How Often Do You Need To See Me?

You may wonder how the decision is made to making the next appointment for a patient. Is there a book, or now a website with guidelines, that guide physicians on when to make the patients’ next appointments? No, there is not. It is not something we learn in medical school but is something that is part of the art of medicine. Some patients really need to be seen in a few days or a few weeks such as the patient with a urinary tract infection where the urine has to be checked to be sure the infection has cleared even after the symptoms have subsided. Then there is the asymptomatic patient who is on no medications and probably needs to be seen only for a screening annual or even a biannual exam. Then there is the majority that fall somewhere in the middle of those two extremes.

What if you had diabetes, coronary disease, hypertension, high cholesterol, and sleep apnea, but no symptoms to indicate any acute problems? You’d probably see your primary doctor fairly routinely (mostly for management of diabetes) and maybe your cardiologist every six months or so.

Here’s the big question: When you’re coasting along pretty well with no actively changing symptoms but with chronic medical problems, how often do you need to see your doctors? Let’s take the example above: with those particular problems, should you see your cardiologist yearly, biannually, quarterly, monthly, or what? In the non-hypothetical world a patient’s follow-up is likely to be dictated by the doctor and set at the end of each appointment. “Okay, Mrs. X, it looks like you’re doing well. Let’s plan to see you again in 6 months.”

How does the doctor know when to see you next? There are a few ground rules to take into consideration. The pharmaceutical industry doesn’t allow us to write prescriptions with refills that extend past 12 months, and many clinics have a policy of not providing new prescriptions after the 12-month mark unless they’ve at least laid eyes on the patient (apparently to make sure the patient is indeed alive), and so most people with chronic problems will likely have to be seen at least once a year. It is amazing how many men using erectile dysfunction drugs will keep that annual appointment in order to obtain a refill of their medications! The other ground rule is common sense.

So, routine follow-up will most likely fall somewhere between “less often than weekly” and “at least once yearly or more frequently.” But within those limits, as a doctor I’m pretty much free to choose whatever I like.

I don’t know how other doctors do it, but I like to burden healthy patients with as few doctor visits as possible, so I mostly try to set my return appointments for a year. This works well for most people, but there are clearly exceptions. I see a lot of men with prostate cancer. Many of them are on medications to decrease the testosterone level and receive injections every 3-6 months. If it is possible, I try to convert these men to injections that can be given once a year. Most of the men with prostate cancer like the idea of getting a yearly injection and coming in every six months for a blood test, a PSA level. However, there are some men that want that more often and I allow them to make appointments to be seen more frequently. This, again, is where the art of medicine is used to guide how often a patient returns for an appointment.

There are patients with certain conditions like bladder cancer that should have a cystoscopy or look into their bladder with a lighted tube every 3 months. This guideline is written in all urologic textbooks and is good medicine to see these patients on a frequent basis.

I commonly ask certain patients to see me more frequently. Any patient who is on medications that is having side effects is asked to come back more frequently until I can get the dosage or the medication straightened out that provides them with the beneficial effect and with manageable side effects.

Bottom Line: How often should you be seeing your doctor? I have no clue. Between you and your doctor you’ll come up with some type of balance that works. Just understand that none of this is written in stone….i.e., a kidney stone!

This blog was inspired and modified from a blog by Dr. Eric Van de Graaf, which appeared in Patient on January 17, 2011.

To Screen Or Not Screen-That’s the Question, What’s the Answer?

Annual cancer tests are becoming a thing of the past. New guidelines for cervical cancer screening have experts at odds over some things, but they are united in the view that the common practice of getting a Pap test for cervical cancer every year is too often and probably doing more harm than good.
A Pap smear once every three years is the best way to detect cervical cancer. Recently it was recommended against prostate cancer screening with PSA tests, which many men get every year.
Two years ago, it said mammograms to check for breast cancer are only needed every other year starting at age 50, although the American Cancer Society still advises annual tests starting at age 40. A large study found more false alarms for women getting mammograms every year instead of every other year.
It’s a fact that the more tests that you do, the more likely you are to be faced with a false-positive test that leads to unnecessary biopsies and possible harm. We see an emerging consensus that annual Pap tests are not required for us to see the benefits that we have seen from screening.
Those benefits are substantial. Cervical cancer has declined dramatically in the United States, from nearly 15 cases for every 100,000 women in 1975 to nearly 7 per 100,000 in 2008. About 12,200 new cases and 4,210 deaths from the disease occurred last year, most of them in women who have never been screened or not in the past five years.
The cancer society and other groups say using Pap smears together with tests for HPV, the virus that causes cervical cancer, could improve screening. Instead, reaching women who are not being adequately screened now probably could save more lives.
Bottom Line: Patients need to be informed about the benefits vs. the risks of screening. By being knowledgeable about the screening tests and having a discussion with your doctor is the best way to come to a decision about screening in your situation.

Choosing a Family Physician-One of the Most Important Decisions You Will Ever Make

People are not just an amalgam of their body parts.  Men are not composed of large prostate glands, sclerosed coronary arteries, and rusty libidos, although sometimes it feels that way. We come in complex packets of various sizes, shapes and colors, and attached to families, jobs, communities and cultures. Just like everyone else, we need primary care physicians as our allies and advocates in staying healthy, and getting the best possible health care.

Your primary care doctor — either a family physician or a general internist — should be the captain of your healthcare ship. Primary care physicians not only can handle the majority of illnesses that you may experience, but they can work with you to keep you healthy. They can help you decide what makes sense in a world where numerous entities are hawking remedies for life’s ills, from pills to diets to operations. The primary care doctor can help you select from this bewildering array of options, and then be your advocate when you do need specialized care beyond his or her repertoire.

So what should the average man do to get the most out of the health care system? The following are my suggestions distilled from over 30 years of being a doctor:

1) Select a primary care doctor.

The time to choose a primary care doctor is before you need one. Ask your friends whom they go to. Check with local clinics and hospitals and see which primary care doctors work near your home or your job. Check and see if your wife or significant other or child has a family doctor who would take you into his or her practice.

Then go and interview the doctor, find out whether their philosophy of medical care jibes with yours. Discuss your approach to health and illness, and see whether they will support you in your quest. Check their training and references to make sure that they have the training and skill that you need. Make sure that they are board certified in their respective specialty. There are advantages to seeing the same doctor as other members of your family. But probably the personal chemistry between you and your doctor is the most important factor in this choice.

2) Visit your primary care physician before you’re sick.

Almost all doctors have health maintenance protocols that are aimed at men your age, and consist of a schedule of regular visits and diagnostic tests designed to catch important problems as early as possible. Make sure your health maintenance protocol is up to date. For most patients, this will involve a visit every year or two, depending on your age, back­ground, and the medical problems you may have accumulated along the way.

3) Negotiate a plan with your doctor.

Medicine is a team sport, you and your doctor share the quarterback duties. Your doctor has a set of guidelines that are based on medical science and the evidence it produces. You have a set of values and preferences that will determine which of those guidelines make sense for you. Work with your doctor to come up with an approach that makes sense for you.

4) When you do need specialty care, work through your primary care physician.

Specialists will give you their honest opinion about the best therapy for your problem, but your primary care physician will help you put it into context. Primary care doctors can also help to coordinate care among multiple providers, watch out for interactions among drugs or therapies, and will still be available to care for you after a more specific problem is resolved.

Bottom Line: It is almost impossible these days to sort out the best approach to health care. Your primary care physician is the strong­est ally in choosing a path that makes sense for you.  The few minutes you take to make this very important selection may just be the most important decision of your life.