Letters from Maine

Closure … Now or Later?



One of our newer physicians asked recently if I had any suggestions for increasing his efficiency. It's getting closer to the day his income will be based solely on productivity, and the handwriting on the wall is coming into clearer focus.

Never being bashful about pontificating, I began by suggesting that he move efficiency up his priority list to the same level as quality care and professional enjoyment. I continued by urging him to arrive early enough to make his call-backs and see his first patient on time. Playing catch-up isn't fun, and it certainly isn't efficient.

Then I said, “I've noticed that you do a lot of double-dipping.” His puzzled expression prompted me to explain that every time a physician leaves and returns to the examination room to see the same patient he must invest valuable time reestablishing the dialogue and the continuity of the visit. These return trips can be as costly as a full office visit, but of course the insurance companies don't reimburse for them.

A typical example involves a visit for a sore throat at which one does a rapid strep test. Before leaving the room with swab in hand, the efficient physician will have already discussed Plan A (test is positive) and Plan B (test is negative) with the patient and will have written a prescription for his choice of antibiotic so that his assistant can finish the visit. The experienced physician will have anticipated all of the usual questions and touched on them before exiting the room.

My student-for-the-moment said, “I can see what you mean, and I've been trying to get it all done with one trip into the exam room when I can. But, communication is important to me and I want to take advantage of every opportunity to achieve closure.”

Contorting my face into what I hoped was my wisest expression, I said, “Ah, closure—now there's a troubling concept.” Most training programs are in large metropolitan areas and serve outpatient populations that are often transient and economically disadvantaged. This fact, combined with the reality that house officers rotate and graduate, makes the establishment of a medical home model extremely difficult. I know that some programs work very hard to create continuity, but still most outpatient encounters exist in a vacuum. The physician-in-training and the patient understandably assume that they may never see or hear from each other again. In this dynamic, the physician's concern about achieving closure may squeeze common sense out of the picture.

Lab work is ordered to make sure that all the stones have been turned. Treatments of dubious value may be recommended and anxiety-provoking options are discussed unnecessarily because the practitioner is worried that he only has one chance to cover all his bases.

Many patients arrive at the physician's office in the early stages of an illness that is likely to be self-limited. Even the best diagnostician can't predict exactly where the process will go. Attempts at achieving closure in this fluid state are fruitless, time consuming, and potentially dangerous.

I urged my young associate to take full advantage of the fact that we live in a stable community of reasonably educated people. I suggested that he tell the patients that he is sure what they don't have, but that it is too early to be sure exactly what they do have or to expect the illness to have run its course.

I said, “Remind them that you and your partners are truly available by phone around the clock. Promise that you will call them the next day to see how things are going and then keep your promise. If you detect in your follow-up call even a hint of uncertainty, don't hesitate to have the patient return for another visit. That kind of double-dipping can teach you something, and you'll get paid to boot.”

As I rose to see my first patient of the afternoon 5 minutes late, I reminded my young associate that, “In a well-organized and compassionate outpatient setting, closure will come naturally. You won't have to waste time forcing it before it's ready to happen.”

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