Posted by: notdeaddinosaur | June 9, 2010

Advice for the New Patient

I’ve had a recent spate of new patients coming in with long, complicated medical histories. This is not a problem. Despite Internists’ claims that they are the complexity experts, I am perfectly capable of handling complicated patients and in fact, I rather enjoy it. It turns out, though, that complicated patients have some issues about coming to us for the first time. How much to tell? How to tell it? Bring the records or leave them behind so as not to “scare off” the poor new doctor?

I thought I’d weigh in with some advice from the doctor side of the doctor-patient relationship, which, just like any other relationship, requires a minimum of two parties.

First and foremost, decide what you want from me; what you want to have happen at the initial visit, as well as your longer range expectations. The more specific you can be, the better. Here are just a couple of examples:

I’m new in town and a need a doctor to refill my blood pressure/diabetes /cholesterol meds.

Great. I trust that what you’re really saying is that you’d like me to manage your chronic medical conditions, which includes office visits and blood tests at appropriate intervals. Happy to work with you.

I want to improve my health.

What does that mean? Do you expect me to bug you to stop smoking? Am I supposed to follow you around and yank away that doughnut before you stuff it into your face? I’m a doctor, not a life coach. I can do a physical exam and screening blood tests to make sure you don’t have diabetes, hypercholesterolemia, or vitamin D deficiency, but we’re not going to get very far unless you’re able to identify what “improving your health” means to you.

I want you to prescribe opiates for my chronic pain.

Okay, but you’d better be prepared to tell me what’s already been done to diagnose and treat your pain, what has and hasn’t worked, and what opiates you’re on. You’d also better be able to assure me that you will not get prescriptions from any other doctors, that you will only use one pharmacy, and that you understand lost prescriptions will neither be replaced nor refilled early. I have no problem with patients who address these issues straightforwardly.

Bottom line to the new patient with a complex medical history, here’s what I want to know:

How are you feeling right now?

What is the CURRENT STATUS of whatever medical problems you may have? Is your disease flaring, or is it okay for the moment? Do you need refills for long term medications? Are you having a new problem? How are you managing right now. Emphasis is on the present.

Please list your diagnoses.

They have to be real ones. (Lupus is real; CFS is not; Fibromyalgia is, but is frequently wrong.) If you have symptoms that have not been diagnosed, rattle them off for me, please. Self-diagnoses can be accurate, but don’t cloud the picture with them to start. Eventually I’ll want to go through this list with you, finding out more about the history of each condition (when it was diagnosed, how it’s been treated, etc.), but start with a complete list please.

If you include the fictional ones, I’ll record them in quotation marks. Later on, as we get to know each other, I’ll try to explain to you why they’re bogus (and why your Lyme doctor, your chiropractor, your naturopath, and your acupuncturist were basically ripping you off).

All your current medications, preferably with the bottles. Include all vitamins and supplements too, please, as well as any eye drops, creams, and nasal sprays. Don’t forget your birth control pills and your Cialis.

If you come prepared with that basic information, don’t worry about the rest. It is my job to “take” your history, meaning I will guide you through the telling of your story. Whether it’s a novel or flash fiction, I’ll figure it out as we go. Don’t worry; you really are very unlikely to tell me anything I haven’t heard before, and who knows: maybe I’ll come up with something new, that no other doctor figured out before.

In fact, consider letting me get to know you over a series of visits. Spend the initial visit concentrating on what’s going on right now, then come back in a week or two to flesh out the past history. Finally, come back again for the physical examination. (Doctors reading this: Bill for time for the first two visits. 45 minutes for the first visit and 30 minutes for the second allows you to charge for two level IV visits, one new and one established. Your complete physical plus medical decision making at the third adds up to yet another level IV.) I know there’s only one opportunity to form a first impression, but a series of visits can either cement a good one or salvage a less-than-optimal one.

There you have it: one doctor’s guideline for the “complicated patient” to establishing a new doctor-patient relationship.

    Advertisements

    Responses

    1. “Am I supposed to follow you around and yank away that doughnut before you stuff it into your face?”
      LOL.

      Thank you! (for the laugh and for the excellent advice)

    2. […] Huge thank you to the Not Dead Dinosaur for Advice For the New Patient.  All my meds, in their bottles?  Really?  Ok, what the hell.  I’ve seen this listed and […]

    3. What an upgrade it would be to have you as a family doctor instead of the one I got now. But then, here in Quebec, those of us that have one are the lucky one.

    4. If your website or office brochure published this essay, and I were looking for a new doctor, I’m pretty sure you’d scare me away. You seem to have a lot of baggage.

    5. If I needed a new doctor and saw this in an office brochure, I’d be pretty sure I’d found myself a good one.

    6. DahliaK: not baggage; experience. Part of delivering good patient care involves understanding them and their expectations as well as what their medical problems are.

    7. Are you sure you don’t want to move to Central Virginia? Actually, I am lucky to have a great doc, but it took some looking to find him, and he is also a RPh and knows his stuff. He is blunt with me, but understands that I am a nurse and he has to EXPLAIN rationales to me…and does so cheerfully. Without his skillful management, I’d likely be unable to work full time and enjoy a fairly normal lifestyle.

      You great docs are worth your weight in GOLD!

    8. Wonderful post! If only I’d had this at my disposal when I was working in family practice. Things run so much more smoothly if we’re clear about expectations.

      Also, I’d love to hear more of your views on Lyme. I have an acquaintance that seems to think this is her major issue, and I’m………..skeptical, but can’t quite put my finger on why.


    Leave a Reply

    Fill in your details below or click an icon to log in:

    WordPress.com Logo

    You are commenting using your WordPress.com account. Log Out / Change )

    Twitter picture

    You are commenting using your Twitter account. Log Out / Change )

    Facebook photo

    You are commenting using your Facebook account. Log Out / Change )

    Google+ photo

    You are commenting using your Google+ account. Log Out / Change )

    Connecting to %s

    Categories

    %d bloggers like this: