How of­ten should you see your doc­tor?

Not even your physi­cian knows, says in­ternist Ishani Gan­guli

The Washington Post Sunday - - OUTLOOK - Twit­ter: @IshaniG Ishani Gan­guli is an in­ternist at the Am­bu­la­tory Prac­tice of the Fu­ture and a fel­low in health pol­icy and man­age­ment, both at Mas­sachusetts Gen­eral Hos­pi­tal in Bos­ton.

Larry is the sort of per­son who comes 30 min­utes early to his ap­point­ment and brings a novel to read in the re­cep­tion room. We talk blood pres­sure, the pub­lish­ing in­dus­try, his prostate can­cer his­tory, his grand­chil­dren. At the end of our visit, I re­cap our plan. We’ll try the higher dose of his beta blocker, keep a sleep di­ary to ad­dress his in­som­nia and start phys­i­cal ther­apy for his arthritic knee. Then the clincher: Let’s see each other again in three months.

We rarely think about all the cal­cu­la­tions that go into those fi­nal words. There’s the clin­i­cal ques­tion of when a di­ag­nos­tic test might yield re­sults or an in­ter­ven­tion might take ef­fect. Prac­ti­cally speak­ing, putting an ap­point­ment on the cal­en­dar means the pa­tient and his prob­lems are not (as we say in medicine) lost to fol­low-up. And it con­sti­tutes a re­la­tion­ship-build­ing ex­pres­sion of con­cern: I care about your health. We are in this to­gether.

As doc­tors, we usu­ally base the tim­ing of fol­low-up vis­its on some mix of habit and a

gestalt of pa­tient need, all within the ar­bi­trary struc­ture of the lu­nar cal­en­dar. Not sur­pris­ingly, then, Dart­mouth re­searchers have shown that visit rates vary tremen­dously. In a study of Medi­care data, they found that se­niors in Grand Forks, N.D., av­er­age less than three vis­its each year, while those in East Long Is­land, N.Y., go to the doc­tor as many as 12 times a year on av­er­age. Pa­tients tend to have more vis­its per year if they are sicker, the study found, but also if they live in an area with more doc­tors or with doc­tors who tend to ask pa­tients to come in more of­ten, even when ad­just­ing for fac­tors such as health sta­tus. What the pa­tient prefers seems to have no sig­nif­i­cant as­so­ci­a­tion with visit rates.

The tim­ing of fol­low-up vis­its, in other words, has tended to fall un­der the art, rather than the science, of medicine. While stud­ies sug­gest that con­nect­ing with a doc­tor is gen­er­ally a good way to build a trust­ing re­la­tion­ship and to pro­mote health, we don’t re­ally know the right fre­quency of vis­its. The few stud­ies that ex­ist on the sub­ject per­tain to spe­cific con­di­tions, such as kid­ney fail­ure: In one ob­ser­va­tional study of pa­tients on he­modial­y­sis, pa­tients who had four vis­its per month had the same risk of death and only a slightly lower risk of hos­pi­tal­iza­tion in the fol­low­ing year com­pared with those who had less-fre­quent vis­its. Sev­eral other stud­ies, of pre­na­tal care, for in­stance, have found that fewer vis­its may be just as good.

So the broader trend to­ward ev­i­dence­based prac­tice in medicine hasn’t quite caught up with the ba­sic ques­tion of how of­ten to see your doc­tor. With ap­point­ments harder and harder to come by, med­i­cal costs still ris­ing and a long-stand­ing prob­lem of both overuse and un­der­use of health care in the United States, doc­tors ought to pay closer at­ten­tion to how and how of­ten we ask pa­tients to see us. Cut­ting out un­nec­es­sary vis­its would free up doc­tors to see pa­tients who truly need care, shrink­ing lengthy wait times (like the 66 days it takes to book a phys­i­cal in Bos­ton, where I prac­tice pri­mary care) and po­ten­tially re­duc­ing vis­its to spe­cial­ists or emer­gency de­part­ments for prob­lems that pri­mary-care doc­tors could treat bet­ter. This is par­tic­u­larly im­por­tant in light of the pro­jected in­crease in vis­its by a grow­ing in­sured pop­u­la­tion un­der the Af­ford­able Care Act.

