As I climbed up the step ladder to retrieve the alligator leather doctor’s bag on the top shelf in the closet, I thought of my father doing house calls when he was a general practitioner in Queens, New York. When he retired in the 1980s he gave me his doctor’s bag. There, it sat on the top shelf until three weeks ago when I began seeing children and their families in their backyards because of Covid19.
I’m a behavioral/developmental pediatrician/family therapist, a mouthful to describe my MD specialty. I’ve practiced in a Bay Area suburb for the last forty years. I see children and their families who are struggling at school or at home. I can prescribe medication but unlike many of my MD colleagues, I remain committed to using non-drug interventions like parenting strategies and special education support at school.
Because of Covid19 I stopped seeing any patients in my office in the middle of March. I was lucky in that I already had a HIPAA compliant Zoom platform in place because I used telepsychiatry once or twice a week out of a thirty-hour case load. I was a relative pioneer in the use of telepsychiatry in children and family therapy. I lived and worked in Melbourne, Australia for a year in 2015-2016 and during that time managed to maintain seventy California families that had been in my practice. I even wrote a Huffington Post piece when I came back entitled, “I Shrunk the Shrink and They Liked It.” (https://www.huffpost.com/entry/i-shrunk-the-shrink-and-t_b_10544710).
So, I knew what I could and couldn’t do well with video. In terms of effectiveness, I rate the average telepsychiatry session as a 0.9 to the 1.0 of an office face-to-face visit. I give a telephone consultation in comparison only a 0.6. Formal studies comparing the three modalities tend to conform my informal ratings.
But I felt there are a couple of situations where I still need to see the child/family in person. I like to meet children, even teenagers, first with their families. Near the end of the first meeting I have them draw a picture together without talking. It takes only five minutes but repeatedly I have found that particular five minutes to be the most revealing in terms of manifesting family dynamics.
Try as I may (and I’ve asked other docs and IT specialists), I haven’t found a way to see a family online and have this initial connection with the drawing game. I also found I couldn’t truly evaluate a child with learning problems without my watching them perform some academic or processing tasks in the office. And since learning problems often accompany attention-deficit/hyperactivity disorder (ADHD) I believe I cannot perform a decent ADHD evaluation without the child coming into the office at least once as well.
Finally, there are just some times in working with families that you need a face-to-face visit, like with a severely depressed adolescent, a check-in with families whose children are under ten, or a couple on the brink of divorce.
I still Zoomed with most of my patients but began again in May seeing those few situations that needed an office visit. My office has large 18x20 foot room where I would see families, even individuals, because it was easy to maintain a six-foot separation. I read about a judge who insisted witnesses wear clear masks during their trial testimony so the jury could read their body language more easily. I obtained those same masks for my office and distributed them to family members when they arrived for a visit.
I even bought a high-quality air purifier. I thought I was doing okay even though I couldn’t open any windows in my office. But when the latest surge hit California, my two grown sons and their mother (my wife) did an intervention with me. They forbade me to see anyone for any reason in the office. I felt I couldn’t go against all three of them so I agreed to stop the office visits.
But I couldn’t sleep for two or three nights. I wondered how I could still do a decent job without some face-to-face encounters. One night at 2 a.m. I came up with an idea. I’m lucky in that I practice in a middle to upper middle-class suburb. Most of the families live in homes with backyards. I’m also fortunate that winters, even in Northern California, are relatively mild. Middle of the day temperatures usually get at least into the mid-fifties. And so, I resolved to see patients and their families in their backyards.
I had done some house calls before. You learn a great deal as an MD when you make a house call as I’m sure my father experienced in his years of practice. You see the pictures on the wall and where everyone sleeps. You gain a much more intimate sense of the family.
It isn’t quite the same visiting the backyards. I don’t go into their homes but I get to see their neighborhood, the street they live on, etc. Some of the homes were in exclusive gated communities. Another was right next to a six-lane freeway. They had to shout so I could hear them.
And I learned certain things that I just never would have picked up in a Zoom meeting. In a Zoom, a father had told me of his spinal fusion operation. But I had no idea how incapacitated he was until I saw he could barely walk with a cane. A fourteen-year-old being evaluated for ADHD looked fine until I asked him a question about a paragraph he had just read. He was unable to give me the answer indicating a problem in his reading comprehension. When asked specifically, he said when he read, “the words felt empty,” an apt way to describe his problem. A five-year-old was so hungry for company and attention that every other moment I was in his backyard he would jump up and show me another rock that he liked.
I recently received my first Covid19 vaccination and by next month I should be well protected against the virus. Soon my wife will get vaccinated and I will no longer have to do the backyard visits and no longer need the doctor’s bag.
I’m sure I pack my dad’s doctor’s bag differently than he did. The rubber of my stethoscope dried out long ago. I have a sphygmomanometer at home for blood pressure readings but don’t bring it on my house calls. I put markers for the drawing game, puppets and clear masks in the alligator bag. But like my dad, I learn a lot on every call I make.