Editor’s Note: Emily Howard, MD, PhD, was most recently a Staff Pathologist at Children’s National Medical Center, Washington, DC. She is currently working on a book, The American Health Care Community: A Guidebook. She will discuss how to navigate the US healthcare system efficiently on Rabbi Address’ “Boomer Generation Radio” program August 20, and contributed this article as a supplement to that interview.
Most people have gone to a doctor’s office for an illness or injury. Many people assume that as long as they show up on time, the nurses and doctors will do all the work. A patient just needs to pay the bill and follow any prescriptions. Nobody ever explains how a doctor’s appointment is structured. And rarely does anyone provide advice on how to prepare for an appointment. In practice, the appointment will be far more productive, if the patient does their homework. The following describes a recent doctor’s appointment. It illustrates the importance of preparation, note taking, and follow-up after the appointment. These tips can be used for any type of clinic appointment, whether the patient has a broken bone, an infection, a chronic disease, a cancer or a stroke.
Dr. Emily Howard, MD, PhD. Photo © 2011 Greg Schaler. Used by permission.
Day Before Appointment: My mother was scheduled for an appointment with the Neurology Clinic two months after a stroke affected her speech, her right arm and her right leg. The evening before her appointment, I visited my mom to prepare for the clinic visit. On a notepad, I made a list of all of her current medications:
Name: Generic name and/or brand name
Dose: How much? How many mgs? Units? Or %?
Method of use: Pill taken by mouth? Under the tongue? Skin patch? Skin injection?
Frequency: Once a day? Once a month? As needed? How often does she need it?
Timing: Morning? Dinnertime? Bedtime?
Next we discussed what had changed since she left the hospital. In other words, what had changed since she had last seen the neurologists? We covered the following topics.
Changes since last visit
Physical Walking, balance, fear of falling, speech, swallowing, hand dexterity, palpitations, pain, weird sensations, weight change, appetite change
Sleep Difficulty falling asleep? Early awakening? daytime naps?
Memory Changes of short term memory? Long term memory?
Mood Depression? anxiety? frustration?
Thinking Changes in her ability to concentrate on conversations, follow written instructions, fill out forms, figure calculations?
Together we made a list of questions for the doctor.
Questions for the doctor
Was her recovery on schedule? Typical for her type of stroke?
What was the prognosis for recovery? Particularly the use of the right hand?
What were the results of the tests performed in the hospital?
Did they have any recommendations on her medications? Therapy?
Traveling to the clinic was going to be a tiring outing. I hoped she would have a good night of sleep. I helped her into her pajamas a little earlier than her usual bedtime. I made sure she took her pain medicines.
Finally, I researched where we were going. According to the paperwork, the clinic building did not have valet parking, which was unfortunate. There was a garage next door. The hospital’s website did not indicate whether the garage connected to the clinic building. On Google maps, the street view showed a long ramp from the street up to the main entrance. Getting mom safely into the clinic building looked like the most challenging part of the day.
Day of the Appointment: I arrived at my mom’s apartment more than 30 minutes before we planned to leave for the clinic. We had plenty of time to talk and relax before leaving. Mom had slept well, which was super. We checked the news. The entire state was under an extreme heat advisory.
Transportation: We left very early, particularly since I was unfamiliar with this building. Not knowing the location of the elevators, the clinic, the restrooms, the refreshments or any patient wheelchairs, we might need extra time to walk and rest. When we pulled into the garage entrance, there was a confusing sign on the sidewalk: “Patient Drop Off No Standing.” Not sure what was best, I helped mom out of the car and handed her the walker. The handicapped spots were full. I parked at the top of the first ramp in the garage. Hurrying to the entrance, my mother had walked up the ramp and was standing outside in the heat, looking warily at the revolving door. I pressed the button to open the side door for wheelchair access. We were safely in air conditioning.
In reception, check-in was quick. All of mom’s contact information was correctly on file. I took two business cards, one for mom and one for me. The questionnaires were easy, since we had already prepared for the visit. We had an extra long wait since we arrived early and the doctor’s clinic was behind schedule. Mom said she hoped the doctors would come soon, the chairs were uncomfortable. Realizing she was getting stiff, we stood up, walked back and forth in the small room, and stretched our arms over our heads.
The appointment: We were escorted into an examining room with a small sign that said “Resident Clinic.” Residents are real doctors who have graduated from medical school. A resident is a physician in training, with one to four years of experience. Many residents, including Neurology residents, have already finished a yearlong internship. They have a license to practice medicine in the state. Residents spend long hours in hospitals and clinics talking to patients, examining patients, and treating patients. They study the latest advances in their field. There are several advantages of an appointment with residents. Residents often spend more time with a patient than an attending physician would. There are now two physicians checking all the records, making sure nothing is missed.