Then there is cost. Out­pa­tient care is the largest and fastest-grow­ing sec­tor of the U.S. health-care sys­tem, ac­count­ing for $436 bil­lion of “above ex­pected” spend­ing, by one es­ti­mate. The price tag for doc­tors’ vis­its also adds up for pa­tients who must take time off from work and shell out cash for trans­porta­tion and co-pay­ments. As my col­leagues and I re­cently ar­gued in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion, health sys­tem ad­min­is­tra­tors will need to think more about de­creas­ing the num­ber of un­nec­es­sary vis­its (and the as­so­ci­ated risk of un­needed, pos­si­bly harm­ful ad­di­tional tests and treat­ments) as they adopt new care mod­els in which in­sur­ers set cost tar­gets for health care for a given pop­u­la­tion of pa­tients.

To fig­ure out the “right” num­ber of vis­its, we can start with bet­ter in­for­ma­tion about what we al­ready do. Clin­i­cians need to ask one an­other how of­ten they re­quest that pa­tients come back, and why. We should ex­am­ine the topic more closely and in­ten­tion­ally, both through well-de­signed stud­ies and by scru­ti­niz­ing the messy, real-time data we can get from elec­tronic health records. An­other idea that could im­me­di­ately cut out some un­nec­es­sary ap­point­ments: Co­or­di­nat­ing vis­its be­tween pri­mary-care doc­tors and spe­cial­ists, and get­ting each to agree on who does what for shared pa­tients.

Most im­por­tant, we must be more nim­ble in how we connect. Many goals of Larry’s three­month fol­low-up visit may be ac­com­plished just as well, or even bet­ter, with­out get­ting him into my of­fice again so soon. If Larry is game, I can sign him up for a tele­mon­i­tor­ing ap­pli­ca­tion that al­lows me to see his blood pres­sure read­ings re­motely. I can sched­ule a vir­tual visit with him by tele­phone or video to check on his in­som­nia. I can or­der an au­to­mated e-mail sur­vey that will ar­rive in his in­box in four weeks to as­sess his knee pain. I can use an ed­u­ca­tional video or hand­out to ex­plain when to call me about a sus­pi­cious mole on his arm, and I can vir­tu­ally con­sult a der­ma­tol­o­gist to re­view a photo of it if nec­es­sary. I might ask him to sched­ule a fol­low-up in a year, to ex­am­ine his knee and maybe check some blood­work, know­ing that if I don’t hear from him, he can still stay on my radar with the help of a mas­ter list of pa­tients and their needs that I co-man­age with a pop­u­la­tion health co­or­di­na­tor onmy team.

Th­ese ap­proaches com­ple­ment and en­rich the tra­di­tional face-to-face vis­its that re­main the an­chors of the doc­tor-pa­tient re­la­tion­ship. The bar­rier to more wide­spread use is not tech­nol­ogy (which al­ready ex­ists and keeps get­ting bet­ter), but the mun­dane forces of in­er­tia and an­ti­quated fee-for-ser­vice pay­ment mod­els. Many in­sur­ers are still re­luc­tant to re­im­burse doc­tors for non­tra­di­tional vis­its and care co­or­di­na­tion, for in­stance, which have made them chal­leng­ing to adopt.

As we learn more about the im­pact of visit fre­quen­cies and get bet­ter at non­tra­di­tional vis­its, we can start to tai­lor care for in­di­vid­ual pa­tients with their unique med­i­cal prob­lems, per­son­al­i­ties, goals, and at­ti­tudes about health and health care. Rather than lament­ing the use­less­ness of the an­nual phys­i­cal (a popular tar­get th­ese days), we can ex­am­ine the tra­di­tional visit and strip it for parts: What as­pects are use­ful for a pa­tient like Larry? To­day, it might be man­ag­ing his knee pain from afar. Two years from now, if his prostate can­cer re­curs and metas­ta­sizes, it might be a frank dis­cus­sion — in per­son — of how he wants to spend his fi­nal months.

Tra­di­tion­ally, a doc­tor’s work has cen­tered on car­ing for the pa­tient sit­ting in the exam room. It fol­lows, then, that the best way to make sure I’m tak­ing care of the pa­tient in front of me is to get him back into my of­fice. But this sen­si­bil­ity is shift­ing as we re­al­ize that we must ex­pand our reach be­yond clinic walls and re­cal­i­brate how we connect with pa­tients. Let Larry read his novel in the com­fort of his living room. He and I will be in touch when, and how, it makes sense for his health.

Pa­tients tend to have more vis­its per year if they live in an area with more doc­tors. What the pa­tient prefers seems to have no sig­nif­i­cant as­so­ci­a­tion with visit rates.

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