Rachel Pearson – writing in an article on the vulnerable child syndrome in The New Yorker – claims that “scheduling an early follow-up is as important as doing a detailed exam and having a broad differential diagnosis” (“The Durable Feeling That a Child is Always at Risk,” June 10, 2019) At first blush that may sound like a rather radical observation. How many medical school instructors and house office mentors would begin a teaching session by telling their trainees that doing a complete exam and developing an inclusive list of diagnoses really wasn’t all that important?
MichaelJung/Thinkstock
But I completely agree with Dr. Pearson’s observation. An early follow-up is the answer when you don’t have clue what is causing the patient’s symptoms. Or you have too many clues, but don’t have the time to sort them out. Or you have a solid diagnosis, but you don’t have the time to adequately explain it to the patient. Or maybe you have the time, but you sense that the patient is uncomfortable with your opinion. Early follow-up also is the answer when the patient’s illness is one that can worsen before it begins to improve. You may have warned the patient of this phenomenon, but scheduling an early follow-up visit can allay their concerns.
Scheduling an early follow-up may allow you to sleep better when you are concerned about the patient’s condition. Particularly in the situation in which the patient isn’t quite sick enough to warrant the risks and expense of a hospitalization. If you and your office staff feel as though you are drowning in phone calls, a liberal use of timely follow-ups can dramatically reduce your phone interruptions. Particularly if you have earned a reputation of keeping your promises. If you are worried about being sued for malpractice, early follow-ups are far better protection than shotgun ordering of lab and imaging studies. And if you are the new guy or gal in town, early follow-ups are one of the most potent practice builders I know.
Dr. William G. Wilkoff
Does an early follow-up have to be an office visit? It depends on the situation. Most patients quickly realize when your scheduled follow-up visits aren’t necessary. You and your staff should be sensitive to the inconvenience and expense that an office visit may create. Would a phone call be just as effective? This is a particularly knotty question when it comes to newborns. On one hand, office visits can be very disruptive to sleep and nursing schedules of sleep-deprived parents. However, I have seen too many situations in which a physician’s office has relied too heavily on the observations of inexperienced parents when an eyeball in the office or by a visiting nurse would have headed off disaster.
And who should make the call? Never underestimate the power of your voice, even if it’s just a message on an answering machine or smartphone. It leaves an impression. “You know my doctor calls me to check to see how I am?” I think whenever possible, the provider should make the first call. If you fail to connect, your staff can make subsequent attempts.
Finally, you may ask what is an “early” follow-up? The better descriptor would be “timely.” You won’t find this answer in a text book. This is another case in which art trumps medicine in the practice of medicine. The “when” of a timely follow-up depends on the patient’s illness, what is its usual course from your experience. How anxious is the patient? How anxious are you? The answer is that scheduling the follow-up should err on the early side. Another can always be scheduled if the situation is still fluid. At worst, it will demonstrate you are a caring physician.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.