House Call
Synopsis
Physician Tobin Greensweig makes an unannounced visit to a patient’s house to check on him after he leaves the hospital.
Listen
Storyteller
Dr. Tobin Greensweig is a physician currently practicing critical care in Seattle. He went to medical school at Ben-Gurion University of the Negev in Israel, and did a combined residency in internal medicine and pediatrics, followed by a fellowship in critical care at Indiana University.
Credits
Hosted by Emily Silverman.
Produced by Emily Silverman and Jon Oliver.
Edited and mixed by Jon Oliver.
Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.
Illustrations by Ashley Floréal.
Story coached by Will Rogers and performed at The Nocturnists’ “Transitions” show at Yerba Buena Center for the Arts, San Francisco in January 2020.
Emily’s interview with Tobin was recorded at Women’s Audio Mission, San Francisco, November 2021.
The Nocturnists is made possible by the California Medical Association, and people like you who have donated through our website and Patreon page.
This episode of The Nocturnists is sponsored by Healthcare Huddle.
Transcript
click to expand
The Nocturnists: Stories from the World of Medicine
Season 4 Episode 8: "House Call"
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
In 2021, much of patient care takes place in the electronic chart. Doctors sit at computers placing orders and writing notes. And when we do meet patients face to face, it's often as strangers. What about the old days of medicine? Are house calls a thing of the past? You're listening to The Nocturnists: Stories from the World of Medicine. I'm Emily Silverman. Today, I talk to Tobin Greensweig. Tobin is a father, husband, and physician, currently practicing critical care in Seattle after several years of practice in Indianapolis. He went to medical school at Ben-Gurion University of the Negev in Israel, and did a combined residency in Internal Medicine and Pediatrics, followed by a fellowship in Critical Care at Indiana University. Before we speak with Tobin, we'll hear the story he told at The Nocturnists in San Francisco in January 2020. Here's Tobin.
Tobin Greensweig
I was introduced to Carl over email. The email came from one of my co-fellows and it was a way of introducing me to the 15-odd patients whose care that I would be assuming in the intensive care unit the next day. The email went on to say that Carl was a 55 year old man and he had severe COPD; he was on 6-8 liters of home oxygen. He had heart failure, reduced ejection fraction, pulmonary hypertension, OSA and a litany of other medical problems. Carl had called 911. And he did this because he couldn't breathe. By the time he got to the emergency department, he was blue. The emergency doctors immediately placed a breathing tube through his mouth into his trachea and connected him to a ventilator. At that time, his PCO2 was 130. And his chest X-ray: it was ARDS, maybe multifocal pneumonia. Despite best medical treatment, antibiotics in the works, Carl didn't get better. We were now five or maybe seven days in. I don't think Carl's gonna make it out of the hospital. And if he does, that breathing tube in his mouth, I'm pretty sure it's gonna have to get moved–surgically implanted in his neck, a tracheostomy.
Carl's family knew that something was in the works. And they had arranged for a "goals of care" update to happen tomorrow–my first day. I thought to myself, "Really? My first day? Strangers, I have to tell them that Carl might die." I took out my checklist of things to do the next day, and I added a checkbox. I also made sure there were some Tums in my backpack and got off to work the next day. Somehow, I just… I couldn't reconcile this medicine that I had signed myself up for with the medicine that I had grown up around. See, my dad is a family doctor. And when he finished residency, he joined the practice of Dr. Van Steyn. Gertrude, as I knew her. Long after Gertrude retired, I would go to Gertrude's home, a ranch in Santa Rosa, and she would regale us with stories. These stories were very often about her cutting down trees with multiple chainsaws in the lower 40 and then subsequently burning out the clutch on her old Dodge pickup as she chained it to the back of the truck and attempted to pull these big stumps out.
But the real gems, the real golden nuggets: they were the story of her medical practice. Gertrude took care of generations of families. She started in the OB room in the hospital. She continued in her clinic. Maybe when grandma got admitted to the hospital, she'd follow her there and then into the nursing home. And if necessary, Gertrude went right into the living room. House calls were the norm. Now, Gertrude was old enough that she had lots of stories of the hospital wards clearing out with the introduction of penicillin and sulfa drugs. But she was young enough to see medicine change into what we would consider modern medicine.
