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"When do you want to see her again, Dr. Pelzman?"

"I don't know, when does she want to come back?"

This is a frequent conversation that takes place at the door of my office, after I've wrapped up a visit with a patient and we've talked about the plan, labs have been ordered, referrals placed, healthcare maintenance updated, questions answered. This happens as I'm moving on to my next patient, taking a quick peek in the electronic medical record to see what was going on with this next patient, any clues or insights I could glean to help prepare me. Or maybe just checking e-mail. Then the patient from the previous visit swings by the front desk, requesting to schedule a follow-up appointment.

There was probably some conversation that went on between the patient and the support staff -- "Did he tell you when he wanted to see you back again?" or something like that. Then the staff will often chat me through the electronic medical record: "How long till you want to see her again?" Or they walk down the hall and stick their head in my office. "Mrs. Smith wants to know when she should come see you again."

What's the Right Answer?

Is there a right answer for this? I'm often asked this by residents when they are seeing patients, and I think both they and more seasoned providers develop their own standards, their own gestalt, rather than a fixed set of rules.

So, for the relatively healthy when they are there for their annual physical, unless we've uncovered something specific that needs an intervention and close follow-up, the answer is fairly obvious: return in 1 year. And I think for patients that are acutely ill, where we are convinced we want to eyeball them again in person after an intervention -- such as starting a new medication or intervening on a health condition that's gotten out of control -- we want to see them back in a few days, a week or two, maybe a month, not too long, so we don't let things slide out of control again. And I think that basically we settle on every 3 months for people who have a bunch of medical conditions that need fairly close follow-up, and perhaps 6 months for a healthy elderly patient, even if they're doing pretty well, when we sense that things could go off the rails.

But that leaves an awful lot of uncertainty, a lot of uncovered time, when things could go wrong and we might not even know about it. I'm pretty sure I'm not advocating for continuous patient monitoring, such as the idea that we should monitor multiple physiologic variables 24/7 in all of our patients, all of the time, and have their data downloaded to the health system for analysis for perturbations -- clues that something might be going wrong. Nor am I advocating for a complete free-range model: "Come back whenever you want, come back whatever you feel like it." Although this works fairly well for open-access scheduling, sometimes I've had patients disappear for far longer than I thought was actually safe for them.

Building in Ongoing Care

Ideally, it would be great to figure out ways to build in the ongoing care of a patient-centered medical home for our patients without overwhelming either patients or providers, or the systems that support them -- and, while we're at it, find ways to reimburse the healthcare team for the effort and energy and work that goes into caring for patients between in-person office visits.

Video visits and scheduled telephone calls, much of which have been developed and advanced during the pandemic years, have gone a long way towards moving the dial towards better interim care, helping us figure out better ways to take care of people without making them travel all the way in to see us in the office. And certain models of care, such as for mental health issues, where I start a medication for depression in the office, and then additional members of the mental healthcare team reach out to them in subsequent weeks to augment their care, keep better tabs on them, and spot problems before they get out of control, is one way to extend care and ensure better outcomes.

Similarly, managing certain medical conditions, such as diabetes, hypertension, and heart failure, with remote monitoring and smart systems that can analyze data and help the entire team figure out why things aren't going well, can be powerful new models of care. Now when I start a new blood pressure medication, I can have a patient buy a home monitor, they can upload their daily BP readings through the portal, electrolytes can be ordered at a local lab, dosages can be titrated, and suddenly we've avoided an office visit.

A new cellulitis can be managed with oral antibiotics, with a starting reference image taken and placed in their chart. A home care team can check on them after a few days and send me updated images to check for improvement or worsening. And collaborating and coordinating with our specialists and subspecialists to make sure that everything our patients need gets taken care of and nothing slips through the cracks, can go a long way towards making sure that people don't disappear from care.

Welcoming Back "New" Patients

In some ways, I think the annual physical examination and panoply of blood tests was created long ago by doctors simply as a way to make sure their patients didn't stay away too long (and maybe also a way to guarantee ongoing income). Every once in a while, I have a patient call who hasn't seen me in 3 or 5 or more years, and they say they want to schedule an appointment. The system wants to call them a "new patient," even though they're not new to me -- they just haven't really needed me much in the past few years, and I don't think there's anything wrong with welcoming them back. Many senior clinicians have panels that are "closed" to such "new" patients, but I think that patients should not be punished for being too healthy to need the healthcare system, and thus lose their doctors.

To build a truly patient-centered model of caring for patients, I do think we need to figure out a way to layer on care outside of the office, to not make patients come in as often as we sometimes think they need to. It's true, in our very brief office visits, when because of financial pressures we are forced to squeeze patients into shorter and shorter time slots, our patients often feel rushed, we feel we cannot give them the attention they deserve, and they more often than not leave with some of their healthcare issues unaddressed. But if we open up a world of continuing care, by creating a team of resources and support personnel around us, we are likely to be able to augment the care they receive in the office with enough care that makes sure they make it to the next office visit with us, in person.

See you next time.

, of Weill Cornell Internal Medicine Associates and weekly blogger for 木瓜直播, follows what's going on in the world of primary care medicine from the perspective of his own practice.

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