Why Follow Up Appointments are Important

In the past week there were at least three situations where patients were upset with us and all three were versions of the same issue, wanting treatment over the phone in lieu of an appointment.  These misunderstandings make me realized that we had not done a good job in explaining why we wanted to see the patient in the first place. I will try to correct that here.

When a patient comes to PRHC, our goal is simple.  We want them to have a better quality of life by at least 75%, when it comes to headaches. The better quality of life is measured by fewer headaches, better treatment for the headaches when they come and no adverse reactions from the treatments. I’m going to discuss two particular areas that seem to be recurrent points of confusion.

Situation 1: Where the patient does not show up for the scheduled follow appointment, then wants refills on medications. 

The first time we see a patient we spend 60-120 minutes with them, depending on the complexity of the problem. It takes this much time to do a careful review of the history, do the exam and make a definitive diagnosis bases on the diagnostic criteria of the International Headache Society. We want to make sure that we don’t miss anything that could be contributing to the headaches. We also want to do a good job educating the patient and coming up with a tailor-made treatment plan for them.

Headache work is different from other medical disorders because it involves the most complex organ in the body, the brain and structures of the head. The best treatments in the world only work for 65% of patients. Therefore headache treatment involves a period of trial and error before we can reach our goal of 75% better quality of life. There is a spectrum of success, from getting it perfect from the first visit, to an on-going battle over months, sometimes years, to keep the headaches in control. For the average patient it takes about three visits to get it right.

The second visit is planned in about 3-5 weeks to monitor our success, make adjustments and to check the safety of the treatments.  Often patients just do not show up for their second appointment. As I’ve interviewed them, I hear them giving three main reasons for not showing up.

The first reason is that we failed to meet the patient’s expectations. Those expectations are that we would find one simple cause of the headaches, such as an allergy to something, a jaw out of alignment and etc.  In real, honest, headache work, there is virtually never a simple cause and solution like this. I wish, more than anyone, there were.

The second reason is that our first treatment didn’t work well.  Time after time I’ve heard patients say, “I knew it wouldn’t work. Nothing is going to work for me.”  That is absolutely not true. The vast majority of our patients, if they are willing to do their share of the work, are able to reach that 75% improvement goal.  Only a few patients fail to see improvement even though they are trying their best.

The last reason that patients don’t show up is that they are doing better and simply want prescriptions called in from that point forward.  It is vital that we see the patient back, at least once, even if they are doing better. The reason is, some patients stop at 25% improvement and we can make changes on that first follow up appointment to realize the 75% goal.  The other reason is for safety. Before we turn a patient loose, who has success, we must make sure that there are no side effects and no risks of future harm by the treatments.  Many of the malpractice cases in the U.S., where patients are harm, happened because the provider was prescribing treatments without face to face follow up with the patient for safety.  Once our patients are doing well, we can see them annually or turn them back over to their PCP. Some medications require monitoring at  least once every six months. It is the common standard of care to do this follow up. To not do so, would be reckless.

I want to mention here the problem of just not showing up for a visit is being insensitive to the patients who want desperately to get in and have to wait for an appointment. If you are scheduled for an appointment, and then just don’t show up, you have wasted an appointment that could have been used for them.

Situation 2: Where a patient has seen Michael Jones or Jim Moren in their previous practices (now being over a year ago) and want us to call in prescriptions for them. 

When we created the Pacific Rim Headache Center, it was totally new entity. None of our patients’ charts followed us as they belong to our previous practices. When requests come in for refills, we have no chart records and to prescribe these medications would be to do so blindly. This is way outside the standard of good medical care. If we see you face to face, put you in our system, including your medication list, you past medical history, allergies and how things are working for you, only then can we deliver good care to you.

I think I can understand why patients don’t want to follow up. All of us are busy. Many patients have to pay a $10 to $30 co-pay. Some patients have to pay the full amount of the visit until their deductible is met.  However, we would never schedule an appointment in frivolous way.  It is a dream of ours that our patients reach at least that 75% improvement point and then we don’t have to see them again.