One day, I'm sitting in her living room. It's heated to a constant 95 degrees by this wood-burning stove that she would collect wood at the fairgrounds and burn it. It's probably toxic, frankly. But, but, I'm in there. And she says, you know, kind of reflecting on how my dad's practice has changed over the years. She said, “I wouldn't do what he does, not for love or money. It just doesn't make horse sense.” She went on to say, “In my day, my patients, they were my friends. Didn't matter if they couldn't pay. Many of them were poor, but they were all good people. Inevitably, they'd come back with a leg of lamb, maybe a box of apples, or even a freshly caught salmon.” I thought to myself, if I had Gertrude with me on rounds the next day, she'd probably be mortified to see me telling this family of strangers the worst news of their lives.
The next morning, I showed up at work and went and found a secluded terminal where I could chart stalk Carl. I looked up everything. I found his cardiology notes and his pulmonology notes, chest X-rays, echocardiograms, I even got a good look at Carl's colonoscopy report. Incidentally, he'd done an excellent job on his prep.I knew everything about Carl's medical past—all of his ailments. Yet somehow I knew nothing about the human. Who was this man? Finally, I gathered my things and made my way down the hall. And as I walked, I had heartburn. I'd forgotten those Tums. And I thought to myself, "How am I going to do this?" "How can I step into this room as a stranger?" And I thought about this class that I had taken just a week before. Total coincidence. It was a class about having hard conversations. And in this class, we learned a technique, a skill called “mapping”. I'd never tried it before in real life, but sounds like a good idea. And hey, what was I going to lose?
So, mapping is basically just asking open-ended questions, and then listening to the narrative that came back. And from there, you can take the medical specimen and align it with the human and hopefully get somewhere. As I approached Carl's room, the door was just ever so slightly cracked open, and I could peer in. Carl was lying there motionless. There was a white milky bottle of Propofol that was dripping into his veins. I could hear the ventilator, “coochch, coochch, coochch.” It was working overtime to fill Carl's lungs with oxygen. And the monitor… “beep beep beep.” I was looking at his vitals from across the room. And then I caught the sight of his wife. She was sitting there right at his bedside, and she was holding his hand. I slipped in as humbly as I could, and thank God she was expecting a new doctor.
So, I decided to fire off my first open-ended question. "So, tell me a little bit about Carl." I got probably what many medical providers have experienced: a loving, very, very well intentioned, and woefully inadequate history of a long medical past. Chart stalking: 1. Mapping: 0. I try it again: "So tell me a little bit about Carl before he got sick." “Ooh…” her face lit up. It was like Hanukkah, all eight lights shining brightly. And she started to tell me the story of a man who always, always put family first. Carl had worked three jobs in construction to build a home. And it turned out that this home was in my neighborhood, a few blocks away. Carl, according to his wife, could do anything with his hands. And in fact, he had just remodeled the kitchen in the house. I probably looked a little bit in disbelief knowing that Carl had been in a wheelchair for the last year, but she didn't miss a beat. She said, "No, no, no, Carl was the foreman." The nieces and nephews, sons and daughters and all the siblings had laid the tile, put up the cabinets, done the plumbing.
Over the next several days, Carl's lungs got about this much better. Just a little bit. Better enough that we can wake him up. And better enough that Carl could talk to his wife. Not through his mouth–he still had a breathing tube–but with thumbs-up and thumbs-down, head nods and shakes. And his wife was able to explain to Carl that there were two options: nursing home or home with hospice. And there was no doubt in Carl's mind–he was going home. So we were pretty worried. We didn't think we could take that breathing tube out. We didn't think we could get him home. And that was his last wish. So we moved mountains. It took a small army. Might be the first time I ever actually got a call on my phone from a hospice agency. But we found a way to do it. And two days later, I'm standing in the hall. And Carl goes rolling by me on the ambulance stretcher, and he gives me a thumbs-up.
That night, I drove home and I passed Carl's house. I didn't expect to. But it's almost like someone else took the wheel and I was circling back around the block. I was nervous. I was really curious: What was going on with Carl? What was going on with Carl's family, who I had learned to love so much during that last week we'd gotten to know each other? And by the time I got to his house, I had lost all confidence and kept on rolling by. Then that same turn came up and I turned right back around. And it took about three circles before I finally convinced myself that: number one, I wasn't going to get fired from the hospital; number two, my insurance didn't matter, but number three, it wouldn't be wholly awkward or inappropriate to show up unannounced.
