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Im 9 months into my first job as a PA and working in family practice.  Just two providers in our office, myself and the MD.  The MD has set certain rules and guidelines for the practice, and one is on return visits.  Any patient that has a prescribed medication needs to be seen every 6 months at minimum for management of care.  Only acceptation is with OCP.  I have denied more refills lately for because they are over the 6 month timeline.  Many patients are complaining and aggravated when I see them because they have been on these meds for many years and have been stable (example, levothyroxine).  We also continue to see all diabetics and "pre-diabetics" every 3 months with labs.  Many of our "diabetics" have never had an A1c over 6.2 and are on minimal metformin doses.  

 

Also, on the newest guidelines for cervical screenings with pap's.  We still do every year even though guidelines are saying otherwise. 

 

i understand that these are the rules of this practice.  Im curious as to what other family practices do?  

 

Thanks....

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Your doc may be overdoing it a little by my standards.

 

I see stable diabetics every 6 months for HgbA1C, not three.  A lot can change with diabetics, and I think most need that structure.  Once a year, they get microalbumin and foot exam.  More often if needed.

 

New diabetics get a shorter leash and more frequent follow ups until stable.  All my new diabetics get sent to our hospital diabetes class.

 

stable hypothyroid gets checked once a year.

 

I almost never refuse refills.  When a patent leaves my office, they get their next 6 month appointment right then.  If they cancel or reschedule, I will give an additional 30 days if they make a new appointment.  I never want my people to run out of meds.  It does me no good to see a diabetic for HgbA1C if they have been out of meds.

 

I follow the guidelines for PAP, mammo, physical exams, PSA, etc.

 

By the way, the CP has his guidelines for chonic disease management and I have mine.  We practice very similar, but he never forces his opinion on me.

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I won't refill unless seen once per year: They get a free annual preventative medicine exam if they have any insurance we take, so no one has any excuse.  No Schedule 2's without visit every 3 months, period, and most patients are on 1-2 month cycles for those.

 

I DO NOT like paps more often than recommended.  I do not push DREs.  Invasive, painful procedures should be saved for things that can actually save lives and suffering, like colonoscopies (although I am fine with serial yearly fecal occult blood testing...)  I do not want to drive patients away from prevention/care of DM II, HTN, etc. because they're afraid I'm going to say "bend over and assume the position".  Those are part of the reason we are getting less aggressive with testing (that, and Gardasil...).

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I used to go by disease and age - hypothyroidism, annual labs and PHE as recommended in national guidelines; new diabetics quarterly until stable, then q6months (skin checks on the even appointments); HTN - anually if young and q 6 months if >65, sometimes more often if older and on their own - with labs appropriate for their meds and age/comorbidities; lipids -  if stable, q 6 months for CK and AST/ALT, especially on high doses post MI; Paps, mammography, colonoscopies, DRE/PSA - by current provincial guidelines.  The province has  "Breast Check", "Cervix Check" and "Colon Check" programs that actually let you know in the mail when you hit certain ages that you should get x,y,or z checked via the mail, cc'd to your primary care provider.  Mind you, we have about as many people in Manitoba as y'all have packed into one burrough of NYC, so it's workable.

 

Of course, old people on a bazillion meds with more problems would be followed up based on what I saw was happening - including  by house call for a number of them.  The other issue here is that this is in a system where people don't pay out of pocket (except some of the Old Order Mennonites that lived in my cachement area - they'd pay cash, as many didn't register for provincial health care due to religious reasons).

 

I think in the end, state/federal/consensus/common sense guidelines should apply...and also what the insurance pays for (heaven forbid).

 

SK

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Surprised of patient upset if this has always been the practice policy.  I think this is actually better patient care to see them every six months.  You can catch things quicker.  I understand the well controlled patients may find is wasteful, but wait until something with them goes wrong and you catch is 6 months sooner.  I'm working outpatient psych and we require 3 month check ups.  I know my patients better because of it and I know when something is off quicker then if I only saw them once a year.  

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I inherited the whole panel of a retiring doc and his word was gospel....

 

Makes my life painful trying to convince a diabetic on suboptimal meds with a once a year A1c of EIGHT that he has to be seen and is NOT controlled.

 

So, I agree with the 3-6 month protocols and setting standards. Part of our job is TRAINING the patient to understand their needs and participate. They have responsibilities too.

 

Our office will not fill if not seen in a year or rx 10-14 days to get them in. Then the training begins.

 

Controlled meds are 3-6 months with contracts and urine drug testing even for ADD meds in adults.

 

HTN six months - one visit is their complete physical and one is mid year appt. Diabetes is every 3-6 months depending on complications and control. Thyroid 6-12 months depending on stability.

 

We follow AAFP on paps, no more rectal exams on men and discussion of PSA and all that controversy. Way more complicated than 10 yrs ago.....

 

Logic doesn't always win out the ones who thought the old doc was king but I stand my ground and hand out lots of guidelines and smile.

 

The battle of the colonoscopy and hormone replacement and ambien and benzos occupy the majority of my time these days......

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I see no problem with 6 month follow up

 

12 months is a LONG time

 

I see every 3 months in a Geri house call practice 

 

BUT it really depends on your patient......   hard fast rules commonly don't work for everyone....

 

 

Now let's talk about the business of medicine.   Office based intellectual medicine is so highly devalued by the system it is next to impossible to make a living at it.  The only possible way to succeed is to see a lot of patients - ie 25 a day.  And be billing level 4 visits.   With this in mind you need to see a lot of stable complex patients to keep the doors open and the lights one and the employees paid.  It is just to hard to do extended complex visits once a year to try to play "catch up" with someone's medical conditions, and really not be paid for it.   So the answer is that everyone gets seen every six months.  

 

 

Outside of the business side I actually like it as it keeps a good working relationship and if a patient is not interested in their health enough to come in every six months, well they can find another PCP.  It fosters an ongoing knowledge of the patient and their lives that is invaluable when the hard decisions come up....

 

Just go with it.... learn the hows and whys, remember the weak points so if you get the option you can do it your own way, but in general it sounds like a good set up.

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I am in agreement with the 3-6 month F/U, sooner as needed. Even if a person is stable when they leave, letting them go an entire year is not good medicine in my opinion.

 

If I could make my schedule II patients come in every month for their medications I would, but I know we would have people leave for other practices, and the RVUs are too good to let go.

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