Takeaway
Visiting a patient’s home environment, either virtually or in person, may shed light on the source of their distress.
Lifelong Learning in Clinical Excellence | December 7, 2021 | 3 min read
By Deirdre Johnston, MBBCh, MD, Johns Hopkins Medicine
“Nothing will sustain you more potently than the power to recognize . . . the true poetry of life: the poetry of the commonplace, of the ordinary person, of the plain, toilworn, with their loves and their joys, their sorrows and griefs.”-William Osler
This poetry is most evident when I visit a patient at home. A woman with Alzheimer’s disease described having intruders in her house and two skulls appearing at the end of her bed every night. She’d been calling her family each night, agitated and distressed. On my visit to her apartment, I noted several mirrored cabinets that reflected every movement she made, and two white plaster sconces hanging on the wall at the foot of her bed. Had I seen her in the office, I would never have known about the reflections causing illusions of intruders, nor would I have known about the white sconces on the wall that appeared like skulls when she awoke at two in the morning. Had I seen her during an acute admission to the hospital, I wouldn’t have had an inkling of the environmental contributors to her symptoms of hallucinations and delusions despite a thorough H & P at the time of admission.
Osler also encouraged us to use our senses. To learn to see, hear, feel, smell, and to know that through much practice we can become an expert. It always helps to apply this advice when seeing a patient in the hospital or in the clinic. But when seeing a patient at home, we get the whole sensory experience, which helps us understand our patient and create the most meaningful care plan.
In the home, we can see the things that matter to a patient, such as family photos, a pet, or homemade art projects. We can see how she’s managing her medications, and that the metal piece sticking out of her bed frame is what caused the recurrent skin tears on her leg. We note fall hazards, such as the broken towel rail in the bathroom that she used as a grab bar until it pulled away from the wall. We can hear the smoke alarm beeping at regular intervals because it needs a new battery. We can feel the temperature in the home—in some older adults’ homes in Baltimore it can be close to 100 degrees in the summer.
Osler’s teaching is just as relevant to the care of the patient in the community as it is to their care at the hospital bedside. Many older adults have multiple medical conditions, including mental health or cognitive challenges. Over time, I’ve gradually gotten to know my outpatients in the office, which is my world. But the patient’s experience of their conditions is lived in the community and homes, and I’m grateful for the privilege of getting to see their world firsthand.
Remember that a patient’s home environment may hold clues to their illness: Ask yourself:
1. What would I look for if I were seeing this patient in her home? For instance, the location of her washing machine; many homes have it in the basement, and this can be a fall hazard.
2. What do I need to know about her home situation to prescribe a new medication that she will take safely?
3. During video visits with patients, what can I learn about their home environment that can help me understand them better?
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.