"Oh, one more thing!" The phrase every medical provider dreads.

[Aristus]

Not just because we're so strapped for time every single day in clinic, but often because of the disparity of the conditions the patient wants you to look at.

The complaint on the schedule: "Uncontrollable bleeding." We spend the entire visit addressing the issue.

The 'oh, one more thing' issue: "Can you take a look at my toenail? I think it's ingrown..."

[Ferrets are Cool]

1. So, I am paying for an allotted time slot, NOT

to get assistance for my problems? I am not one of "these people" you are speaking about, but WHEN I go to a Dr., I expect to be given ALL the time needed to help me with my problem(s). I don't go there because I have nothing better to do. Maybe there are those who do. I can't speak for them.

[Iwasthere]

3. Many clinics are now giving their doctors 10 minutes per patient

About enough time to write some prescriptions. Big Pharma owns most docs. Socs risk their jobs if they question pharmaceuticals. How did we live before? Without the hand full of daily pills? It's often the pill that kill! I am 63, I take NONE!!

[Aristus]

6. I take exception to the assertion that Big Pharma owns most medical providers.

Most of us are not pill-pushers. Most of us would like to treat as conservatively as possible, I know I do. My goal is as few medications as possible at the lowest effective dose.

I'm a Physician Assistant, not an MD; I confess, my productivity requirements are lower than those of my MD colleagues where I work. The MD's are frequently called upon to see as many as thirty patients a day. For me, a frantically-busy day is twenty-four patients.

If an MD is really strapped for time, writing a quick prescription is sometimes the only way to stay on schedule. I don't agree with that kind of medical practice, and avoid it as often as possible. But I can understand the temptation to fall into the habit.

[getagrip_already]

7. maybe not, but lets not forget

where the opiod crisis started. It was with a prescription pad, not some back alley or hand to hand sale.

[Aristus]

8. That, I agree with.

There's no doubt there are some unscrupulous medical providers out there. And there's no doubt that those of us who don't engage in such dangerous and unethical practices come in for a torrent of abuse from Percocet addicts.

I've been accused by people right here on DU of 'enjoying' the suffering of my patients because I refuse to prescribe opioids for chronic pain. (The reason I don't is because they are no longer considered standard of care; precisely because of the dangers of abuse and overdose, not to mention tolerance.)

No provider I know will write an opioid prescription just to get a drug-seeker out of our office. But I know they're out there.

[Hoyt]

11. Nowadays, most docs are careful with prescriptions. The health plan gets on their ass,

regulators do as well, and patients demand a lot of unnecessary drugs too.

Except for pill mills, with main purpose of making money off pain pills, most docs don’t prescribe pain pills unless patients request them and there is an indication. Clearly, some docs took the easy way out in past, like prescribing a months worth when a few days were indicated or providing perfunctory refills.

But, times have changed. In fact, a lot of pain patients complain about it being difficult to get meds now.

[mr_lebowski]

26. Not sure that's 100% true ... I'd bet $$$ a shit-ton of OC's were diverted before even

reaching the pharmacies, during the distribution chain.

The 60 Minutes special with the fired DEA leader about 1 year ago hinted at that idea pretty strongly.

Also, the sheer number of OC 80 mg pills my dealer used to have at one time (like 1000 of them) suggested to me there's no way he's getting them from some doctor. That's 16,000 x 5mg Percocets, if you're counting

Then there's the fact that the CIA and Military took over Afghanistan from the Taliban as soon as they banned poppy farming, and have continued to occupy it ever since ...

[Aristus]

4. Our schedules are formatted in fifteen-minute slots. But there is some fluidity in there, as well.

Whether it's a medication refill, or a monitoring visit for a patient with multiple co-morbidities like diabetes, high blood pressure, high cholesterol, congestive heart failure, COPD, chronic kidney disease, etc., everyone gets the same fifteen minute slot.

What I do is get the med refills and lab result reviews knocked out as quickly as possible, to free up time for the other type of patients. I then give the complex patients as much time as they need. My main source of frustration is patients who complain about the long wait to get into the exam room, and then hit me with "Oh, one more thing" when their chief complaint is dealt with. I usually tell them that the reason you had to wait so long for your appointment is because every patient ahead of you had 'just one more thing.'

On really busy days, I try to triage the patient's secondary complaint to see if it's something that can wait for another visit.

Every patient is different. Some people wait until they're on their death bed to go to the clinic. Others dash off to the clinic the minute they get a little sniffle.

[Ohiogal]

9. My crappy insurance

calls for a $60 co-pay any time I want to see my primary care doctor and a $120 co-pay for a specialist.

If I went to the doctor for every little ache, pain, or sniffle, I'd go broke!

