Thank you very much. I want to talk to you about the Return of the House Call. This is
one of my favorite paintings in medicine. It’s a physician, the late eighteen eighties
caring for a child and numerous people have written about this but what strikes me is
the intent with which he’s caring for the child and where he is. The child has not come
to him but he has come to the child. Throughout the history of medicine, technology is fundamentally
transformed medicine and the eighteenth century Edward Jenner developed the smallpox vaccine
which allowed us to prevent the unpreventable. In the nineteenth century, William Roentgen
developed the x-ray and took this picture of his wife’s hand to allow us to see the
invisible. In the twentieth century, Sir Alexander Fleming developed the first antibiotic, penicillin,
to let us cure the incurable and the gift that we have for the twenty first century
is that Steve Jobs and others have allowed us, have developed technologies that increasingly
allow us to reach the unreachable. These technologies will be critical to our treatment of infectious
conditions like the Ebola virus but will also be increasingly important to address the rising
tide of chronic conditions that increasingly will affect all of us. Currently a hundred
and forty million Americans have at least one chronic condition and these chronic conditions
account for over seventy five percent of health care expenditures. With the aging of the US
population and populations around the world, chronic conditions will only increase in there
prevalence. In 2005, we estimated conservatively that the world’s most populous nations,
there were four million individuals with Parkinson’s Disease and the span of just one generation
the number of individuals with Parkinson’s Disease in the United States and around the
world were more than doubled. The challenge is that many of these individuals with Parkinson’s
disease and other chronic conditions cannot access care. In the United States, over forty
percent of Medicare beneficiaries with Parkinson’s disease do not see neurologists. Over forty
percent of Medicare beneficiaries with Parkinson’s disease, a common neurological condition,
do not see neurologists. In New York State, as you can see on this map, there are areas
in New York State, right here, that were over fifty percent of individuals with Parkinson’s
Disease don’t see neurologists and we know that individuals who don’t see a neurologist
for Parkinson’s Disease are twenty percent more likely to fracture their hip, twenty
percent more likely to be placed in a skilled nursing facility and twenty percent more likely
to die. What can we do? We can use the same technology that you’re using to communicate
with your children and grandchildren, to use that technology to communicate with your physician.
In essence, we’re bringing back the next generation of the house call. So, how many
people here ever received a house call? How about any clinicians here who actually performed
house calls? So we’re trying to bring, technology actually ushered out the house call in the
1930’s, forty percent of all encounters between a physician and a patient took place
in the home and the rising, the rise of automobile and the complexity of medicine drove care
back to the institutions. Now we have the opportunity using telecommunications technology
to take care back to the home. Seven years ago, a nursing home in New Hartford, New York,
population twenty thousand, right outside of Utica, Anyone from Utica?, a few people
from Utica, contacted us and said we have about fifty nursing home residents who have
Parkinson’s Disease and no neurologist to care for them. Would you care for them? My
colleague, Dr. Kevin Biglan, did what we think was the first house call into a nursing home
to care for someone with Parkinson’s disease. Mr. D was an eighty year old man with Parkinson’s
disease who was having behavioral problems. Was trying to climb outside the window of
the nursing homes, was belligerent to the nursing home staff and to his fellow residents.
He was on a medication that was making his thinking worst. He was actually on a drug
to make his thinking better. Dr. Biglan took him off both those medicines, made some further
adjustments to his medicines. His score on a standard cognitive exam, which essentially
asks you, what today’s date is and where you live went from twenty one out of thirty
to a perfect thirty out of thirty. His behavioral problems disappeared. He became a model citizen
of the nursing home. Two years later we took that exact same model and said how about providing
care to people like Mr. D, directly in their home. The first patient I ever saw was an
older man, who lives only thirty miles from Rochester, New York, but was becoming increasingly
difficult for him and his wife to come see us in clinic so when I said would you like
us to see you virtually in your home, he was game. The second visit he ever did was in
his kitchenette. He was sitting on a chair and his wife in the background making soup.
Based on those experiences, we conducted a small pilot, randomized controlled trial,
randomizing patients with Parkinson’s disease who were seeing Dr. Biglan or me to continue
to come see us in clinic or for us to see them virtually in their home. We asked three
questions. The first, are we crazy? Is it feasible to deliver care to grandma and grandpa
with Parkinson’s disease directly in their home? It turned out that more of the virtual
visits were completed then the visits in person and one person actually got in a car accident
on their way in to see us in clinic. The second question we asked is we can provide vastly
inferior care and it turned out the measures of quality of life and Parkinson’s disease
both care models seem to improve care. And the third was, are we providing any value
to patients? So we asked patients to time themselves from the time they left their home
to the time they came to clinic here at the University of Rochester to the time they returned
back to their home and it turned out for a simple thirty minute follow-up appointment
patients were spending over four hours of time for simple one thirty minute appointment
with us. By contrast we said well time yourself from the time you turn your computer on, the
time you turn your computer off and their only spending fifty three minutes and three
quarters of that time is spent with the patient, with the physician. Each virtual visit was
saving patients and their caregivers three hours of time and a hundred miles of travel.
So we’ve taken the same model that we’ve used to deliver care into patients homes and
we’ve gone nationally, principally through care and research visits we’ve connected
to patients and in thirty eight states around the country. We had a research grant from
the Michael J. Fox Foundation which enabled us to connect to research participants with
Parkinson’s disease who wanted to contribute to the advancement of our knowledge of Parkinson’s
disease and let us do that by seeing them directly in their homes and their communities
rather than having them coming to a medical center. We’ve extended that same approach
to care for individuals in over twenty countries on six continents. Some of the patients I
care for live in Panama and although Panama’s a wealthy nation and has fifteen neurologists
to care for three million people, it doesn’t have a single Parkinson’s disease specialist.
By contrast, the University of Rochester, right here, has eight. In 1962, President
John F. Kennedy set a bold goal. He says, “We chose to go to the moon, we chose to
go to the moon in this decade not because it is easy but because it is hard, because
that goal will serve to organize and measure the best of our energies and skills because
that challenge is one that we are willing to accept, one we are unwilling to postpone
and one which we intend to win.” Let us today, here on Meliora Weekend set a similarly
broad goal. Let us say that anyone, anywhere in New York State with a chronic neurological
condition, be it Autism or Alzheimer’s disease, MS or ALS can receive care. For the history
of medicine, the care you receive is largely dictated by two factors. The first was, “Who
you were?” “Were you the right age?” “Were you the right sex?” “Were you
the right pigment?” “Were you the right creed?” The second was where you live. “Did
you live in an area where you were able to access care?” Let us today, for the first
time, say that for a defined group of illnesses, for a defined geography, that anyone anywhere
can receive care. “Meliora”.
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