I had a patient that came in the other day for a routine follow up. She hadn’t been to the clinic in about 6 months. She had over 20 diagnoses in her medical record. One of them being Diabetes Mellitus type 2. She was overdue for blood work, her diabetic foot exam and annual eye exam. She also told me her insurance was no longer covering byetta, so needed a different medication prescribed.
She then told me she needed medication refills, some were not even on her medication list. She also needed a referral to orthopedic to get a hip injection. She was also feeling depressed and wanted to try a new medication. She was interested in getting therapy so I placed a referral to our mental health department as well.
She said she called her insurance and they told her acupuncture was covered so would like a referral to them for her multiple joint pain.
At the end of the visit, she said she forgot to mention she also needed a referral to neurology for her headaches. She wanted to try botox.
I told her I had already placed orders for her labs, did a thorough physical exam, placed referrals for her eye exam, orthopedic, mental health, and acupuncture; in addition to refilling her medications, changing byetta, and trying something new for depression.
I thought it would be best to hold off on the neurology referral until a later date. She seemed disappointed but I told her that perhaps her headaches were due to her depression and may improve with medication for mood disorder, and that acupuncture may help with her headaches as well.
It got me thinking about the fact that primary care providers always wish they had more time with their patients. 15-20 minute visits is often not enough to treat a complex patient. After I was done with this specific visit, I asked the other providers if they would have preferred to have an hour with this patient to cover all bases, or just to have her come back more frequently such as monthly (she doesn’t have to pay a copay).
Interestingly, they all said they would prefer the longer 1 hour visit. I used to have that same perspective, but after working at the geriatric clinic for several years, I have realized that frequent visits are more effective in providing good patient outcomes.
For instance, it’s not ideal to have a patient try more than one new medication at a visit. This is because if they have side effects, you wouldn’t know exactly which medication was causing it. Additionally, such as in the above visit, when patients request multiple referrals, it can become overwhelming. Most of the time, when a patient has more than one referral, they are unlikely to go to all the specialist visits without you reminding them at a later visit.
In one visit with a complex patient, I can easily adjust their blood pressure medication, review their lab results, refer them to nephrology, order compression stockings for their leg swelling, and encourage them to quit smoking. After the visit, the patient often forgets the summary of the visit, no matter how many times you repeat it to them. Thus, they will forget to pick up their new blood pressure medication from the pharmacy, and are unaware they need to follow up with referrals to get their nephrology appointment scheduled or find out where they can pick up their compression stockings.
This is why I think it is best for each visit to be focused. That way you have ample amount of time to evaluate a disorder and the patient can be more proactive in their care.
Once I explained this to the other providers, they all seemed to agree that frequent targeted visits may be more effective after all.
I know patients are often looking for a quick fix, but the reality in healthcare is that the body is so intertwined that one problem can cause other problems to occur. There is no point in giving a pill for every single symptom. That is why it is important to treat one thing at a time and perhaps you won’t even need to treat the other problem at a later date.
Would you prefer to see patients more frequently or have longer but more rare visits with them?
I prefer more frequent vs as well.
Yesterday I did a 5 kid well-child check via telemedicine!! Each kid was crazier than the next one. I logged on at 1000, off at 1130. 2 hrs of charting. No vs in forever, multiple meds, referrals. And I didn’t get to lay eyes on 4 of the 5 – they refused!!
At the 3rd time mom put me on mute, she forgot to mute me. She was screaming and slapping the autistic 13 y/o who was throwing stuff/kicking the wall! They were initially to be seen in clinic, but cancelled ~30 min before their vs. Tried telling mgr this is NOT good care, they still have to come back within 2 weeks for h/v, ht/wt, labs, immunizations, etc.
All mgr can say is we need to see pts. Day before my 3-fer WCC were 90 min late. They showed up at the same time as my next 3 for WCC, who were on time. Thank God the doc was back from vacation, bc they did not reschedule my late pts, and actually brought them back before the on-time pts!
I asked is she sure the billing and collections are correct? We are both seeing a lot of pts, but she’s talking about closing down! Needless to say, I’m looking for another job!
As an aside, how would I find a Geriatrician for my parents? They live in Ocala. He’s 90, she’s 88. Mentally doing well. He’s been in for CHF 4 times in past 15 mo. When he’s d/c’d with instructions to f/u in 48 hrs. He can’t get in for 3-4 weeks! My mother who runs their appointments, knows to work the system. That’s doing her a favor – 3-4 weeks!
They have excellent insurance via my dad’s NYC union, so no issues there.
If you know any one or even how to find a Geriatrician, I would appreciate it.