Wednesday, February 27, 2019

A Home Medical Doctor’s Journal

In his two decades as a home medical doctor, Dr Tham Weng Yew has served many frail and home-bound seniors through the “Code 4 Home Care” programme under Care for the Elderly Foundation (CEF).

Dr Tham discovered his interest in the Community Care sector when he was a medical student. During a one-week attachment to the community nursing service then, he saw how visiting nurses could provide only written memos for caregivers to pass to the clinic doctors. Home bound patients who needed proper medical care or advice often delayed seeking medical help until their condition became more serious.

Today, Dr Tham ensures the patients can get the care they need at home in his role as clinical director and consultant physician for CEF. He shares with mosAIC what he does as a home medical doctor.

As a home medical doctor, what would you say is the biggest difference between what you do and what a doctor based in a clinic or hospital does?

The home care doctor has the advantage of assessing the patient in his/her own living environment. This setting often yields valuable information for the doctor, and helps in formulating more realistic and relevant care plans for the patient’s needs. Also, with the doctor right at the door-step, the patient is less likely to default on medical follow-up.

What are your guiding principles in providing care to your patients?

I have two important guiding principles. First, to address patients’ needs holistically. Merely prescribing medications may not achieve the desired results if other needs such as proper nutrition, personal hygiene, ability to function, and emotional support are neglected.

Second, the patients’ interests should always be our primary concern. Many home care patients face complex medical and psychosocial challenges involving several parties who may have conflicting interests. In such situations, the healthcare practitioner should always act in each patient’s best interest.

Beyond these, attention must be given to caregivers too.

Can you describe what you do on a daily basis?  

I start the day with a morning meeting with our nurses and medical social worker. The clinical team discusses and evaluates issues faced by the patients seen the day before. Then we formulate care plans and schedule the day’s activities.

Home visits are prioritised based on the acuity of patients’ clinical needs. Normally, each doctor makes four home visits per day. Each visit typically lasts about 45 minutes. For new patients, the initial medical assessments generally take about two hours.

The registered nurse, who is also the primary case manager for each patient, accompanies me on home visits. Being familiar with the patient’s care, the nurse is able to provide relevant clinical and psychosocial information about the patient.

On these visits, I may speak with the patient’s caregiver and family to find out any concerns or expectations, and counsel them accordingly. I will also be able to evaluate the patient’s home environment, and identify potential issues, which the patient or caregiver may not be aware of, such as the risk of the patient falling.

Sometimes, I may have to perform bedside procedures such as removal of impacted earwax, changing of PEG tubes or tracheostomy tubes.

After each visit, the care team will huddle for a discussion, followed by setting goals and creating a care plan. When needed, we may have to liaise with hospital clinicians or community partners involved with the patient’s care.

Can you share what a home medical doctor’s “care bag” includes for home visits?

The essential items in my bag include a sphygmomanometer (blood pressure set), pulse oximeter, glucometer, stethoscope, ophthalmoscope and auroscope, hand sterilising lotion, disposable gloves and lubricant gel.

Is there any item not usually in a doctor’s list of supplies that you cannot do without?

My tablet has become indispensable. It allows access to the patient’s medical records anytime and anywhere, and enables me to organise and keep track of the patient’s problems and care plans.

Some indispensable items in the doctor’s bag.

What are the most common conditions or issues you face among your patients?

One of the most challenging issues older homebound patients face is getting adequate support from their family. Financial support aside, family members need to give their time and emotional support too. The burden of care often falls on the shoulders of one person - usually a single child or a foreign domestic worker, with the other family members not contributing adequately to the care. It is not uncommon for the patient to live with only the foreign domestic worker in a flat. When a crisis occurs, the family expects the home healthcare worker to make an emergency home visit to address the issue on their behalf.  

Who do you work with most closely in the process of serving your clients?

We work closely with community therapists (from home rehabilitation services or day rehabilitation centres). A good rehabilitation programme makes a significant difference in improving the function of our frail patients and enhancing the quality of their lives and that of their caregivers.

Can you share any memorable experiences you had with a client?

CK was a manager in his mid-forties when a serious stroke left him paralysed in all four limbs. He was living with his elderly parents in a two-room HDB flat. Being bedbound, CK was dependent on his caregiver, a foreign domestic worker, for all his basic activities of daily living. He was put on nasogastric tube feeding, which caused him discomfort and his right eye was blind from exposure as he was unable to fully close his eyelids. He also had a tracheostomy made to help him breathe. Unable to speak, his only means of communication was by laboriously spelling with his finger using a set of letters on a communication board.

When I first saw him three years ago, he was miserable and often talked about wanting to die. Fortunately, a close friend offered to take over his care. CK moved into his friend’s apartment and the friend supervised his care and supported him both physically and emotionally.

On our end, we referred him to a gastroenterologist for a PEG tube to be inserted directly into his stomach for feeding purposes, replacing the nasogastric tube and easing his discomfort. His self-image improved and he could go out of the house without an unsightly tube sticking out of his nose. We also referred him to a home therapy service to improve his physical function.

With the attending therapist’s encouragement and his hard work, CK is now actually able to walk with assistance. This is a remarkable achievement since his stroke three years ago.

CK is also now equipped with a modified tablet that functions as a more efficient communication board, and also allows him to send emails and post messages on social media sites. With motivation, encouragement and support from his friend and healthcare professionals such as the therapists and nurses, CK is now a very different person - cheerful, optimistic and full of drive. His story is a testimony to the resilience of the human spirit and what it can achieve given the right opportunity.

What would you say to encourage more doctors to join the Community Care sector like yourself?

This form of medical practice relies heavily on clinical skills, and trains a doctor to develop a strong clinical acumen. It gives him/her the opportunity to manage the patient holistically and develop long-term relationships with the patient and the family. The doctor is also usually part of a team that co-manages the patient, allowing him/her to interact with and learn from fellow healthcare professionals.

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