Learning from home visits

The consultation is at the heart of general practice and is where primary care is delivered. This includes home visits.

The RCGP curriculum includes numerous learning outcomes that are underpinned by a commitment to patient-centred medicine.¹ This article will briefly outline these requirements to summarise what can be learnt, and how, on a home visit.

Learning about the patient

When visiting a patient's house, contributing factors towards many conditions can be discovered. The saying 'A picture paints a thousand words' is very apt. Home visits may alert doctors to alcohol bottles, cigarette packets, sweets, damp, pets, loose carpets, unused health appliances, and cohabitants, none of which may be addressed when a patient presents in surgery.

Home visits allow a better understanding of interventions. In terms of medication, for example, a patient may say their analgesics are working when they attend the surgery, but the GP may come to a different conclusion when observing how mobile and pain-free the patient is at home.

Similarly, adherence to taking medication safely can often be better assessed on a home visit, for example, by the presence of numerous unopened, or far too quickly finished, packets of tablets.

Such information also provides details of the patient's beliefs regarding their medication, the likelihood of potential side-effects, and the possible need for investigation of alternative diagnoses or dementia.

Support at home

The social and economic situations of patients and their families can be better understood on a home visit. Knowing who the patient's relatives are and who is involved in their care helps to provide medical care for the whole family, all or some of whom may also be patients.

Questions such as whether the patient has enough basic amenities, including heating and food, whether they have enough appropriate support, and if the support comes from family members who may also need assistance, may prove useful.

This can benefit later consultations at the surgery when seeing family carers who may be presenting with fatigue, depression, anxiety or joint pains, for example, for which the social part of their presentation has previously provided clues.

Learning about yourself

Various professional and life skills can be developed and improved using home visits.

The doctor/patient relationship dynamic has been qualitatively reported to shift on some home visits for patients, compared with consultations at the surgery.² This requires varied consultation styles to be employed by the GP.

Similarly, the home visit requires the GP to develop examination methods that greatly differ from conventional methods learnt while at medical school.

This may be because the environment lacks the perfect couch, light, or assistant. It could be because of the presence of certain hazards, which can range from pets to broken glass.

Plans involving access to primary and secondary care for home visit patients may also need to differ from surgery-based patients.

All of this tests the GP's flexibility, their ability to adapt, manage and develop risk identification skills.

Learning about the team

Home visits potentially allow the GP to have greater contact with the primary healthcare team.

This might be by being present on a visit at the same time as another team member.

This can help to further your knowledge of the roles, responsibilities and referral methods for such allied agencies. Meeting these individuals also helps in forming professional relationships with them.

There may be information from such agencies at the patient's home, either in shared care folders or through the presence of supporting aids, leaflets and letters, all of which can help to form or confirm a GP's understanding of who is involved in the patient's care.

Teaching using home visits

Using the home visit to teach and learn can start early in a career. Various learning outcomes for students,³ in their foundation year or on GP specialty training (GPST) courses, can be acquired on a home visit.

A two-week, home visit based course that required undergraduates to undertake at least five supervised home visits 'helped them in organising their thoughts and planning a follow-up and an intervention programme. All students reported a better understanding of the role of home visits in family practice.'⁴

Joint visits should not be forgotten as a potential learning method for GPSTs, but these do not need to be solely with their GP trainer. Using the training period generally to observe and learn from other members of the primary healthcare team on home visits could be useful.

Some qualified GPs may benefit from such an opportunity if it will help in their personal development plan. Cases and significant events from home visits could be a formal subject at peer group and vocational training scheme sessions.

In terms of teaching, methods such as case analysis and video analysis could be specifically performed for home visits, whether the learner is a trainee or a GP.

Home visits should also be a potential source of feedback. Regular patient questionnaires could include those who are housebound.

Clinicians who are involved in medical education could also use joint home visits for feedback to their students or GPSTs on clinical and teaching skills. Feedback can be obtained from team members, for whom home visits may be a better opportunity than surgery meetings to comment on interaction with patients and colleagues.

Conclusion

Home visits are an important part of GPs' work. They can provide various learning opportunities about patients and the community, as well as about GPs themselves.

However, there may be barriers to learning from home visits, and surgery or telephone-based consultations can also be used for learning development.

With these caveats, the learning potential of home visits is important to consider for professional development, just as much as other forms of consultation.

Owing to the role of home visits in primary care, they could potentially be used as a formal method of learning and assessment for medical students and GP trainees, as well as a specific source requirement for GP revalidation.

• Dr Metcalfe is a GP in York

References

1. RCGP. Royal College of General Practitioners Curriculum 2010. London, RCGP, 2013.

2. Yuen JK, Breckman R, Adelman RD et al. Reflections of medical students on visiting chronically ill older patients in the home. J Amer Geriatr Soc 2006; 54(11): 1778-83.

3. Zabar S, Hanley K, Adams J et al. No place like home: teaching home visits. Medical Education 2009; 43(11): 1102-3.

4. Kannai R. A systematic approach for teaching the home visit. Medical Education 2005; 39(11): 1152.