Caring for Eagle Feathers
A physician's reflection on his first home visit (republished from July 11, 2014)
I have been practicing exclusively home visiting (house calls) medicine for the last 3 years. Prior to that I’ve consistently included house calls as a part of my practice since I completed residency in 2014 (9 years ago). My first home visit was with the Veteran Administration’s Home Based Primary Care program out of the Batavia VA, an hour east of Buffalo, NY. It was an optional learning experience I volunteered for as part of my geriatrics rotation during my last few months in residency. We went to visit “Rita” (not her real name, details changed for patient protection, written permission from the patient to share this story).
I originally wrote this blog post in July of 2014, just as I was finishing residency. Almost a decade later, this first house call as a doctor, is the most transformative experience I had in medical training. It set me on the trajectory I’m on today, founding a technology-enabled, home visits only primary care practice. I’m reposting it now, as I think this post most clearly captures for me the power and beauty of home visits.
If you are a medical student or a resident, seek out an opportunity to do a house call. It just might change your life.
Originally published July 11, 2014
The drive out to visit Rita is beautiful. Driving through the vibrant countryside of Genesee County, NY we see rolling fields of soybeans, grazing grasslands, and luscious old growth forest. Thick pungent green trees reach high into the heavens, with birds of every color and species darting low and high between them. Not too far from here, you can see through a telescope set up at the Iroquois Wildlife Center, the fortress like nest of a family of some of New York State’s last wild bald eagles. As we drive, a woodchuck pops his head out of a hole in a ravine near the little road and quickly disappears again. We pass a sign, written in English and Onödowága, that says “Entering the Tonawanda Seneca Nation”. As soon as we enter the reservation, I notice that in this place, the beauty of the world created by the Great Mystery, is matched only by the poverty of the world created by mankind.
I am accompanying, Sandy Chenelly, Nurse Practitioner for Veteran Affairs’ Home Based Primary Care program in Western New York. We are to visit Rita, a seventy year-old veteran of the US Navy and member of the Seneca Nation, who is homebound here due to her near blindness from cataracts, unsteadiness on her feet, multiple chronic medical problems, and the remoteness of her house. The Rez is littered with excessively loud colored signs advertising tax-free cigarettes and gasoline to the white neighbors who like the low prices. Behind the signs, gas stations, and smokeshops are a scattering of dilapidated old trailers and small housing units falling apart under the extreme poverty of America’s First Nations. Yet, among nearly every sign, cigarette ad, crumbling doorpost of a double-wide, and dashboard of a rusting car, is a proud drawing of a bald eagle. In fact, there is no place I have ever seen this many images of the bald eagle other than, well, the VA.
To get to Rita’s trailer home, we pull off the single lane country road onto the grass in front of a red ranch house with boarded up windows and flaking paint, drive past it, turn around a grove of trees, and park in an unmowed field where a tiny tin-roofed trailer with no running water sits in the middle of the forest. Right now in the summer, with the red-breasted grosbeaks chirping on the birdfeeder outside her door, it’s a stunning environment. Just a few months ago, though, this place was surrounded in over a foot of snow for the entirety of the Buffalo winter. (Winters in the rural areas surrounding Buffalo, NY are actually worse than those in the infamously snowy city). Rita is happy to see us as she creaks open the door, her little dog, Tino, yipping away. Right atop Tino’s cage rests a blue “Veteran-US Navy” baseball cap, with a two pins: a purple one depicting the Hiawatha Belt, and a silver one of an eagle feather.
I notice there are eagle feathers all over Rita’s tiny home. Some are hanging from a giant dreamcatcher in the corner, some on the walls, and even one over the edge her framed Law Degree from the University at Buffalo. “The eagle feather is sacred to my people,” she says, her tremulous hand guiding my view of the description given by her tremulous voice. “Of all creatures, the eagle flies closest to the heavens.” When a Seneca receives an eagle feather, traditionally she takes good care of it and displays it proudly. It is considered disrespectful to hide the feather away in a drawer or a closet.
Without missing a beat, Sandy and Rita pick up the conversation where they left off at the last visit three months ago, like old friends. They easily slide from discussing the warm weather, to her problems with extreme incontinence, her self-image after her radical mastectomy for breast cancer two years ago, and the chest pain that comes when she does light housework which is relieved by nitroglycerin tablets. Today, after months of denial, Rita finally agrees to let Sandy schedule a cardiac stress test for her. She trusts Sandy. She didn’t trust the doctor in a non-VA emergency department who suggested the stress test the first time this happened.
The home visit is like nothing I’ve seen before in my eight years of training through the US health care system. There is something beautiful about the comprehensive physical exam Sandy performs in Rita’s kitchen. Rita mentions that she gets that funny chest pain when she tries to climb up a chair and put a screw in the wall above the window to hang up her new blinds, but she has no one to do it for her. I spend two minutes putting the screw in the wall. I may have just saved the US taxpayer several thousand dollars by preventing an admission for a heart attack.
She thanks us and offers us something to drink. I imagine this is what medicine was like when my grandmother talks about the family doctor coming to exam my infant mother in Brooklyn in the 1950s. But it’s not just nostalgia for Norman Rockwell-style medicine that makes this home visit so valuable. The VA and others have published multiple studies demonstrating that not only is this style of practicing extremely cost-effective, it also dramatically improves patient lives in everything from reducing unnecessary hospitalizations to standardized measures of quality of life.
“Before the VA home care program, it was hit or miss for me,” Rita explains. “I never knew who I was gonna see. I just saw doctors here and there, no body seemed to be talking to each other. Indian Health Services was ok, but they couldn’t do everything. And the private hospitals? It was a mess. When I got breast cancer, I was going to Rochester every six weeks, Indian Health Services couldn’t pay for it. The paperwork was overwhelming, I didn’t know who to turn to. Then I got in touch with the VA. Since Sandy and the nurses started coming to see me it is completely different. I know if I need something they are just a phone call away. I know someone is looking out for me.”
The VA system is very different than the rest of US healthcare. It is in this sort of system where data-driven programs, like home-based primary care, can most easily be tried out and proven to work. Private sector medicine struggles to serve people like Rita. The deplorable outcomes statistics for health in our country demonstrate this, especially for our nation’s most vulnerable and isolated people.
Rita carries the blood of a people who protected these beautiful forests for thousands of years and built the continent’s first democracy, the Iroquois Confederacy. She served in the US Navy during the Vietnam Era. She practiced housing advocacy law for over ten years, helping keep people who would have otherwise been on the streets in their homes. People like Rita are the eagle feathers of America. Their wisdom, their experience, and their time spent soaring close to the heavens have built the society we inherit. Now, due to old age and disease and historical injustice, these feathers have fallen to the ground. We receive them into our hands as a gift. We must care for them. It is disrespectful to hide them away in a drawer or a closet.
