A 68-year-old man comes to the office for follow-up of type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient's diabetes and hypertension are inadequately controlled, requiring multiple modifications to his medication regimen. Extended counseling is provided regarding today's changes and the overall long-term care plan. The patient's next appointment is in a month for a routine health maintenance examination. As the physician is getting ready to leave the room at the end of the scheduled appointment time, the patient states, "Doc, my urinary stream has been slow for the past 6 months, and I've been waking up twice overnight to use the bathroom. Can we talk about this today?" Which of the following is the most appropriate response by the physician?
Outpatient office schedules are typically arranged in regular time intervals (eg, 15-20 min) corresponding to the time needed for an average patient visit. Typically, the time interval allows the physician to evaluate one primary objective, either evaluating a new problem or following up on well-known chronic conditions.
Sometimes, patients raise unexpected concerns that require additional time beyond what is allotted for their appointments; evaluation of this patient's urinary symptoms would extend his appointment, which has already been spent addressing his chronic conditions. Extending the appointment without having adequate time would make subsequent patient visits late and can lead to rushed and incomplete assessments (for this and/or subsequent patients), potentially resulting in misdiagnosis, mismanagement, or poor patient-physician communication (Choice A).
Therefore, physicians should generally direct the patient with an unexpected concern to schedule another appointment to address it; doing so allows the physician to fully address the concern without causing delays in subsequent appointments. However, when the unexpected concern is urgent or likely serious (eg, shortness of breath), it should be addressed immediately, and subsequent patients should be informed of the delay.
(Choice B) This patient has a health maintenance examination (ie, routine physical) in a month. Evaluating new concerns in the time allotted for preventive care is usually not recommended because it may impact the quality of care for preventive services. Instead, a dedicated appointment should be scheduled.
(Choice C) Querying the patient at the beginning of the visit regarding any unexpected concerns can help the physician prioritize the discussion. However, the patient should not be dismissed at the end of the appointment without making arrangements to address his concerns properly.
Educational objective:
When a patient raises an unexpected concern during an office appointment and adequate time has not been allotted to evaluate it, the physician should generally ask the patient to schedule an appointment at a later date to address that concern.