“I Thought I’d Wait Until My Appointment”

It happened again. A sick patient needed to be double booked this morning. Looking at my schedule, I saw Gordon Plourde had his six month diabetes visit today. He is well controlled, takes as good care of his health as his impeccable lawns and gardens.

“Have her come when Gordon is here, he’s usually a quick visit”, I told Autumn.

As soon as I walked through the door I knew this wasn’t going to be a quick visit. Gordon had lost a lot of weight. His blood sugars were up and he started telling me about all the symptoms he’d been having the past couple of months.

“My wife kept bugging me to call you, but I figured I’d wait for my appointment”, he said. “I probably should have listened to her.”

“Probably”, I answered. What more could I say?

His visit ran over, as did my double booked patient who had done what I wished Gordon would have done. It took a few hours before I caught up. But I did, and everybody was understanding.

Tonight, over barn coffee with the animals, my random thoughts returned to this morning’s patients.

Some people have a rigid view of when they need to see us – every so many months, whether they feel well or very ill. That is not good. Have we, as a profession, fostered such an inflexibility? Or is it procrastination, or maybe for cost reasons, although so many of my patients have Medicaid or Medicare with supplemental insurance and virtually no copays.

I have experimented with letting patients decide when to come back and often seen that this doesn’t work.

I have said “Come back in three months, but if all your blood sugars are good, you can push your followup out to six months. That just seems to confuse people, so I almost don’t do it anymore.

If we had more staff, and if we were capitated (payment per member per month) or paid for outcomes (although risk -possibility of losing money – isn’t something a small group or clinic might dare to get involved with), perhaps we could reach out to patients with chronic conditions and see if they needed to come in or not.

Even though I like the old fashioned, patient centered interaction once I’m in the room with my patients, the surrounding clinic routines can seem old fashioned in a bad way.

The “Patient Centered Medical Home” was supposed to fix all that, but the rules were stilted and ultimately counterproductive. For example, you HAVE TO use the EMR for things like educational handouts, even if the old fashioned preprinted handouts have better information. And you get credit for keeping open same day slots but not for squeezing people in, like I did today.

So, since I can’t change the system, I’ll have to work harder at reminding patients that three or six months until the next appointment is the plan AS LONG AS THERE IS NOTHING NEW GOING ON.

PCMH Certification and Designing the Perfect Car

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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