I parked my car and instinctively grabbed my stethoscope off of the passenger seat. I don't know what I needed it for, but somehow it made me feel comfortable. It gave me a purpose and a reason to be there. As I walked up those steps, I was shivering. It was November. I frankly had no idea if Carl was even alive. Or worse yet, maybe Carl was in extremis, and all that wonderful Morphine and Ativan and accoutrements of the ICU. They were far, far away. I knocked on the door and stood there for a very, very long time. I almost was convinced nobody was home, til finally the door cracked open and there were a pair of eyes peering around. And then the next thing I knew, the door swung open as fast as possible, and I was enveloped in the middle of a big huge hug.
I was invited in and I came right into the living room, and there was Carl. He was relaxing in a hospice-provided hospital bed. And he said, "Hello." It was the first time I'd ever heard Carl's voice. I'd never met him without a breathing tube. And our conversation was very, very short because he was engaged in a serious game of Restaurants with small gaggle of grandchildren right at his feet. And off to Carl's right were his siblings–all those family members that I had met during that week. They were watching a game on TV. Off to Carl's left, I could peer in and see that beautiful, sparkling new kitchen. And his kids were there; they were preparing supper. Finally my eyes came back to Carl and looked straight up. And right there in front of me was a picture wall. On the wall, there were pictures of grandkids. There were pictures of birthday parties and weddings. This was Carl's circle of life. As I stood before Carl, a man who always put family first and who had come home to live, not to die, true to his values, I was in awe. I realized, as I stood there, that I think Gertrude was probably standing right next to me. I realized that, just like she had done for so many years, I had mapped my way right into that living room. I had mapped my way right into that circle of life. And what a privilege it was to be there.
Emily Silverman
So, I'm sitting here with Tobin Greensweig. Tobin, how have you been since we last saw each other over two years ago?
Tobin Greensweig
Emily, I'm doing, I'm doing great. World is upside down still for me, but, uh, life is good.
Emily Silverman
Good. Reflecting back to the performance–January 2020–tell me a little bit about that night, how was it to perform in front of a live audience of several hundred of your peers and colleagues?
Tobin Greensweig
It was a really, just incredibly special night. It's amazing how when you're on stage, you truly can feel the rest of the audience in the room with you, and going through the motions of the story along with me. You expect that you're going to go into this cavernous space, which is dark, and you're totally blinded by lights. And to some extent, that's true; it's the reality of it. But, somehow the rustling of people's jackets and pitter patter of feet in the background make it into a warm space, and it feels small. And instead of, you know, you stand in front of your microphone for hours at home, recording yourself and re-listening back. And did I phrase that right? And did I do it properly? But somehow when you're in front of the audience, it simply becomes a conversation.
Emily Silverman
So you are a doctor descended from doctors; your dad was a doctor. Tell us about your family history in medicine.
Tobin Greensweig
I think my dad's practice was decidedly different from what a lot of people think of as a medical practice today. As I drove in through San Francisco, I saw a lot of practices, for example, like One Medical or Checkpoint Clinics at CVS. And this didn't have the grit that his practice had. His mornings would start rounding in the hospital, then he'd be in his office throughout the day. Maybe he'd have to make a jaunt across the street back to the hospital to deliver a baby in the middle of the day. And it might end with rounds in the nursing home down the street. And so it was a truly... I call it “cradle-to-cradle” practice... where he took care of multiple generations of families. And it is a very different perspective on medicine, even than my kids will have growing up in my household.
Emily Silverman
And in the story, you mentioned your dad's medical business partner, who you called Gertrude. I don't know if that's her real name or not. And you focus a lot of the story actually on Gertrude rather than on your father. Tell us a bit about your decision there.
Tobin Greensweig
When my dad finished residency and moved to Northern California, he joined the practice of Dr. Van Steyn__Gertrude. And that is her real name. And Gertrude's medical practice was in a small house in Santa Rosa. And it was on Cherry Street, and their group became Cherry Street Medical Practice. And I lived through my dad's practice, and he practiced so similarly to Gertrude, and I'm sure that that's why they worked together. But there were quite a lot of differences too. I think one of the funny ones is that Gertrude never took appointments. It was always first come, first served. And people would sit in the waiting room and wait to be seen by the doctor throughout the day. Of course, my dad, sort of of the new school, came into the practice and said, “No, no, no, appointments! People expect this.” And Gertrude tried to follow suit. As I thought about, “How can I tell this story? How can I bring people back to the roots of what medicine was?” To have somebody who literally saw the transformation of pre-antibiotic medicine to, during her life, saw modern surgical procedures, endoscopy, radiographic CTS, on and on and on and on, you just can't capture that type of breadth and experience in any other way than with her example.
