the country or around the world.  With chutzpah, I would boldly invite myself virtually into hospital family meetings or ask a patient’s specialist or family doctor to ‘join’ our home visit. Amazing potential!

 

It didn’t take me long to realize that virtual visits were no proxy for face-to-face home visits.  Honestly, they were barely ‘good enough’.  Virtual visits provide a view into the world of home visits that is narrow at best.  There is little peripheral vision to see what I know is so important and right out of virtual view.  

 

Home visits start in the driveway.  The exterior of the home often speaks volumes about how people are faring inside.  The garbage, the unshoveled snow on the steps to the porch, the wilting perennial flowers, the uncut grass – they’re all clues.  Who answers the front door?  How long does it take?  Are they wearing their PJs at 3:00pm?  

 

As I walk through the home on my way in, or out, I am flooded with extra bits of
intel.  Without judgment, I notice the state of the home.  My assessment is shaped by all of my senses and goes far beyond the interview with the patient.

While I assess the patient, I also assess the family. Every ‘informal care team’ or patients’ personal ‘care crew’ is different and the care plans have to match their willingness and confidence.

When I am in their home, I’m on their turf.  The power differential between physician and patient/family is equalized – as it should be. I know that the care plan I suggest must be co-created with the patient and the family – as it should be.  

Everything is negotiated – the best practice and evidence based clinical guidelines are whittled away and tailored until we find common ground on the best way forward. It’s an art as much as a science. 

 

Millions of doctors necessarily pivoted to virtual care when the pandemic hit. They, too, probably thought it was the ‘missing link’ to practice.  But most doctors whose clinical practice was only in hospital and clinics had NO pre-pandemic experience in home-based care. Unlike me, they didn’t know what they didn’t know. It’s not their fault that medical training is devoid of home-based care. We train doctors to only feel comfortable in acute care and clinic settings. 

 

The silver lining here is that doctors were forced by the pandemic to ‘see’ people in their homes. Maybe this is the icebreaker we’ve been waiting for? 

 

I could extrapolate based on my years of experience in the home.  So, when I made a virtual visit, I knew to have the visiting nurse connect me online while outside the home. I knew to have the family position the camera so that I could have the most expansive view and see faces, interactions, and the dynamics at play. I knew that when the nurse or family member carried me by tablet or cell-phone to the patients’ room, I would take in the virtual tour of the entire home environment as if I were wearing a GoPro.  

 

We have an opportunity to learn; to truly build back better. What if doctors and other healthcare professionals were encouraged to integrate knowledge of home-based care into their practice? It is no longer acceptable that community-based care is absent from the curriculum of medical trainees.  Doctors practising in acute care settings and clinics have no peripheral vision without understanding home-based care. We need this better approach, not just to be ready for the next pandemic…but because it’s what our struggling healthcare system needs now.