He makes house calls - and provides a sympathetic ear

Dr. John Patterson begins his rounds carrying a leather satchel that makes him look like someone out of a Norman Rockwell painting.

His doctor's bag - with blood pressure cuff, stethoscope and a few other simple tools - is all he needs.

Rather than toiling in an office brimming with technology, he examines 95-year-old Isabella Harrison in the soft-lighted comfort of her Virginia Beach apartment.

"Where are you?" he calls out after being let in by Harrison's caregiver. "There you are. In the chair instead of the sofa?"

It's a small detail, but it gives him a hint of just how much the woman's hip has been hurting. She no longer wants to sit on the sofa because it's too difficult to get up.

This and a dozen other topics related to her worn-out joint will take up most of the next hour as they try to answer this question:

Should she get her hip replaced?

The 46-year-old, boyish-looking Patterson is a rarity: There are only about 4,000 house-call doctors in the country. Most of his patients are older - many in the last few years of their lives, others homebound because of disabilities.

Issues that have come and gone in the health care debate - end-of-life counseling, rationing, primary-care doctor shortages - are ingrained in Patterson's daily work in subtle, less sensational ways.

A test for cancer for someone who might not get it treated? Surgery for hip replacement for someone in the last years of life? Measures to treat, or medicine to comfort?

At some of the homes Patterson visits, the radio might be tuned to Rush Limbaugh pontificating about death panels. But the main question the doctor's 125 or so patients have for him about health-care change is this:

"Will you still come?"

For them, at this stage of their lives, that's what matters.

His practice is heavy on conversation and observation, lighter on testing and intervention - which provides a prism on health care spending in America.

In patients' homes, Patterson can see how they're functioning, and he's also away from the easy access to testing of an office setting. He's also not under pressure to use that equipment enough to pay it off.

"It gives us the opportunity to give a test a second thought," he says. " 'Is this something we really want to do? Will it give me information I can use?'

"The whole way of practicing lends itself to more conservative management."

It's a style that is not lost on legislators.

The health-care overhaul bills of b oth the Senate and the House contain an "Independence at Home" demonstration project that would provide high-need Medicare patients with primary care where people prefer it - their homes - to gauge savings in emergency-room visits and hospitalizations.

With much of the health-care overhaul package now in question, supporters of this home-based care initiative are hopeful the project won't be trimmed, since both sides of the aisle support it.

For Patterson, it's not just an idea, but his day-to-day practice.

His first patient this day knows the lingo better than most. Harrison - thin, white-haired and spunky - is a retired surgeon who worked most of her career for a Veterans Affairs hospital in West Virginia.

Now she's on the receiving end of care.

"How's your hip been doing?" Patterson asks as he pulls up a chair to talk with her eye-to-eye.

"It gets worse all the time," she says.

Recent tests have shown that the cartilage is nearly gone, which is causing her pain every time she moves her leg.

"I can stand up and put weight on it, but then I can't make it move," she tells him.

"Are you walking at all?"

"With the walker," she says. "When we go out, we take the wheelchair."

"I think that's wise. Then you can be like the queen."

"I don't like that very much. It's so obvious I'm decrepit."

They laugh. Then he asks her about a consultation she had with a surgeon about getting a hip replacement, and she tells him the details of how they plan to do it and a possible date.

He asks her to consider various factors before making a decision:

Her age. Whether the risk of surgery is worth the likely benefit. Whether a change in pain medication would do the trick instead.

It's this kind of conversation - an hour long on this day - that sold Patterson on house calls.

The family practice doctor tried group practice for years but grew tired of juggling the high volume of patients necessary to make insurance cover the costs. So in 2002, he started his own practice in his Virginia Beach home and did house calls as well.

By 2006, he was getting so many referrals from people who wanted him to come to them that he began doing just house calls.

"As I found people who needed a closer relationship and were willing to bring me into their homes for the care," Patterson said, "it became more and more interesting. You see what these people's lives are like. The office is an artificial environment as far as how people function in their homes. It's a whole new level of understanding."

Medicare pays more for a house call to make up for the time and travel, and he doesn't have the office overhead of equipment and staff. He also works for Sentara's hospice program, which treats people at home.