Emily Silverman
What was the age difference between Gertrude and your dad? Was she like a generation or half-generation older?
Tobin Greensweig
Well, I'd say she was probably on the order of 40 to 50 years older.
Emily Silverman
Very unusual to have a woman physician in that age.
Tobin Greensweig
Yeah. And she actually would tell a lot of stories about what it was like to be a medical student. She graduated from an osteopathic college in Southern California, which today I believe is Pacific College of Osteopathic Medicine,but in those years was a different institution. And at some point, she actually converted her DO into an MD, because there was a period in California history when DOs were no longer allowed to practice medicine. And so they just converted them all over. And she tells a lot of stories about what it was like to be a woman in school in those years, and she suffered a lot of discrimination.
Emily Silverman
Paint a picture of you as a kid. Are you hanging out on Cherry Street in the office? Are you at home waiting for dad to get back from work? Is dad telling you stories about work? Like, how did your dad's professional life bleed into your childhood?
Tobin Greensweig
Every Saturday after soccer, while I was still in my cleats and uniform, we typically would go round in the hospital. And sometimes the nursing homes. But dad would come to games and cheer me on, and then we would go and see patients. And I particularly liked the graham crackers. That was a huge, huge bonus. Being there, for those moments, that was part of life. I was whisked off the floor, playing with Legos, and thrown into a call room while dad delivered a baby. Or we would go see his patients and occasionally even do house calls together. Not that I had anything to contribute other than a smiling kid's face. But I actually think that the patients loved that. And I sometimes think to myself, What if I could bring my kids into the hospital? What would that do to the tenor of the room?
Emily Silverman
What an interesting thought experiment. What do you think it would do to the tenor of the room?
Tobin Greensweig
I think people would have a huge grin on their face. And I think for a brief moment, it would transport them outside of the hospital walls. And when we lived in Indiana, Larry David, who is our very lovely Labradoodle; he was certified, board-certified, as a therapy dog and joined the therapy dog program at Eskenazi hospital, and would come on rounds with me occasionally. I think some of my most enjoyable moments in that hospital was bringing Larry around to meet the staff and, more importantly, to meet the patients. And the stories that Larry would bring out of people and how much they missed their pets… And for just this brief moment, they forgot that they were in the hospital. And I think it was really special.
Emily Silverman
It's got to make the doctor less intimidating, to have their kid there next to them or have their pet there next to them. There's such a power differential in medicine, especially these days, when so much of medicine is practiced in a shiny building on top of a hill, as opposed to, for example, in the home, that there's got to be something about having that window into the physician's personal life that flattens that hierarchy a bit.
Tobin Greensweig
I couldn't agree more. At the end of the day, there's no difference between us. And to be able to find those human connections, I think is unbelievably important.
Emily Silverman
So, back to your childhood, having been exposed to this world of medicine so early on, did you always know? Did you always know that you were going to follow in Dad's footsteps? Did you have a period of rebellion where you were like, there's no way I'm going to become a doctor? Because I've heard it go both ways with the sons and daughters of physicians.
Tobin Greensweig
Yeah, I remember watching friends study for the MCAT during college and thinking to myself how awful that looked. And just being exhausted from college, studying, and just needing a break.
Emily Silverman
Did you take a break?
Tobin Greensweig
Yeah, actually. I don't know that it was the ”go sit on a beach for four years” kind of break. But it was doing something else. And it was doing something I loved, which was engineering. I worked as a mechanical engineer for a number of years. And during those years, I actually got my pilot's license and started flying. And coincidentally, started flying medical missions down to Baja–Baja California. And it was working with those physicians in Baja–and really just being their transportation back and forth–and then doing engineering projects in their clinic on the side, whether that was power distribution or internet-connectivity-type projects… It was through working with those folks that I realized that that was the life that I wanted to have.
Emily Silverman
The life of a physician?
Tobin Greensweig
Yeah. My fear at that time was–and I was actively working as an engineer as well–is it just felt like a move from project to project. And, sure, you could invent a widget that purified water for millions of people. But, would you ever talk to any of those people?
Emily Silverman
When you came back to medicine, how did your family react?