[Aristus]

10. I'd give anything for us to have a single-payer health insurance system like every other

developed nation in the world.

There's no need for this kind of thing to happen.

[Ohiogal]

13. You and me, both, Aristus.

[hunter]

16. Ain't that the truth.

I don't think the U.S.A. has ever been a "developed" nation.

We are divided into those who think we are, and those who know, often by terrifying experience, that we are not.

Some sort of national health care plan would cost our nation less and serve everyone. And it's not an impossible dream, it's a hard fact, as demonstrated by many truly developed nations.

Even U.S. Americans who think they have good or excellent health insurance can suffer absurdly expensive, grotesquely inappropriate, and sometimes deadly medical care.

There's plenty of dead celebrities and people of wealth who would have been better off had they disguised their identities and gone to a free clinic to treat their medical problems.

[RandiFan1290]

15. That is how they like to treat poor people

My sister is rushed and treated like garbage by these doctors that couldn't give a shit less about her.

[MicaelS]

2. I learned a long time ago..

To WRITE down my list of problems and tell my DO what was on the list. Otherwise I would forget.

[Midnight Writer]

12. Yes, I write everything on a note card, whether it's for the doctor, the vet, or the furnace guy.

Nothing worse than getting to see a professional and later realizing you forgot something.

[csziggy]

14. I do that for my annual Medicare check up

Anything else is treated whenever it reaches a critical state and I have to make a special appointment for it.

Of course, over the last twenty years about half of my appointments other than the annual visits have been follow ups after surgeries.

Now the list of things the doctor needs to make sure is OK gets longer every year. Getting old sucks.

[Lulu KC]

27. YES!

I finally went in after experiencing dizziness. I had about six, "While I am here" items on my list. NP who saw me regarding dizziness sent me to six different specialists. Everyone gave me some treatment for the symptom--the range of things I was doing was mind-boggling. With the help of sciencedirect.com I ran through every Rx and supplement I was taking and finally figured out they were all related to one prescription I was taking. The dosage was just enough too high to make me look like the "side effects may include" poster child.

This is aging, while I still have enough of a brain left to grasp sciencedirect.com.

It's the system. It's no one in particular's fault. I told the GP at my physical and she said, "You are lucky." I was.

[csziggy]

34. That is why I carry a list of every surgery I've had and condition I'm being treated for

And give it to every doctor's office and hospital I go to. Since 2001 I've had 14 major operations. After two of them I had a vasovagal syncope and fainted. All that, and all the supplements and medications I am taking are on the list.

What is annoying is although I have gone through the medications, etc with the various offices to remove or add my daily doses, they keep showing up with old/ancient medications or supplements that were supposed to be removed. They also leave on stuff that was strictly limited time - such as opioids prescribed for immediately after surgery (which I never finish) - and mark it as though I am constantly taking it. I have on my list medications for "in case" such as Valtrex in case the herpes that lives in my hand flares up - but in the hospital they always try to give it to me daily even though on my list it is clearly marked.

It is amazing how much medication they seem to expect old people to be taking. I recently stopped taking my blood pressure medication - after two incidents of extremely low blood pressure (vasovagal syncope) my doctor and I decided maybe I no longer need it. Since I've been off it, my blood pressure has been great, never above 120/70.

[gibraltar72]

5. I never feel hurried by my Dr.

Staff asks why I want to see her I assume they schedule based on that. On the other hand I don't whine when some other patient gets her time and I have to wait.

[Major Nikon]

17. Oh, one more thing

My prostate is swollen to the size of a tennis ball and I haven't had a piss in 3 days. Is this normal?

[Aristus]

18. If it was normal, you wouldn't have brought it up, would you?

No joke, I had a patient yesterday, a recovering meth addict, who says he 'found' a full syringe on the ground in the park, and says he injected it, thinking it was meth. (BTW, who does that???)

He spent the next two days in the hospital with acute prostatitis. They cathed him and drained a liter of urine.

Moral: Before injecting yourself with an unknown substance from a syringe found in the park, be sure and ask around first. "Is this yours?"

[Major Nikon]

20. You'd think they would teach that in primary school

[Mike 03]

19. I'm guilty of doing this to... my veterinarian.

We come in for vaccinations and kidney lab work...

"I almost forgot, could you please look inside his mouth. Is his neck normal? Sometimes at night he sounds like he's choking."

"By the way, for the last two weeks he's constantly been rubbing his eyes..."

Seriously, I try not to do that. Sometimes it just happens.

[applegrove]

21. Did that today to my Dr. My mom used to say sometimes people come in and are embarrassed

about something and beat around the bush until they get up enough guts to ask her, a GP, the embarrasing thing. Does that happen or are people more assertive these days?