Every clinic appointment has the same structure: history, physical exam and plan of action. When a patient meets a doctor for the first time, it is possible that the doctor has not read the patient’s chart beforehand. Sometimes, the doctor will just skim a few highlights – name, gender, age, diagnosis – before meeting the patient. This is true for many residents and many attending physicians. In the old days, a doctor could face a patient while he thumbed through a patient’s paper chart. In today’s world of electronic records, the doctor may spend the first five to ten minutes with their back to the patient, as they search a computer for patient information. This is a largely unavoidable consequence of computer records.
First, we discussed medications. There was a complete discrepancy between the two medications which the clinic had on file and the three medications my mother was actually taking. They approved all the new medications which were prescribed by her primary care doctor. They agreed that one drug they had started was no longer needed. We discussed how the second drug may have been dropped as mom was transferred from the hospital to an inpatient rehabilitation facility to home. They strongly recommended that she resume this medication. We asked if this drug had any side effects or risks? Would it interact with her other medications? Fortunately, the answers were “no.” Even better, it was an inexpensive, over-the-counter drug which did not need a prescription.
Next we discussed her history and test results. Since mom had prepared for the meeting, she was able to articulate in her own words what had happened. This allowed the physician to respond to her specific concerns. My mother particularly wanted to know why they had run so many tests in the hospital. Did they learn anything? I asked some very pointed questions about blood work, heart tests and radiology studies. The resident gave very clear, accurate answers.
In addition, the resident taught us about strokes and common symptoms. For example, he clearly explained that depression is very, very common in stroke patients. In today’s thinking, depression is part of the “stroke syndrome,” just like weakness or tingling sensations. It is treated like any other stroke symptom with work, therapy, medication, socialization, and patience.
The resident performed a focused physical exam, concentrating on my mother’s face and limbs. I was impressed with how much improvement my mother had made in two months. I jotted down notes on all of his comments and findings.
The resident stepped outside to debrief his supervising attending physician. While they were gone, I asked my mother if she had any questions. I assumed she didn’t follow the whole conversation. My mom is hard of hearing and misses words and phrases. At times, we had used medical jargon which she might not understand. Finally, clinic appointments can be overwhelming. Most people only absorb one or two points during a clinic appointment.
When the two physicians returned, the attending did most of the talking. He clarified a few points with mom. He did a few more tests of her physical strength. He provided additional education on strokes in general, and mom’s situation in particular. Mom asked him about the tingling sensations and pain in her right hand. Would she just have to live with it? I asked if desensitization might help. He thought it might help. He was optimistic about her progress so far, but could not predict how much her right hand would improve. He encouraged her to continue therapy. Most improvement occurs within the first six months. He would forward his formal recommendations to mom’s primary care doctor.
After the appointment: Departing from the clinic, I insisted that mom rest in the air conditioned foyer while I drove the car around the block. It was too hot and too far for her to walk to the car. Besides, there were too many confused drivers in the parking lot, so it was not safe for her. As I walked out, I made sure she saw me hit the button to open the automatic door. When she saw my car, she started towards the street. I parked illegally in front of the building with the flashers on. The ramp was too steep for her to walk down. She felt she was losing control of the walker and her balance. I helped to steady the walker and helped her into the car.
During the drive home, I asked mom if it would be okay if I informed all of her children about the clinic appointment. As a doctor, I know she has a right to her privacy. As her daughter, I knew all of her children wanted to know what was said. She said it would be fine to update the kids. Later, I organized the paperwork. Receipts for copays and parking went into a file of annual medical expenses. The business card and discharge instructions were filed in mom’s Health folder. I typed up my notes: Medications, Physical Exam, Test Results, Patient Education, and Recommendations. I emailed the notes to my sibling and printed a copy for my mom.
The next day we ate lunch together. I brought her new medication and my notes. She was shocked to read three typed pages. She acknowledged that it was accurate, but she didn’t realize how much information was discussed. She only remembered the long wait and one piece of advice. We tried desensitization, a technique to help retrain injured nerves to respond more normally to sensations. I asked her if it would be okay if I wrote about our clinic visit for a public website. I would show her the text first. She agreed, hoping it would be useful for other patients and their families. She saved her pie for dinner.
Tips for a Productive Clinic Visit
1) Before the Appointment
Write down medications (prescription drugs, vitamins, supplements, herbs).
Write down changes since last visit (improvements? new problems?).
Write down questions.
Get directions and information on wheelchair accessibility, if needed.
Try to get a good night’s rest before the appointment.
Plan for extra time if the patient has limited mobility or the clinic is new to you.
2) During the Appointment
If waiting a long time, stand, walk or stretch to prevent stiffness.
Tell the clinician why you came to the clinic or what has changed since last the visit.
Ask questions or hand your list of questions to the physician.
If possible, have a companion write down notes.
3) After the Appointment
Follow up with any new prescriptions for medicine, therapy or exercise.
Make sure any new clinic appointments are scheduled and added to a datebook.
File receipts and paperwork where you can find them.
Provide the patient with a legible copy of notes from the appointment.
Ask the patient with whom they wish to share their health information.