Tobin Greensweig
Yeah, no, my parents, Dad and Mom were incredibly supportive, as well as the rest of the family. I think that there was a bit of skepticism as to whether I would be able to enter into the field of medicine because my grades were pretty abysmal. And so there was a lot of overcoming to do, in order to even be accepted to school.
Emily Silverman
Did you get a Post-Bacc?
Tobin Greensweig
I didn't do a Post-Bacc. I took courses in the evenings while I was still an engineer, actually at UC Santa Barbara, which is where I went to school, and did well in those courses and just studied very hard for the MCAT and did well, but still had a lot to overcome in the admissions process. And thankfully, there were people that really believed in me, to give me that privilege to go on and study.
Emily Silverman
Your dad was Family Medicine, and you chose a combined Medicine-Pediatrics residency. Were you deciding between the two? Or how did that choice come about?
Tobin Greensweig
I went to the medical school for international health in Israel. That's a school that's hosted at Ben-Gurion University of the Negev and those years was co-sponsored by Columbia University, and it's for people interested in global health. And it was global health that brought me into medicine, right, those medical missions down to Mexico. And it was that work that I anticipated that I wanted to continue doing. And when I looked at, broadly, what were the skill sets that would be needed, it really came down to Family Medicine, Emergency Medicine, or Med-Peds. I knew it was really important to me that I would be able to care for critically ill kids or very ill kids. And I felt that internal medicine was also something that I was passionate about. So Med-Peds was a great combination of that.
Emily Silverman
And for listeners who aren't aware, what's the difference between Family Medicine and Med-Peds?
Tobin Greensweig
Huge overlap between them... Med-Peds is a full Internal Medicine and a full Pediatrics residency. My gestalt is that Med-Peds physicians are more comfortable taking care of sick kids and medically-complex children. Family Medicine certainly gets a great intro to pediatrics; we had Family Medicine residents who rotated with us on the wards. But usually it was only one or two or maybe three months of inpatient pediatrics experience. And a lot of their knowledge base is more preventative health and clinic-based practice. And so, that I think is a difference between the two.
Emily Silverman
And Family Medicine doctors deliver babies.
Tobin Greensweig
That's a big difference. And Med-Peds gets very little exposure to that. Of course, pediatricians are present in the delivery room, but only to take the baby, not so much dealing with mom.
Emily Silverman
You open the story with getting sign-out on Carl. And you're about to go in for this new rotation. And on day one, you're going to be sitting down with his family with these strangers and having a really intense conversation with them about goals of care for their loved one. What is it like to walk into an intense situation like that and to have never met these people before?
Tobin Greensweig
Unfortunately, or fortunately, this is what I do in the intensive care unit. A lot of illness reaches its pinnacle in the intensive care unit. And almost never a day passes that I don't have to have a really, really hard conversation with a family that I've never met. Sometimes you don't realize how unusual what you do is. I had to have one of these conversations with a family a few nights ago, and we always forget in the hospital how thin the walls are. And I had one patient who was on a breathing machine and who was really on the precipice of potentially passing, and the patient next door was in the intensive care unit just to be monitored. He was ready to run out the door, but really needed to be there after his surgery, just to make sure everything was okay. And he was a super nice guy and we got to talking. And he said, "You know, I just can't believe what you do." And he had heard the conversation from the room next door, or at least some murmurings of it. And he was just shocked in disbelief that this was my average night. And so, you know, sometimes I do, I need to pinch myself and realize that, no, it's not normal to go in and talk to Carl's family and have life and death conversations. And they're not just casual conversations.
Emily Silverman
How do you think the experience would be different if the patient and the family were not strangers? Thinking about Gertrude, how would it be different if this was a patient in a family that you had known for decades? You had taken care of the grandfather, you had taken care of the father, now you were taking care of the child. You knew the family dynamic, the arc of their lives, the arc of their story? If you could imagine yourself into that scenario, do you think it would feel different?
Tobin Greensweig
I think it would be really different. We pride ourselves in medicine, about giving patients full autonomy, to make their own decisions. And that's incredibly important. But some of these decisions are so complicated that I often wonder whether we can educate families enough and patients enough to be making truly fully-informed decisions. And how that, I think, can play out in a long term longitudinal relationship with a family or a patient, is that you get to know them. And we can start to make some of those decisions in good faith on their behalf. It brings up a lot of questions about autonomy. And it brings up a lot of questions about advanced directives and how we communicate the things that we may or may not want. And I think, in general, we do a really poor job of that. We've lost that communication. And it can be re-created to some extent through documentation, but it's different.
