A Patient's Home Can Tell Us More Than the Clinic

Every year, medical students graduate having spent countless hours learning in classrooms, in libraries surrounded by textbooks, and later, in hospitals or clinics. Yet there is a less used, but equally important, location for education that is critical in developing empathetic, caring physicians: the patient’s home environment. Academic medical centers are recognizing the importance of adopting home visitation programs for physicians and medical students. As a fourth-year medical student completing an Albert Schweitzer Fellowship, I conduct home visits to assess patients’ social determinants of health in their homes. As these visits have been the highlight of my medical training, I implore other medical students to create or seek opportunities to prioritize learning in the patient home environment.

Some of the tangible skills medical students can gain include empathy, sensitivity toward chronically ill patients, appreciation for care of chronically ill patients, recognition of the need for individualized care, and greater connection between patient and health care provider. The opportunity to step into a person’s home affords us an empathy-building opportunity that cannot be realized in the hospital or clinic. When we are invited into someone’s home, we turn away from our assumptions about a patient’s life, with all of our hidden biases, and turn toward understanding.

As an example, I would like to describe Ms. Smith, a home visit patient of mine. Ms. Smith was a frequent utilizer of the local community emergency department and we wanted to address the social determinants of health that were influencing her use of the ED. Another medical student and I drove to her rural trailer home where an intimidating-looking, yet sweet dog waited for us. Ms. Smith, a frazzled, elderly-appearing woman (she was actually only middle-aged), invited us into her home. She ushered us to sit on her only piece of furniture, a battered couch, but we elected to have her sit while we leaned against the counters and walls. The unfinished floor had wood shards sticking up and broken tiles in an area that was the kitchen. She had no fridge or freezer; fruit and meat were sitting out on a counter. The entire apartment smelled of cigarette smoke and pet urine. The pet bowls in the kitchen contained only goldfish. 

I admit that I made multiple assumptions about Ms. Smith before entering her home. I made assumptions after reading her medical record, after meeting her in the ER, and after pulling up to her trailer park. I imagined where she lived, but that place turned out to be completely different from her home. Every patient home is a reminder of the number of assumptions and hidden biases I hold.  

My colleague and I learned that Ms. Smith had no driver’s license, but relied on a previous roommate to drive her to appointments. Sometimes, the roommate didn’t show up and she missed appointments. Her EMR was filled with no-show visits and she was labeled as a “frequent no-show.” In recent months, she had begun calling an ambulance to go to the ED for her pain attacks because she was unable to proactively prevent them or call her primary care physician. 

We listened, trying to assess the nuances of her situation. Certainly, she was not blameless — but seeing her physical circumstances, I was able to understand better the factors that were preventing her from meeting her responsibilities, and I searched for a way to improve her health by addressing her social circumstances. 

We know that patient health is not assessable on the individual level. Indeed, health is heavily influenced by social determinants. During home visits, we are able to directly enter a patient’s environment to observe social determinants of health in real-time. With Ms. Smith, I didn’t just hear about her poverty — I saw it. And while I can never presume to understand her situation fully, I certainly have a greater ability to deliver compassionate care for her by understanding her limitations. 

As students, we have the time to bridge relationships between patients and the medical care system. That bridge leads to improved adherence to care plans and commitments to healthier lifestyles. Still, perhaps the greatest gift we can give to our patients is our time and our ears. Entering someone’s home is akin to entering their life — it’s a realization that an individual is a person that exists outside a clinic or hospital room. 

I encourage every medical student to find opportunities to engage in home visits. Many academic centers are now integrating home visits into the curriculum, but if your center isn’t, find mentors to help you start or expand home visit initiatives. My mentors for this project helped me navigate challenging patient situations, identify and develop patient care skills, and reflect on my own emotions. I recommend starting with primary care mentors, who are likely the closest providers to systems for home visits. It also helps to find peers who can participate and grow with you (it’s also advisable to never go on a home visit by yourself)!

Conducting home visits has been my favorite part of my medical training, and the greatest opportunity to develop my skills. I encourage you to be the medical professional who lets patients know they are seen. Give patients the chance to be teachers in their own homes, and give yourself a bit of time to serve them. Stepping into a foreign environment, even just once, is a lesson in cultural humility, and attempting to understand a person’s situation better will make you a better physician. More so, it will make you a better human. 

Megan Barnes is a fourth-year medical student at the University of North Carolina in Chapel Hill, NC. She has spent the last year as an Albert Schweitzer Fellow, conducting home visits to identify and address social determinants of health for patients who are high utilizers of a local rural emergency department.

All names and identifying information have been modified to protect patient privacy.

Illustration by April Brust

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