Keywords: Followup, physician-patient communication, patient-physician communication, patient engagement, participatory medicine, medication errors, medication side effects, lab results.
Citation: Smith CW, Graedon J. Solving the followup dilemma. J Participat Med. 2012 Jul 4; 4:e14.
Published: July 4, 2012.
Competing Interests: Charles W. Smith is the founder of e-Doc America, a medical information company that addresses followup issues.
Participatory medicine cannot exist unless both provider and patient participate in an effective followup process. Unfortunately, in many practices, most of the care occurs primarily during office visits, without sufficient attention to what occurs between visits. In today’s pressure cooker environment, health professionals are forced to see patients faster and “more efficiently,” which leaves little time for a satisfying interaction and increases the likelihood of diagnostic and therapeutic errors. For example, the prescribing of medications is usually left until the end of an office visit, with little time for discussion of the expected outcomes and potential side effects.
Many office visits also include ordering lab or imaging studies. But how are these results typically communicated to the patient? How long does this usually take? How much explanation is included when the results are shared? Information from these studies often result in the need for important changes or adjustments but, in many cases, this is left until the next scheduled office visit. This practice can lead to frustrating, or even dangerous, delays in taking the needed action steps. Does a medication dosage need to be adjusted? Does a new medication need to be prescribed or discontinued? Is further testing needed?
Addressing any of these questions or issues depends upon the existence of effective followup communication between the doctor and the patient. But how often does this happen? What are the barriers and how can we overcome them? Patients don’t typically have an easy way to communicate with physicians. Phone trees have become common in almost all medical practices. They can be incredibly frustrating and complicated: “If this is an emergency call 911; Push 1 if you are a doctor, Push 2 if you want to make or cancel an appointment, Push 3 if you want to renew a prescription, Push 4 if you want to speak with Dr. J’s nurse,” etc. You may get a call back from a nurse within a few minutes or within a few hours, or from the doctor within a day or two. In some practices you may speak to a receptionist who may have the responsibility of telephone triage. If the receptionist thinks it is not very important, the patient may simply be scheduled for a followup appointment, which might be weeks later. If the receptionist thinks it is important, the patient might be scheduled within a day or two — or a message may be left with the nurse or the physician to call the patient back. This is all very subjective and depends, in part, upon the ability of the patient to communicate over the phone as well as on the skills of the triage person. There is no guarantee that the person who makes the decision about followup has been trained in the decision-making process.
And, importantly, how are we to teach the next generations of health care providers to create an effective followup system for their patients? Medical students and residents are not usually taught how to follow up with patients. It is not considered to be a formal component of the curriculum in most medical schools and may not be emphasized in any classes that teach communication skills. Even during residency training, the emphasis is usually on what occurs in the hospital or the office, rather than consideration of the patient and the provider as part of a continuum of care.
As a result, most physicians, physician assistants, and nurse practitioners learn how to do followup “on the fly.” Individual physicians frequently determine their own system for handling followup issues and, in many cases, there is no system at all. Some doctors make a good individual effort at getting lab results back to a patient. Patients in my practice (CS) are encouraged to follow up by email. I give every new patient a card with my contact information and they often write to give me a status report, request a refill, or ask for guidance about something. Even if the physician wants to follow up with a challenging patient to find out whether the treatment plan is working as expected or whether there were any complications, there is usually no reward for spending time on the phone. At the end of a very busy day, spending another hour or two on the telephone talking to patients about lab results, changing medications, discussing side effects, and responding to questions may seem like cruel and unusual punishment, especially if it is not reimbursed. There are some pilot programs developing that financially support this type of communication through the Patient Centered Medical Home Model and, hopefully, health care reform will eventually make this a routine part of practice but this will, at best, be several years from now.
Increasingly, institutions and hospitals are creating patient “portals” which may offer patients access to their lab or radiology results, but these are usually deployed at larger medical centers that have integrated electronic medical records systems and information technology staff resources available to them. Most solo or small group practices don’t yet have an electronic health record or the technology to provide online lab results. In a fascinating study by Casalino and colleagues, 5,000 patient records were reviewed in 23 different medical practices. There were 1,800 abnormal test results. Of these, 135 patients had never been told the results of their test; a 1 out of 14 rate. In some practices as many as one-fourth of abnormal test results were not communicated to patients. Jordan Schlain and his colleagues, recognizing the absence of systems and tools for effective followup, have founded a company called Health Loop and are entering a beta testing period in the fall of 2012. One of the authors, CS, founded a company, eDocAmerica.com, that responds to clients’ questions and followup issues for those who don’t have ready access to answers from their own providers.
What is the answer to all of this? What are we to do to help create more effective followup? We need to create systems that make followup a key component of the doctor-patient interaction. This followup system needs to be fast and efficient. A triage person in the doctor’s office could presumably review electronic data of this sort and let the doctor know quickly how things are going and whether any changes need to be made to the care plan. If weight loss or smoking cessation is essential, progress can be tracked over time and “attaboys” sent by email when a patient is improving. Among other benefits, a system like this would also allow better self care. For example, a person who takes an over-the-counter medication should be able to interact with a health professional to monitor possible side effects over time and arrange for testing, if appropriate. The same is true for blood glucose and blood pressures in diabetic and hypertensive patients. Tracking progress and tinkering with dose can be accomplished with great followup and far fewer office visits.
Solving the followup dilemma will be the dawn of a new age in medicine, one in which participatory medicine will be the norm, rather than the exception. To work, though, we need e-patients and e-docs working together with adequate support (financial, electronic, etc) to accomplish improved health outcomes.
- Casalino LP, Dunham D, Chin MH, Bielang R, Kistner EO, Karrison TG, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Archives of Internal Medicine, 2009 Jun 22;169(12):1123-9. ↩
Copyright: © 2012 Charles W. Smith and Joe Graedon. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.