Emily Silverman
I'm glad you brought up advanced directives, because I saw a recent article in, I think JAMA, I'll put the link in the show notes for the listeners. But it was about advanced directives and how palliative care physicians have been really pushing physicians to talk to patients: "Fill out the advance directive". And then when they look back, they actually didn't see as strong an effect as they expected. And so all of these palliative care experts got together to write this article, and to kind of noodle about, like, “Well, what went wrong?” And there were a lot of different hypotheses. One of them was that, let's say you sit down with a family and fill out an advance directive, and then seven years later, they're back in the hospital, the physician may be really busy and see the old advance directive and say, "Okay, good. Someone already did that. I don't have to do that." And then not revisit the conversation, for example. It's just so complicated, like how medicine works, when you just lack context, and hard as we try to hit pause and have these conversations. It still may not be enough.
Tobin Greensweig
Yeah, it's... So much of medicine is context. And I'm almost embarrassed to admit on a podcast going out to the world, how few times I've looked at an advance directive. And I think there's multiple reasons for that. One is sort of, as you alluded to, they were written seven years ago, when this was a really different patient. The other thing that I see very frequently is that they're really perfunctory. They lack context and nuance. Okay, this person would never want a feeding tube. Well, would they want that feeding tube for two weeks if it meant that they got better? Document doesn't say. And so more often than not, as somebody who has these conversations on a nightly basis, I trust families. Families and the patients, if they're able to speak for themselves, are the ones who are really able to interpret these infinitely complex situations.
Emily Silverman
In my mind, I spend a lot of time comparing and contrasting the Cherry Street practice, the house calls. Gertrude, you said, didn't take appointments. Her patients sometimes couldn't afford to pay medical fees, and so would come back days or weeks later and pay her with fish and fruit...
Tobin Greensweig
Or legs of lamb. Those were always a favorite.
Emily Silverman
This old style of medicine, comparing it to the style of medicine that we have now. My clinical practice has been hospital medicine, and the word 'hospitalist' was coined around a decade ago, actually right here at UCSF, and it really marked a transition away from this model of the primary care doctor having a panel of patients that they would see in the office, and then if any of them got sick enough to be hospitalized, that primary care doctor would continue caring for them in the hospital and sort of toggle back and forth between the hospital and the office just like you described your father doing. And now this new model, where once you go into the hospital, it's a whole new set of doctors, none of them know you. And how there are pros and cons to this.
Obviously, the pro is that, I can't imagine the job of primary care being harder than it is right now. And so if you were to add on the burden of hospital-based care to a primary care doctor's responsibilities, that would just be impossible at this point. And then there are other pros, like, for example, there are aspects of hospital-based medicine that are worthy of specialization. And it's a very different skill set than taking care of somebody in the office. And so why not have a specialized workforce who are experts in how to do medicine in the hospital? But what we lose is the story. Once the patient goes into the hospital, all the story and all the context goes out the window. So I'm wondering, like, what can we do about that? Do we just write better notes? Do we facilitate better communication between primary care doctors and hospital medicine doctors, so that there can be more of a warm handoff? Where you can kind of try to distill down all that context into like a single phone call? Do you want to reconsider this model? Where do we go from here?
Tobin Greensweig
Everything you say resonates. The intensivist model is the same as the hospitalist model. And I think that where we go is team-based care. And I think that the hospitalist and the intensivists need to be roped into that team, or we rope them into our team, however you look at it. And whether that starts with picking up the phone and saying, "Hey, Carl was just admitted, can we have a chat?", as opposed to looking through notes after notes after notes… I think that's the kind of thing that needs to happen in order to start to have more shared knowledge of a patient's situation.
I recently admitted a lady to the intensive care unit who had head and neck cancer. And she was transferred to us because she was bleeding out of her mouth; she couldn't protect her airway. And there had not been good documentation about this particular patient's goals of care. And I could see the writing on the wall of the direction the case was going to go. And I really couldn't speak to her; she spoke another language, and she had a mouth full of blood. But, miraculously, I was able to page and get a phone call back from her primary oncologists at 10 o'clock at night. And we had a good chat for two minutes. And the context that that provided changed the entire trajectory of this lady's care. I don't even know if he could have put those things in words in a note. Could he have answered that exact question that I had in that exact moment? I think it would have been really, really hard. But making ourselves available, in the old style, where we all carry our beepers all the time? Maybe it's a good thing for patients. I don't know how that works with work-life balance.
