I've spent two afternoons precepting with the residents recently. It's good to get back into clinical work - and after spending 3 years in Washington - separated by the Beltway from the real world - I've really felt the need to get back to the front lines of health care delivery to make sure I still understand the real world. I'm also seeing a window into how these physicians have been trained, and that is different from my life as a family physician in a small suburban practice - which was my reality pre - DC.
I've witnessed two themes that seem to deserve careful thought:
- The follow-up visit. I felt like I had abolished many/most follow-up visits from my practice a decade ago. Sure - many guidelines advise follow-up visits after acute events, but I found that with good communication, most are unnecessary. People know when they don't feel well - so we shouldn't assume that they need us to tell them that they are better. My bias against the follow-up tradition probably stems from my early research work on the management of otitis media: most kids just get better. Only a fraction of kids with otitis media need antibiotics. In either case - with or without antibiotics, if we look in their ears too soon - it looks like they're not better - so risk-adverse physicians write a prescription at the 7-10 day follow up visit. Quite often, I'd argue that this is unnecessary. So I stopped doing it a long time ago. We would keep in close touch with the family - and certainly if symptoms worsened or persisted, we would see them back, or alter the treatment over the phone. But a routine follow-up visit after an ear infection was never my pattern. This saved the space in our office for folks who needed to be there. Seems like this question was asked (and answered) in 1994.
But the follow-up visit persists - and not just for otitis media. Many conversations with a resident ended with "and I'll have them follow-up in __ to make sure things are better." After a while, I started asking "why?" Not to provoke a change in course - but to prompt thought. (Both the resident's thought and my own.) I wondered if my patients in suburbia were fundamentally different from those here in an urban setting - where there is less money, less education. Did this cause us to assume they they can't engage with on the phone? I thought about the residency practice - and how it's not designed so well for continuity and access to the physician for a quick phone call. I thought about the fiscal pressure to generate revenue and keep the schedule full. My suburban practice was overflowing: we didn't need more volume: indeed - we did our best to reduce it to make space for those who needed it most. Here - there is a large practice with empty rooms. Do they need to generate more visits? Is there an implicit bias toward volume?
The real answer is "maybe" to all of the above. There are many reasons why young physicians might schedule the follow-up visit reflexively and why my practice five years ago might have been different. But without asking the questions every time, we won't better understand how to solve the very real problems we face today in our industry: even very simple decisions are complicated.
A few weeks ago, I visited an ophthalmologist because I developed some floaters in my left eye after hitting my head. I knew enough to have my retina examined - because of the small chance that the trauma cause a retinal tear. Fortunately, she saw only some vitreous coalescence, and advised follow-up in 4 weeks. I obediently returned in 4 weeks, wondering why I needed to follow up. The risk of retinal detachment would (by now) have fallen, and it is also quite likely that I would see some evidence of retinal tear from my side of the retina. After my (normal) exam, which cost me $350, she advised another follow-up in 4 - 6 weeks. When I balked - asking "why?" - she agreed that there was no good reason (she generously agreed that it was for her peace of mind more than anything else) - and offered that we should alter our pattern to an annual visit. I departed still wondering what the evidence basis was for an annual visit to an ophthalmologist. I have neither diabetes nor glaucoma. Hmmm. None. I'll probably see her next at the supermarket - not in her office.
- The Physical Exam. It's been over a year since Zeke Emanuel's 's wonderful article in the NY Times. But for years before this - it was clear that putting a stethoscope to someone's chest annually was a waste of their money and our time. So in my practice, we eradicated "physical exam" from our routine a long, long time ago, in a galaxy far, far away.
The staff would never schedule someone for a "physical." It would always be "health assessment" - and the focus would be both age and condition appropriate. The key advantage here is more than just semantics. It changed the expectations on both sides. Physicians felt less obligated to "do a physical" and patients - or their families - felt like they could really focus on their agenda, rather than checking boxes in the doctor's head (and the EHR). The time saved not doing unnecessary physical maneuvers was better spent with depression screening, substance abuse discussion, optimizing health habits, etc. How often should this be done? Well of course it depends. It might be weekly for a preemie, just brought home from the hospital - and it might be every 5 years for a healthy 25 year old who participates in triathalons, has a BMI of 21, and eats kale 3x/day.
But that's not what I've been seeing. I've been seeing lots of young physicians doing "physicals" and then not having time to have conversations - so guess what they do? They schedule "follow-up" visits to have these conversations. Volume again. Hmm ..
How could we be proactive about this? If we really want More Health and Less Care (we do - don't we?) then couldn't we change what we schedule, engage in a much more proactive way to schedule the flu shots, lipid profiles, A1Cs BEFORE visits (rather than after) - and really start to behave in a way that puts the people in the center - rather than the physician. I see very good, very thoughtful, very "patient centered" humans getting caught in the traditions that are - by definition - not patient-centered. Two of these traditions are the "follow-up visit" and "the physical." Let's start by just asking "why" before we engage in either one. It's a first step.