[3catwoman3]

24. Your mom has a point. Odd story - one of my colleagues was scheduled to see a...

...school age child who is having some sort of problem with his penis. There was a note in the scheduling template that specified that the mother did not want the doctor to say anything about that body part in front of the child.

How do you not talk about a body part that you have to examine when that body part is the reason for the appointment?

Next time I work with her, I will have to ask how she managed to finesse that.

[applegrove]

25. I never got that much detail. But i am amazed at the computers doctors have

these days for faxing prescriptions or keeping records. It is a totally different world. So much more efficient.

[3catwoman3]

22. Ah, yes, the "By the way, as long as we're here..."

...when you think you have completed an exam and created a treatment plan. Patients/parents need to be truthful when making appointments, so that schedulers can arrange the proper appointment length. Our sick visit appointment blocks are 15 minutes long. That is barely adequate to take the history, do the exam, decide on treatment, AND make sure the patient/parent understands your instructions for simple problems like ear infections, colds, strep throat, or rashes. No where near enough for asthma exacerbations, concussions, long term abdominal pain, or combinations of problems. Our front desk is more than willing to schedule extra time as long as we know someone needs it. Just tell us - please!

It’s not fair to anyone involved, patients or providers, to make an appointment for something simple and then open Pandora’s box when you have your hand on the doorknob on your way out of the exam room. An example - an 18 year old young man came in for the stated reason of cold symptoms. His exam was reassuringly benign, and he did not require any prescriptions or complicated advice. As I was heading to the door, he said, “Oh, by the way, I’ve been having chest pain when I run.” That is NOT how to do it.

I don’t know if this happens in other specialties besides pediatrics - it is not unusual for a parent to make an appointment for one child, and then show up with 1 or 2 siblings and insist that they also need to be seen. “Can you just take a peek? It’ll only take a second.” Nothing in health care only takes a second - nothing. I don’t think parents make appointments for a dental cleaning for one child and then bring one or more others and expect the dental hygienist to “squeeze them in.” For those of you with daughters, do you make a haircut appointment for yourself, and then take your daughters along and expect your stylist to cut their hair too?

Our practice bends over backwards to accommodate families’ needs for same day sick appointments and we do our damnedest to keep on schedule. Not always possible. I typically work halfway thru my lunch break, getting charting done that there is no time for during those 15 minute time slots, and spend another hour after the last patient leaves. And I still take home 2-3 hours of charting.

It would be good to know that people believed we are giving it our best effort every time we are there, and help us out by having realistic expectations about what can be accomplished during a standard length visit while we try not to fall hopelessly behind.

[Aristus]

23. That is Reason #1,245,718 for why I no longer see pediatric patients.

I haven't had a parent schedule an appointment for just one child, and then bring in all five. But I have had a parent schedule for three and bring in all five. Plus a babe in arms that didn't need examining but did need his diaper changed. Eight people crammed into a tiny exam room while I suffer my way through five well-child checks on the hottest day of the year, my lab coat soaking through, my stomach doing flip-flops from diaper-odor, and needing to step out to my office for a breath of fresh air before doing the last two exams. While there, gasping for breath, I quickly reviewed my life's choices up to that moment, and wondered where I went wrong...

[Jirel]

30. Easy to get frustrated, but it's often not their fault.

It would be easy to also get frustrated with this in my profession, law. But people don’t know what’s important. The guy with chest pain probably thought it was just a weird thing worth mentioning for the future, just like when one of my clients who has been extensively questioned about their problem is about to leave then blurts out some (to them) random issue they were even asked about 10 minutes ago but said nothing about. Extra patients brought in? Ok, that’s a hell no. But people just don’t understand what to tell a scheduler, and stuff comes up between being scheduled and an appointment... especially if the appointment was set weeks before.

[3catwoman3]

31. The vast majority of our sick appointments..

...made on a same days basis, or within 48-72 hours.

Just about a month ago, I had a mom book our 4:45 time slot (last of the day) for one child, bring two, not help hold her kids still so I could examine them somewhat efficiently (2 yr old twins who, of course, do not willingly cooperate with being examined) and then kept telling me to “Please hurry up,” because they had to get home for dinner. I informed her that we did not sacrifice accuracy for speed.

Her kids left the exam room floor covered in crushed up M&M, cookies and shredded table paper, that she made no effort to either clean up or apologize for.

If you must be home for dinner, DO NOT make a 4:45 appointment for one child and show up with 2, and DO NOT then keep telling the nurse practitioner to “hurry up.” Had I rushed thru the exam and missed something important, we know whose ass she’d be coming for.