A house-call practice is not a financial move many doctors are willing to make. For Patterson, though, it works, and it has given him an appreciation of a more personal style of medicine.

Most of his patients are covered by Medicare, the federal insurance for people 65 and older and some disabled.

It's estimated that almost a third of Medicare spending - $67 billion a year - goes to a small slice of chronically ill patients in the last few years of life.

The per-patient cost, though, is vastly different depending on where you live, according to a study by the Dartmouth Atlas Project. Those researchers discovered that frequent use of office exams, tests, imaging and other diagnostic procedures accounts for the differences but does not necessarily improve the outcome, even after adjusting for patient characteristics and regional demographics.

The study, published in two issues of Annals of Internal Medicine in 2003 and recently updated, has led to calls to make patients more aware of risks and trade-offs as a way of reducing health-care costs. As it is now, doctors are reimbursed for interventions, such as tests and procedures, so there's incentive to do more, even if there's not a corresponding improvement in health. The Dartmouth study has fueled health-care-overhaul discussion to create a system that would reward management and outcomes rather than tests and interventions.

Patterson said doctors are geared to find a problem and then fix it. But some people late in life are not looking for that. For instance, he has had patients with cancer symptoms who don't care about extensive testing because they don't want surgery - they're more concerned about easing pain.

Building relationships with patients is critical to teasing out that kind of information. A study by the Archives of Internal Medicine shows that such conversations between doctors and patients can decrease costs by about 35 percent and also improve the quality of life.

Another patient of Patterson's, Bill Gargiulo, 72, has a neurological disease - cerebellar degeneration - that has taken him from using a cane to a walker to a wheelchair.

He weighs 250 pounds, so getting him to a doctor's office was a challenge for his wife, Pat. Hiring medical transportation cost hundreds of dollars, and family members had to take time off from work to get him there. Once the appointment was finished, there was a wait for the transport company to pick him up.

"It would take him a few days just to get right again," Pat Gargiulo said.

Patterson has had patients who stopped seeing their doctors because they couldn't get to their offices. Then they let their prescriptions lapse and ended up in the hospital. Small problems that could be addressed in early stages grew into big ones that required hospitals.

That's the kind of expense the Independence at Home project aims to reduce. It's also designed to be "budget-neutral." Savings in hospitalizations would go toward funding the home-based coordination of care.

The health care debate has fueled fears of rationing care to save money. Patterson sees a lot of room for improvement just in helping people make better decisions about treatment.

"We need to know where to stop," he said. "We keep going to the point where they either say stop or we find out. We need to give them a choice to begin with."

That doesn't mean treatment would be withheld against people's wishes, but rather that the options would be explained more thoroughly.

At Harrison's side, Patterson asks her to consider all the factors.

"Would you rather be in a wheelchair and be alive than have surgery and suffer a heart attack?" he asks.

"I've thought about all this," Harrison says. "And... I really don't care which way it goes."

"I want to make sure it's not excessive risk," Patterson says.

"I have to clear you to have this surgery and I won't clear you if there's a high risk of complications."

"Do you think I should stay the way I am?" she asks.

"No, I don't. No one can feel what you're feeling. I've had people in your situation and they are so scared of surgery, they'd rather be in a wheelchair. Others want to feel better. It's a personal decision."

He gets down on his knees next to her and puts her right leg through some range of motion.

"Relax, relax," he says, but Harrison grimaces as she holds her leg tight.

"It's not our place to say you have to stay like this if you want to try something else as long as you know what you're getting into," he says.

"I want to try," she says.

"OK, I'll do my part."

He asks, and she agrees, to have a stress test first to make sure her heart's in good enough shape for surgery.

By now, an hour has passed, but Patterson feels comfortable that Harrison has considered all the issues she needs to.

"The old school is, you go to the doctor, and the doctor tells you what to do, and you do it," he said.

"Quite a few want to be told. But there are a lot who are independent-minded enough to appreciate determining what happens in their lives."

Tomorrow: The trend of concierge care doctors, who charge private fees for more personalized care, takes a variety of forms in Hampton Roads.

Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com