See You Next Year

How often do you see your doctor?  Once a year?  Every 6 months?  Never?  Most of you are pretty healthy and only show up for screening physical exams or aches and pains.  Some of you may have more health problems and come more frequently.

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 my 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?  As a patient you probably don’t put much thought to this and obediently comply with whatever scheduling recommendation you’re given.  But ask yourself next time you see your doctor “how does he/she know when to have me come back?”  Is there some textbook somewhere, some set of guidelines that tells us how often patients with particular medical problems need routine follow-up?

The answer: Nope.

There are a few ground rules to take into consideration.  The pharmacy overlords don’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.  The other ground rule is common sense.  If, as your doctor, I really wanted to gauge you and your insurance company for money I’d have you come back every week or every day.  That is obviously a silly care plan and you’d reject it immediately.

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-ish 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.  Some patients, most commonly ones I’ve inherited from other doctors, are so used to being seen biannually (or is it semiannually, or biennially?—I can never keep those straight) that I can’t even talk them into going an entire 12 months between visits: “Oh no, that’s just too long!  What if something happens?”  Others give me the exactly opposite reaction: “Really?  A year?  That’s great!  I must be getting better!” and they cheer as if I’m graduating them from a 12-step program.  As I wrap up my visit and suggest a return date there’s no way for me to predict who will be grateful and who will be fearful with a longer span between visits.

The most interesting misunderstanding I had in this regard was with a relatively healthy older patient whom I asked to return in 6 months.  When his appointment rolled around again he was accompanied by several family members who were all visibly nervous.  Once I dug into things a little I discovered that he had become confused by my follow-up recommendation and was led to believe that I was giving him only 6 months to live.  The poor guy had spent the last half year believing he was destined to soon transition to that great medical clinic in the sky, and the rest of his family had come along to hear my next pronouncement of his estimated longevity.

I commonly ask certain patients to see me more frequently.  Anyone in whom I make medication changes I’ll likely have back sooner to assess effect or any problems.  Patients with congestive heart failure (CHF) will generally come in every 6 months or sooner even if they feel great.  I recall sitting in a conference of fellow cardiologists when the issue of CHF patients and their follow-up was raised.  One attendee remarked that it was “common knowledge” that all patients with CHF should go no longer than 3 months between visits.  I don’t know exactly where that common knowledge came from—maybe there is a textbook out there and I just don’t know about it.

Symptom-free patients with chronic heart disease frequently give me a quizzical look when I walk into the exam room.  I’ll ask how they’re feeling.  “Great.  I don’t even know why I’m here.”  I try to tease out a little more—shortness of breath? chest pain? swelling in the legs?—but, no, they really do feel great and wonder why I keep asking them to come in even though they feel so good that they sometimes forgot they have heart problems.  I try to explain that I need to check on things they can’t feel, like blood pressure, heart rate, blood creatinine and cholesterol, etc.  They nod and give me the whatever look.  I offer them another chance to dig up any questions they have and I’m met with utter silence (cue the sound of a clock ticking, or coyotes howling softly in the distance).  So, I wish them well, remind them they can come in anytime if things change, and set up another visit in 12 months.  “Sure.  Whatever.”

Sadly, I’ve known doctors who use the unquestioning obedience of some patients to their own financial advantage.  Does a stable patient really need to come in for visits every two months or need a stress test and echocardiogram every six?  I don’t think so, but I guess I’m not the one trying to make payments on a new Porsche (is that still the cliché doctor’s car?).  I’ve taken on a few of those patients as well and they tend to be surprised and relieved to learn that I don’t think they need that kind of frequent testing or clinic visits.

Another area where I don’t have a clear answer relates to the need for a cardiologist at all.  A patient will come to me for help controlling blood pressure, or to treat benign palpitations, or for a pre-operative assessment.  Once I’ve made the medication changes that are needed and answered all the questions, does the patient need to keep coming back to see me?  I don’t know but probably not.  Primary doctors (family practitioners and internists) are fully capable of treating hypertension, palpitations, and the like.  In most cases I tell the patient they don’t necessarily need to see a cardiologist on a regular basis but that I’d be happy to see them at any point in the future.  Many say they’d feel better with scheduled follow-up and for them I’m happy to oblige.

So, in summary: 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.  Or in some textbook.

Unless it really is and I just don’t know about it.