Doctor's calling

Dr. Myron Siu grabbed a red tool box filled with medical supplies and an Eddie Bauer duffel and set out for his weekly walk through Chinatown -- making house calls. On this particular morning, he was scheduled to see a frail 93-year-old man who had dropped to 102 pounds, another gentleman, 92, with heart disease and a bad hip, and an elderly woman suffering from dementia.

During his visit with Shun Hoi Yu, the 92-year-old, Siu reviewed the dozen medicine bottles in the man's tiny one-bedroom apartment and discovered a potentially dangerous problem: Because of confusion over refills, Yu had several bottles of one drug, and had been taking a double dose of the medication. Siu directed him to throw out the older bottles.

Siu, 32, an internist who works at Tufts-New England Medical Center, started house calls last August; he's believed to be the only Cantonese-speaking doctor in Boston with a weekly commitment to see patients in their homes.

The service has made Siu something of a local celebrity in Chinatown, where patients often stop him in the street for medical advice. That recent morning, a Chinese man carrying shopping bags pulled Siu aside on Shawmut Avenue to discuss his reflux disease. As word has spread about Siu's language skills and the house calls, his practice has exploded.

Siu says house calls are beneficial for frail patients who can't easily get to his office; they might let symptoms go untreated too long, resulting in a hospital or nursing home stay. Studies about the cost savings and health benefits of house calls traditionally have shown mixed results, but more recent data from the University of Pennsylvania and the US Department of Veterans Affairs, both of which have house call programs, have shown reductions in hospital and nursing home stays for their patients. Medicare is now studying the impact of house calls in two pilot projects in five states.

Siu also is convinced that he discovers more problems by observing how patients live. He has seen patients whose homes, because of blocked doorways or torn carpet, put them at risk for falling and breaking bones. House calls may be particularly helpful for immigrants, who, because of language barriers and suspicions of Western medicine, can be even more reluctant to go to a doctor's office or hospital for care, he said.

"Seeing a patient at home really opens my eyes," Siu said. He didn't know, for example, that so many of his patients lived in poverty and needed additional services. "When they come to the clinic they dress well, so you never know how much help they need until you see them at home," he said.

Despite the stereotype that house calls went out with horsedrawn buggies, doctors have continued to visit patients at home, but usually as a favor for an elderly or beloved patient. The practice of using house calls to manage complex chronic conditions among the elderly is relatively new, and research into the practice is just getting started. But as the population ages, threatening to push health care costs even higher, interest is growing among politicians, doctors and health care administrators.

"Overall, if it was a financially viable option for physicians, there are some definite benefits to providing house calls to the elderly, disabled, or chronically ill patients," Dr. Nancy Gagliano, vice president for practice improvement for the Massachusetts General Physicians Organization, said in an e-mail.

But there are barriers too. House calls are time-consuming for doctors, at a time when primary care physicians are already in short supply. Physicians working in homes generally don't have access to patients' electronic medical records or quick radiology and laboratory tests, Gagliano said. And house calls don't make financial sense for many practices.

The federal Medicare program this year cut the fees it pays doctors for home visits by about 8 percent, as part of an overall recalculation of physician fees, said Constance Row, executive director of the American Academy of Home Care Physicians. For a house call to an existing patient, Medicare pays from $42 to $150 depending on the seriousness of the problem, doctors said.

The trouble is that these fees are only slightly higher than those paid for seeing a patient in the office, even though house calls take more time. This means doctors can schedule more patients and make more money seeing patients at work. The Academy of Home Care Physicians believes this is one reason why the number of house calls to Medicare patients dropped slightly in 2005, to 2,073,744 visits -- falling for the first time since 1999. The group plans to lobby Medicare for fee increases for house calls.

Siu sees roughly half the number of patients in four hours of house calls as he would in the office. Dr. David Fairchild, Tufts-NEMC's chief of medicine, said that when Siu asked permission to make house calls, he thought it was a great idea. But, Fairchild said, if a large number of doctors wanted to see patients at home, that could be a financial problem for the hospital.

Boston Medical Center runs the oldest house call program in the country and survives with a subsidy from the hospital, administrators said. That program, which started in 1875 for new mothers and babies and became a geriatric program in the 1970s, serves 600 Boston residents.

"All of our folks who get referred to us, their number one priority is to stay in their own environment at home," said Clare Wohlgemuth, nursing director for the geriatric program.

Siu, who finished his residency at Beth Israel Deaconess Medical Center in 2003 and immediately went to work at Tufts-NEMC, now sees 15 of his 1,300 patients at home. Most are elderly Chinese immigrants who don't speak English and who can't walk easily: a man with diabetes who had a toe amputated, several patients who are blind or are prone to falls, and one woman whose husband was diagnosed with lung cancer and no longer has the strength to push her wheelchair.

Yu, who came to Boston with his wife 27 years ago from Hong Kong, is struggling with heart disease, high blood pressure, and an aortic aneurysm. He fell two years ago and broke his right hip.

On this day, he told Siu he was feeling dizzy. They sat side-by-side at a card table pushed up against a wall crammed with family photographs. Siu asked to see his medications, and Yu's wife took plastic bags from a wood cabinet. Among the bottles -- all labeled in English -- four were for the same medication, three of which were empty. Siu discovered that his patient probably had been taking double his dose of the drug, which likely caused his dizziness.

In an interview later, the Yus explained through an interpreter that getting to a doctor's office is increasingly difficult for them; Mrs. Yu has arthritic knees and a shuffling walk, while her husband's breathing becomes labored with activity. They try to go out for 30 minutes in the morning and at night; Mrs. Yu walks with a cane and her husband pushes himself in his wheelchair in front of their apartment building. Before house calls, their son took his father to the doctor. On the few occasions he couldn't make it, Mrs. Yu would push her husband the several blocks in a wheelchair.

"The house calls are much more convenient," he said.