It was the first time I met her, and I would be quite happy for it to be the last time I see her.

[Aristus]

36. Yeah, I've had patients hit me with multiple complaints, then ask: "How long is this going to take?"

I usually say: "As long as it takes. If you have to leave, go ahead. We'll be here when you have more time."

Another reason why I no longer see pediatric patients is because I got tired of entering an exam room to find three kids climbing the walls (literally), trying on all the exam gloves, and making an unholy mess. All the while, First Place in the Negligent Mother of the Year contest is staring at her phone while her brood tries to set the building on fire.

[Lulu KC]

28. Guilty

Thanks for enlightening me. I will now include when making an appointment, and again at check-in with the nurse. I really thought I was doing them a favor! Live and learn.

[Jirel]

29. I'm not sympathetic at all to be this.

Clinics seeing too many patients per hour? Schedule fewer patients. Patients are not a matrix of complaints that can be conveniently disassembled and treated one at a time. Asking a patient to schedule another appointment (with another co-pay) to delay treatment until it’s convenient for the clinic is bad medicine.

A provider may be unable to address the additional problem(s) immediately, or may need to refer a patient out. In some cases it’s minor enough that the patient should be told that, but set a visit with a NP that day or the next. But it's better to have the conversation and do what can be done then, not leave the patient to the mercies of the scheduler who says, “We can get you in for that 7 weeks from now.”

[Aristus]

37. Unfortunately,I don't have control over my schedule.

I work in community health, not private practice. So my scheduling requirements are dictated by administration. And although I'll happily slag the admins as much as anybody, the truth is everyone in administration is also a medical provider who spends at least part of the day in clinic.

I still try to weed patients off my schedule when I review it in the mornings. Most of the time, it's to make things more convenient for the patient as well as myself. For example, my health organization has a requirement that patients must come in to the clinic in order to get their medications refilled. The reasoning behind this is that, if they have a condition that requires close monitoring, like diabetes, hypertension, high cholesterol, congestive heart failure, etc, we can stay up to date on their progress. What often ends up happening, though, is that patients have other things in their lives that require their attention (jobs, kids, other errands, etc.) and they can't just drop everything to schlepp into the clinic for a med refill. So if a medical provider adheres to that protocol, the patient runs out of medication, and we're back to square one.

I always tell my patients to ignore that policy, and just call me for a med refill if they can't make it in to the clinic. This frees up scheduling time for patients who have something I actually need to examine.

[Saboburns]

32. ALL bleeding stops eventually

I take great comfort in this fact.

[sl8]

33. It sounds like SOMEbody's trying to put one over on Lt. Columbo. n/ t

[stopbush]

35. So, if I have 3-4 medical issues I need addressed by my doctor, I should enumerate them all

when I make the appointment, correct? That way, my doctor can schedule 30-60 minutes for me if I have 3-4 issues.

Got it.

[Aristus]

38. If a patient tells me when I walk in the door that they have several issues to discuss,

I ask him/her to tell me what they are. Then I can do a little triage. This is inconsequential, that can wait for another visit, etc. When time is especially short, I ask them to tell me what is the one thing they don't want to leave the clinic without having it addressed. Most patients, having seen for themselves the Black Hole of Calcutta nightmare in the waiting room, are able to prioritize their issues pretty ably.

Funny story: I had a patient come in once with a skin lesion that worried his wife, and she insisted he get it checked out. I walked in the door, and saw from across the room that the lesion was perfectly benign and nothing to worry about. I told him so, to his great relief, and he laughed and said he couldn't wait to tell his wife. The whole visit took less than a minute. I felt so guilty that his visit was so brief that I invented something to chat with him about, then shook his hand and we made our goodbyes. As pressed for time as we medical providers usually are, we still don't like for our patients to feel shortchanged, as it were.

[Laffy Kat]

39. I make a lot of appnts for our physicians.

Some people will have a chief complaint of, say, insomnia, but when they come in they actually want to talk about a suspected STD. Nobody cares on the clinic end, it's a common screen. It would have helped to know the real CC though to plan for that visit. If patients are embarrassed they can always say "it's a personal issue" which is vague enough but gives the docs or PAs a heads up.

[Aristus]

40. Yeah, I get that a lot.

Not sure I understand the reticence. We're a medical clinic; you can be up front with us about why you're here. It's not like the scheduler is going to announce it to the waiting room. "John Smith with the STD, you're next!"

As I pointed out above, if they tell me when I walk in the room, it's okay ("Actually, the reason why I'm here is..." )

But there have been times when I evaluated them for insomnia (per your example), prescribed a treatment, and then was on my way out the door when they said "Actually, I'm here because I think I have an STD..." And that sends the game into extra innings.