Emily Silverman
Probably not very well.
Tobin Greensweig
But...
Emily Silverman
It's such a puzzle.
Tobin Greensweig
But it is, and it it just begs this question of physician identity too. Is being a physician your life? Or what does that mean to have it be your life? Does that mean we have to carry our beepers and have them on us at all times?
Emily Silverman
And there's already so much overwork that adding that onto the plate just seems really impossible in this moment. But I wonder if we could reimagine some of these care structures to accommodate communication like that. It's just so striking to me how a two minute conversation could be so pivotal.
Tobin Greensweig
I share with you that I think being a primary care provider is probably one of the hardest things in medicine today. My wife is a Family Nurse Practitioner, and I see her working on notes at 11 o'clock at night, and managing a whole panel of patients. I feel like we need to build into the primary care provider's day time to follow up with inpatient providers, or other providers, to have these conversations.
Emily Silverman
The gift of time, the gift of time to do all the things, we never even got the gift of time for the charting.
Tobin Greensweig
Yeah.
Emily Silverman
Much less for all this other stuff that we squeeze through the cracks. So, hats off to all the primary care docs and family medicine docs out there!
I want to ask one last question about house calls. Because, ultimately, your story is one of making the decision to pull up in front of this guy's house. And I love how you walk us through this in the story. You're like, circling the block, you're like, “Should I, shouldn't I? Is this weird? Is this inappropriate?”
Tobin Greensweig
I mean, why should it? It's completely and utterly true. But why should it be weird? It's just another person.
Emily Silverman
Totally.
Tobin Greensweig
And in the course of a week, I had formed a really meaningful bond and what I would call a friendship with their family.
Emily Silverman
But the sad thing is... is, today, it is weird. I don't think it's bad. I think it's great. But it is unusual. It is atypical, it is unexpected, it's surprising. And that's the beauty of the story, is that you're able to surmount all of those cultural obstacles, and knock on that door. So, just tell us a little bit about what it was like to be in that house. I know you go into it in the story, but I think it's still important to paint a picture.
Tobin Greensweig
My senses were so heightened that I can almost feel and see everything that happened. What was so striking is that life was so normal in the house. It was so healthy, despite having somebody in the house who was so, so ill. To see how the children were there playing with Carl. I think I say in the story that they were playing the game of Restaurant. The kids were running back and forth to this play kitchen with hamburgers and plastic fries and bananas and who knows what. And to those kids, Carl was just Carl. Then to gaze back across the room at this wall of pictures, and I've never seen so many pictures on a wall. It was pretty beautiful.
Emily Silverman
Who does do house calls in 2021? I know a few folks in the geriatrics community who do this.
Tobin Greensweig
My wife is just finishing a residency as a Family Nurse Practitioner and starting to look at job postings. And there's actually a surprising number of house call organizations and I think primarily, as you said, serving the geriatric community.
Emily Silverman
Right. Because often it's patients in the geriatrics community who are home-bound. They can't leave the house and so you're left with no choice. They can't come to the shiny hospital on the hill. You have to go to them.
Tobin Greensweig
But think of all that they learn, just by being there.
Emily Silverman
The providers.
Tobin Greensweig
Yeah, and how they can use that to help patients.
Emily Silverman
Yeah, and I've heard some folks talk about telemedicine and how even if it's just a screen view of the patient's living room, that it's like, "oh!" All of that input can be really helpful. So, if anybody listening does house calls or does work like this, reach out to us because I'd love to hear more about what that's like. Well, we've covered a lot of ground today. I've really enjoyed this conversation. Is there anything else you'd like to share with the audience before we end?
Tobin Greensweig
We're together in the studio and I think that, by itself, is pretty amazing. And, you know, to use some of these stories that are coming out on the show now that feel like time capsules… My story was told pre-pandemic. And to let them serve as a reminder for what was medicine like, just two years ago? And how can we keep the good things of the pandemic and maybe ditch some of the bad, as we emerge from this, hopefully.
Emily Silverman
Hopefully. Well, thanks again for coming, Tobin, and have a wonderful rest of your day.
Tobin Greensweig
You too. Thanks for having me.