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Transitioning your patients, part 2.

As discussed last month, transitioning usually involves assisting the patient in finding a doctor capable of caring for his or her needs. If the patient has a chronic condition, then I may need to recommend "adult" specialists for that problem (such as an adult gastroenterologist for a patient with inflammatory bowel disease). I also keep a list of local general internists and family doctors.

I am careful about recommendations--I have no desire to step on the toes of local colleagues. But there are some I can't recommend in all good conscience. Perhaps the young adult could go to the parents" doctor--that's always a good political move. You should keep a list of local internists and FPs for the graduating patient--and for the not-infrequent request from a parent for a doctor of their own. You should probably also have a referral list for all subspecialties. Maybe the doctors in your practice won't completely agree; one may like orthopedist X whereby another may prefer the work of orthopedist Y. There usually will be 90% agreement, but it doesn't have to be 100%.

The list should be inclusive and for internal use only. I have to emphasize that "internal only" aspect. You could run into some problems if you showed the list to each patient to allow him or her to select a subspecialist. Imagine Mrs. Smith, wife of orthopedist Smith, looking for an ophthalmologist. As she scans the list she sees the orthopedic recommendation and realizes her husband is not among your favored few.

Most older patients with chronic problems--diabetes, Crohn's, thyroiditis--know what kind of care they have received. Nevertheless, it would be helpful to copy their chart's problem list and go over it with them at the last well checkup. If you don't have a problem list, then I would suggest you start developing one for the front of each chart--it's good quality medicine to have a summary of major concerns for each patient right at your fingertips--not to mention a frequent chart audit point that is missed by many practices. A problem list has real value--something useful that managed care insurers have promoted and brought to many practices: The list should include chronic conditions and an updated catalog of medicines used. A summary of something akin to "chronic ear infections" is more useful than a list of every sick visit.

Many patients will be completely healthy with no issues. When I do chart audits and see no entries, I often hear it said that "no entry means no problems," but how can you demonstrate that no entry doesn't mean you have failed to document health problems? Consider a single-line entry for every chart as the No. 1 issue to address for all patients: "health supervision/maintenance." Every child has that as an ongoing medical need! It starts each chart's problem list and satisfies audit criteria.

But, to return to the original premise of the older teen or young adult's last visit, review the problem list with your soon-to-be-ex-patient; it's the least you can do for a long-standing "client." Besides, a good exit will likely encourage the return of that patient as a parent of another generation in a few years--assuming, of course, that you don't intend to retire in a few years. Seeing babies of your babies is a very gratifying result of a smooth and effective transition and demonstrates that you really did satisfy the patient's needs.

There are some special situations that need a clear policy development. What do you do with a pregnant teen (other than refer to an obstetrician for most of the primary care)? Obviously you won't be dealing with the pregnancy itself. But do you remain the patient's general doctor during the pregnancy? Remember that many prescribed medicines will need to be cleared through the obstetrician. But this is not a bad scenario, if for no other reason than you will be communicating regularly with the OB, and keeping your name in front of him or her. And it's not bad public relations either, considering newborns are the lifeline of a pediatric practice. Cooperation has its benefits, and if you are collaborating on one patient, the OB may consider it reasonable to recommend you to other first-time pregnant women. And if you keep the pregnant teen in your practice, it will allow you to provide continuity of care.

But what do you do after the teen delivers? Do you continue to see her? I would think it makes sense for you to care for the new baby, but will you care for the new mother as well, since she still fits into the age range of your patient clientele? Obviously the focus of your teen mother will change--and yet she still is an adolescent. Yes, her "wild" teen days will have to be curtailed, something she may not have considered while having "wild teen" times on the road to becoming pregnant. At least we hope that will be the case; it is never pleasant to realize that the teen is headed down a path that results in her ignoring the needs of her new baby. Unless her parents, now the grandparents, pick up the slack, then child protection agencies may have to be called. And it's your obligation to monitor the situation closely; but if you do have to call child protection services, your relationship with the family will suffer. All these considerations need to enter into your policy regarding the pregnant teenaged patient or new teenaged mother. These are tough decisions and the answers may not be a clear-cut; you may be able to temper your policy in light of how the teen handles the new responsibilities thrust upon her. She obviously will still need general, non-ob.gyn, medical care. Should it still be you, or should she be transitioned to a family physician? I can't give you an answer, but you should discuss this among yourselves to decide the best policy for your office.

Let me now move into a different arena that is a more vexing, albeit interesting, quirk. Imagine the scenario whereby you and a family don't see eye to eye. The reason doesn't matter; the family may have repeatedly missed appointments, made too many outrageous demands, behaved rudely, didn't pay their bills, etc. Assume it was something not as egregious as stealing your prescription pad or physically striking a staff member. You gave them their walking papers (obviously with the 30-day notice of providing emergency care and with a certified letter), and they left to become patients of a doctor 10 miles away. Now imagine you and Doctor Ten decide to merge your two practices into one corporation. Suddenly the dismissed family is back in your practice. What do you do? Do you dismiss them a second time or bite the bullet?

That scenario has actually happened to us, and we had long discussions about the dilemma. The most recent occurrence was with a family who had been dismissed because of unreasonable (and vocal) demands. Should we discharge them a second time? We actually decided to keep them and give them a second chance, with some counselling and by reminding them about the original reasons for the discharge. Not surprisingly, the family ha, been pleasant and appropriate at all encounters. Perhaps having been read the "riot act" made them more docile. What ever the reason, the relationship is back or an even keel. I would not have given the family a second chance if there had beet some outrageous act--theft, violence, or threat of a lawsuit if they didn't get their way. But, I suspect these extreme cases account for less than 10% of dismissals. Most are for verbal issues, constantly missing appointments, or showing little regard for your office.

If you accept a family back into the practice, do so fully with one exception: Have a lowered index of confrontation if there is a recurrence of any activity that is unfavorable. Yet you cannot see the child and "bait" the patient to see the response. As difficult as it might be, treat the child and family as equal to all others. Certainly, if they start with previous activities that got them dismissed, end the relationship quicker; don't let unpaid bills mount up for as long as you would with a family without a history--address the problems promptly. But by the same token, do not go into each exam room with them anticipating problems. That isn't fair to you or the family. If you can't do that, then you can't keep them as patients.

Dismissing a patient is never easy, but there are times when even the best of families needs to move onward. Sometimes that move is physical, as with a new geographic locale because of a new job or other requirements, sometimes the move is caused by other circumstances or merely because the patient is now too old to see you. But, regardless of the reason, care must be taken to effect a smooth transition of that patient's medical needs. You have provided that patient and family with many years of quality care; it is your duty and obligation to ensure that the good start you gave them continues. Do everything in your power to make certain that the patient and family are well prepared for their next phase--and next doctor. Prepare the records, and more importantly, prepare the family and yourself.

DR. SCOTT is in private practice in Medford, N.J., and is a member of the Pediatric News Editorial Advisory Board. Write Dr. Scott at our editorial offices (
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Title Annotation:Efficient Pediatrician Practices
Author:Scott, Charles A.
Publication:Pediatric News
Geographic Code:1USA
Date:Jul 1, 2007
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