Amid coronavirus outbreak, American Paediatricians return to old-school approach of house visit to treat young patients
London, May 1, 2020 (AltAfrica)–SEVENTEEN YEARS INTO practising medicine, Dr. Scott Goldstein says he’s recently been able to try a throwback method of care he’s always wanted to explore: the house call.
“When the whole coronavirus thing started and our visits went from 20 patients a day to three patients a day, we had to find some way of seeing these people, especially the babies who need their vaccines,” says Goldstein, a pediatrician who’s part of Northwestern Children’s Practice in Chicago.
Goldstein is part of a contingent of paediatricians across the United States and one of two providers at his practice who have turned to making house calls amid the COVID-19 pandemic. A primary goal: keep children’s vaccinations up to date despite a surge of in-office appointment cancellations by parents wary of the highly contagious coronavirus.
“Even though it’s recommended by the American Academy of Pediatrics that babies still come in and get the checkups, we can understand parents being hesitant to go to a doctor’s office, of all places,” Goldstein says.
With coronavirus cases escalating in the U.S., Goldstein says he made his first house call shortly after Illinois issued its stay-at-home order in March. He performs visits for 2-, 4- and 6-month-old infants, and says he receives about 10 to 20 requests for one each week.
Many parents fear bringing their children into an environment in which they could potentially be exposed to the virus or unknowingly infect others if they’re asymptomatic. But physicians warn that postponing vaccination appointments could lead to other dire consequences, such as outbreaks of vaccine-preventable diseases like measles, which saw a recent resurgence in the U.S. fueled by cases in Washington state and New York City.
Such an outbreak now could exacerbate the stresses already felt by communities working to reemerge from coronavirus lockdowns. Yet in a letter earlier this month to Health and Human Services Secretary Alex Azar, Sara Goza, president of the AAP, and Mark Wietecha, president and CEO of the Children’s Hospital Association, noted that “pediatric practice managers are reporting seeing only 20-30% of their normal case loads due to the pandemic,” resulting in them “reducing staff hours, halting vaccine orders, and cutting their own salaries to cover fixed costs.”
“Pediatricians must be able to continue to vaccinate children to prevent an outbreak of another infectious disease such as measles at the same time COVID-19 is threatening the lives of families,” the letter said.
Data already indicates a drop in protective vaccinations: According to The New York Times, a recent nationwide analysis of vaccine information from 1,000 pediatricians found that measles, mumps and rubella vaccinations had dropped by 50% during the week of April 5 compared with the week of Feb. 16, while diphtheria and whooping cough shots were down by 42% and HPV vaccines plunged by 73%.
While many pediatricians are continuing to provide in-office appointments – taking precautions such as opening up a separate entrance, dividing offices to see well and sick kids in separate spaces and having patients stay in their cars rather than in waiting rooms to minimize interaction – some have pivoted to incorporate home visits into their routines so fear of contagion won’t trump overall public health and safety.
Dr. Dan Feiten, who’s practiced for more than 30 years in the Denver area, says an after-hours clinic where he works with other pediatricians saw an 88% drop in visits after Colorado Gov. Jared Polis issued a stay-at-home order late last month.
PediaClinic began home calls visits /on March 28. As with many other practices across the country, the drop in office appointments has hurt the business’ bottom line, and Feiten says doing two to three visits per day “will not come close to helping the practice stay afloat.”
“However, it does provide reassurance to families who are concerned about their exposure risk,” Feiten says. “I appreciate the goodwill that we all gain by reaching out with a home visit. It’s just the right thing to do.”
According to a paper published in the journal Pediatrics, physician house calls went from accounting for about 40% of patient-doctor encounters in the middle of the 20th century to less than 1% by 1980, in part due to the growth of third-party payers and increased liability concerns.
Today, house calls can offer a valuable alternative to telemedicine – also an option for many physicians amid the pandemic – as in-person interactions often reveal more about a medical condition than can be derived from a phone or video chat, Feiten says.
“You have to be able to examine kids,” he says. “They don’t tell you what hurts, and they don’t tell you what the problem is.”
Dr. Elaine Lin, a pediatrician who directs and provides office and at-home visits through the Pediatric Visiting Doctors and Complex Care Program at Mount Sinai Kravis Children’s Hospital in New York, says there was a growing movement toward more home visits before the pandemic hit, “especially for children with medical complexities, to try to keep the care at home and in the community as much as possible.”
“I do think the pandemic will propel that forward more, too, because of people wanting to socially distance, isolate and minimize traffic in their offices,” says Lin, who has conducted home visits throughout her seven years in practice. Plus, it “allows for a physician to really create a much more personal relationship with their patients.”
“Amongst all the rest of the stress that’s going on and physician burnout, it’s a way for physicians to feel a little bit more whole and human again, too,” says Lin, who’s also a member of the AAP home care executive committee.
Dr. Greg Moyer, head of Lake Country Pediatrics in Waukesha County, Wisconsin, says he incorporated home visits into his practice when he first started his clinic more than 20 years ago, primarily to limit the potential exposure of newborns to illnesses in the office and to check that the home environment is “ready for the baby.”
With the COVID-19 pandemic, Moyer says, “we decided as a group that we would start doing all of our home visits from 2 months to 2 years.” The practice transformed a minibus into a mobile medical clinic, which doctors use from 8 a.m. to 6 p.m. daily for wellness and vaccination visits.
“With the mobile health clinic, we’re doing at least 100 (visits) a week, and we’ve opened it up to all patients,” even those outside of their practice’s clientele, Moyer says.”It’s going really well – we started out doing (patients) 2 months to 2 years, and now we’ve added 4- and 5-year-olds … because these ages get essential vaccines.