The visit-sanctuary hypothesis


Can’t live with them, can’t put them off. (well you could, but it likely to come back and bite you on your heiny).

I find visits and interesting part of my day. For one it is my daily dose of vitamin D, where I get to break out from the confines of the practice building, stretch my legs, and then either trundle over pavement and lawn to a patient’s house (yes I do actually walk to visits if not too far and we enjoying some freaky non-torrential raining weather), or drive aimlessly to a patient’s house, hoping this one has a number and not a name. It’s also a chance to get to see the patients you don’t normally see, mainly as they are likely to be housebound and therefore unable to come and visit you in surgery.

I mentioned in my earlier post the visit conundrum about which people should in my view not be getting visits, so I wont be covering that again.

When going to a visit though, I always find it amazing the places you enter. First off is the issue of getting there. Working as a portfolio GP, I get to work in many places. The trouble with that is working in a lot of new places, I tend not to know the area, and so finding houses, even with the instructive directness that is Jane on my Tom Tom, I will be honest I get lost at times. This is particularly frustrating when people have houses with names instead of numbers ( I know I have ranted on this before, but I can’t help it, it REALLY peeves me off). This is in addition to the idiosyncrasies of the Yorkshire address system. I remember one such visit to a house in the Airedale region, which asked me to go to number 14. Following my ‘trusty’ Tom Tom I arrived at number 12, which was the followed by number 16. Puzzled I rang the patients house, who didn’t pick up, then knocked on number 12, not in, number 16, also not in, and finally got to number 28, who told me they didn’t know where number 14 was.

At this point I had tried to find this house for nearly half an hour. I rang the practice, and no one knew where the house was, so I had to resort to calling the local post office to find out if they knew where the house was. Turned out access to number 14 was by a small path next to number 8, that went behind house number 14. On arrival the patient answered the door, apologizing for not picking up the phone as they had nipped out to get some milk as was feeling hungry. Why they couldn’t come to the surgery instead….. he didn’t feel well enough. Taking into account he had nipped to the local supermarket, double the distance than the practice,  you can tell I was not the most pleased person in the world. However, I miraculously resisted the urge to shout, but instead gave a curt piece of advice, that next time the patient’s visit requests would be screened for appropriateness. Surprisingly the patient apologized (miracles can happen when everything is going wring it seemed) and I cracked on, making sure when I got back to the practice, I added in the directions to the house, and polite advice to call the patient to confirm if a visit was needed.

But suffice to say, when you visit a patient, you visit their home, their sanctuary. It is here that you see the patient in their own environment and you get to peek into the window of how their life might affect their health.

Finding bags of medications stored up in the corner, may hint at issues in compliance. Finding plates full off cigarette stubs in a patient who only 3 weeks ago was documented as an ex-smoker may guide some further health promotion. Seeing which areas of the house are lived in or not may guide mobility and OT issues. Even something simple as the smell or general condition of the house may just hint at medical or non medical issues that would not be apparent having seen the patient in your cuboid consulting room. The other aspect you get to see on a visit, is the condition of the other people in the house. Now I am not saying us doctors are nosey people, but a quick check up on the carer of a palliative care patient, or a sideways glance on the condition of siblings that may or may not have had health/social issues in the past is an opportunity not worth missing out on.

Visits as well as giving clues on health and social status of a patient, also allows you to get to know a patient in different ways. I remember one particular fond patient of mine, who after a rather unpleasant diagnosis of cancer was struggling with eating and generally coping. I remember standing in his kitchen after he had let me in the back door, waiting while he answered a phone call, only to look up and see a large poster of Buffy the vampire slayer. This surprised me a little, what with him being a rather prim and proper octogenarian. On my second visit, after reviewing his prognosis we had come to a low point as he pondered his reduced life expectancy. I took this as an opportunity to ask him about the poster (distraction method), to which his simple reply was, that he liked the way she looked.  My simple agreement with that statement lead to a rather joyous chuckle which lightened his mood a little and allowed us to continue his care planning. I reflected how I would have handled that situation if I had seen him in my consulting room, and though it probably would have been OK, the levity of the situation I feel had made him more comfortable, and made it easier for him to talk with me about his future expectations in care, and lead I feel to a more proper outcome for him.

Outcomes are one thing, procedure is another, and there are several rules I try to live by on visits:

  • Be prepared – if for D&V, I always make sure I have a stool sample bottle in the bag, if a patient with nausea, check I have an IM anti-emetic, just in case if it is that bad, asthma attack a salbutomol inhaler in date, chest pain… first and make sure an ambulance not needed instead of me etc.
  • Be safe – I have been lucky and not been attacked or assaulted on a visit, but there have been a few where it almost came to that (OOH psychotic mental health visits never are appealing). It is important to protect yourself, and the best way is don’t get yourself into a bad situation. Remember, that you can’t care for others if you can’t care for yourself.
  • Be polite no matter what – even though am visiting at request, still am entering someone’s home, so always be respectful of this no matter what I see. Esp true with a big visit bag on your back.
  • Go to the patient – seems simple enough but if they unwell enough to not come to surgery then they unwell enough to come to me in their own house, and tends to be quicker.
  • Check QoF points – easier to know before hand, elderly in particular tends to be some outstanding issues, am visiting might as well check some off, esp items like checking BP, smoking, and if needing bloods can be added on if needed as part of  management plan.
  • Never sit on the bed – infection control and all, but this is applicable to all furniture in respect of pet dander, dribbling children, urine and vomit and god forbid faeces. (A big visit bag makes a nice perch)
  • Never accept a drink – I try not to be at a visit long enough to need a drink but more importantly I feel it constitutes as a gift in a perceptual sense. Also I am very finicky about what I drink and do not want to seem pedantic, it therefore easier to say no.
  • If I need to examine a patient, check windows and doors first – amount of times patients have lifted up their tops to let me look at them, in their front room, right in front of a large open bay window. Always close curtains first or go to the bedroom if able.
  • Confirm actions – any plans or actions work through with patient and carer/co-habitant. i.e. if need bloods, should DNs come and do, if need a script, deliver over collection, be clear and realistic.
  • Write down a plan – feeds into above, majority of visits on the elderly, and particularly if no one else about, want something for them to tell relatives or carers involved. Makes life easier, and I find reduces those extra calls.
  • Document plan in notes asap – self-explanatory, and means I don’t forget. Important in terms of keeping accurate records.
Big list huh. But it works for me. In terms of follow-up I will admit I tend more to phone follow-up unless a deterioration has occurred. This now maybe due to me working predominantly in the capacity of a single-handed GP and so workload demands actually make follow-up visits a luxury and not an act of necessity.
When actually visiting patients, one thing that I find interesting is pets. I am not a great animal lover, but I find it funny that patients with pets, expect that others don’t mind pets, particularly large dogs jumping all over you. I will admit on one occasion I politely told a patient that I would not enter the house till their rather large and loud Alsatian was behind a sturdy door. The patient was unhappy with me, but my simple answer being my safety was just as important as his comfort, and frankly the last time I had visited, his dog had nearly jumped on me and drewled all over my bag and jacket. I may not work in a three-piece suit, but I do like to look professional, and dog drewl doesn’t really come out as easy as you may think.
Visits as I said, like them or hate them, they are essential to primary care and what we as GPs do. They offer that alternate view of our patients and to some, represent what true general practice is about.  In reading this though, you may have noticed the rules and anecdotes refer to home visits, care home visits are a whole other sanctuary to consider, but that is for another time.



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