Doctor Visit Guide

by Danielle Ofri
New York Times

Going to the doctor isn’t most people’s favorite activity. But it is part of staying healthy (the other major parts are what you eat and how much you exercise). So you may as well get the most out of it. As a doctor I often get asked by friends and family how to make the most of a medical visit. Here’s my advice, and it’s basically the same whether you are the patient, or a family member or a caregiver of the patient.

  (Printable worksheet here)

Find a Doctor

Whether you are just checking to make sure things are on track, or have a specific symptom you are concerned about, choosing your doctor is the first step.

 

MAKING YOUR CHOICE

These days, it’s easier to pick out a blender than a doctor. Endless websites compare and contrast home appliances but these same type of sites offer limited information to help you select a doctor. Comments often reflect easily observed items like waiting time and amiability of the office staff, which have little bearing on how good a doctor really is. You can glance at these online ratings sites, but be sure to take them with an enormous grain of salt.

You should also check with your insurance company — find out which doctors are in network and conveniently located. If you don’t have insurance, look up local clinics and health centers. Be sure to ask about their fees before you book an appointment.

If you are looking for a specialist to do a particular procedure (like hip replacement, cataract surgery, a CT-guided biopsy or heart valve surgery), look for a physician who does lots of them. When it comes to complex medical procedures, more is better. A doctor’s experience correlates with fewer complications for his or her patients. Propublica has created a website that publishes the complication rate (and the death rate) for surgeons in the United States doing eight common elective surgical procedures. Medicare also has a website (Physician Compare) that publishes physician performance scores on various self-reported quality metrics. However, this, too, needs to be taken with a grain of salt.

For non-procedure-based specialties (sometimes called cognitive specialties, such as internal medicine, pediatrics, psychiatry or infectious disease) there aren’t comparable statistics because there are fewer concrete things to measure. If you know any medical professionals, you can ask them to recommend a doctor they trust and who is known as a good listener and a thoughtful person.

Ask friends who’ve had a lot of experience dealing with the medical system — here’s what I recommend looking for:

• A doctor who takes his or her time talking with you, as opposed to making you feel like you’re at a drive-through fast-food joint.
• A doctor who engages their patients in decision-making, as opposed to simply rattling off a to-do list.
• A doctor that you can get in touch with on the phone or through secure email.

For uncommon illnesses, do internet research to see if there are doctors whose primary focus is that disease. Your primary care doctor can also guide you to institutions that might have particular experience with specific conditions.

 

HOW BIG A PRACTICE?

Some patients prefer the intimacy of a small practice. The advantages include getting to know all the staff and usually less bureaucracy. Other patients prefer large-practices that offer the convenience of many specialties under one roof. Ultimately, who your individual doctor is matters more than the practice he or she is working for. But different practices have different vibes, though you may not be able to sense this until you are actually a patient.

Another option these days—though much more expensive—is the “direct primary care” model (sometimes known as “concierge” medicine.) In this type of practice, you pay an annual retainer fee but get longer visits and easier access to your doctors.

 

HOW MUCH WILL IT COST?

In terms of costs, it’s not often the first thing you want to think of, especially if you are dealing with a concerning symptom, but it’s important to be aware of how different choices might impact your bottom line. Your insurance company’s website may offer an online tool comparing the cost of having the same procedure or visit with different doctors. If you get your insurance through your employer, your Human Resources department may be able to help guide you to some of these tools.

It’s never easy to call your insurance company, but you can minimize unpleasant surprises if you get a handle on technicalities of your health plan like co-pays, deductibles and co-insurance, and whether things like preventive care, mental health, physical therapy, drug rehab and out-of-network referrals are covered.

If you don’t have insurance and are paying out-of-pocket, it’s essential to call the office before your appointment because fees can run the gamut. Some clinics and health centers offer sliding-scale fees or payment plans while others require payment up front. Be sure to ask what documentation to bring with you.

 

TIMING

Be prepared that doctors often run behind (though it’s usually not entirely our fault). If you can schedule yourself to be the first or second visit of the day, you’ll have a better chance at being seen at your scheduled time. Don’t plan your visit when you have to something critical right afterward. Choosing a day where you have more flexibility will make it all much less stressful.

If taking time off from work is difficult, look for a doctor who has evening or weekend hours (many do).

 

Before Your Visit

You’ve picked a doctor and made an appointment. What next?

SET YOUR GOALS

While you wait for your appointment date to come, take some time to consider: What do you want to get out of this visit?

• Is this going to be a check-up?
• Is this a “maintenance visit” for your ongoing medical issues?
• Is there a new symptom or problem that you need to bring up?

Do you need to talk about big events in the near future? (Some potential topics: you’re planning to get pregnant; you want to address end-of-life issues; you are considering a radical change in diet or lifestyle.)

BE JUDICIOUS WITH YOUR PREPARATORY INTERNET RESEARCH

There’s lots of good medical information on the web but also plenty of snake oil and infomercials, too. It’s often tricky to tell the difference. Safe bets are well-known medical centers, as their information is usually vetted. Avoid websites that sell products or offer any sort of freebies. Any cure-all that looks too good to be true….is too good to be true. (If there was one quirky food out there that trims 30 pounds or cures cancer, trust me — we doctors would be prescribing it in a heartbeat.)

Even with vetted medical websites, though, it’s easy to fall into the rabbit hole of overdiagnosis and find yourself at 3 a.m. self-diagnosed with 16 rare and fatal diseases. Sometimes it’s better not to know every last gory potential detail when you haven’t yet had your symptoms evaluated. Close your laptop, take a deep breath and get a good night’s sleep.

 

MAKE A LIST (BUT KEEP IT REALISTIC)

You may have waited weeks or months for this appointment, so it’s understandable that you want to get everything in. But in the reality of today’s medical world, you’re only going to get a modest amount of time with the doctor. If you try to discuss 27 concerns in a 10-minute window, there’s no way that any of your concerns can be explored in depth. (Just do the math!)

Quality is much more important than quantity when it comes to addressing medical concerns. Pick out the two or three most important issues and focus on those. Keep in mind that your doctor may have a few issues on his or her mind to discuss with you, so allot time for that.

 

GATHER YOUR SUPPLIES

If you are seeing your general doctor, dig out your vaccine card and results of your last mammogram or colonoscopy (if you did them at another health system). Be aware that it can sometimes take a week or two to obtain those records, and you might be charged a “reasonable fee” for the results.

If there’s a new symptom that you need evaluated, keep a symptom diary ahead of your visit. This should include:

• What does the symptom feel like?
• When does it occur?
• How long does it last?
• What makes it worse?
• What makes it better?

If your doctor had asked you to do certain tests in advance (blood work, X-rays), make sure you do them with enough time to allow the results to be available for your doctor. (Usually a few days or a week is enough time, but check with the office to be sure.)

 

Tips:

• If you’ve had any recent tests at another medical facility that is not connected with your doctor, bring those results. (But again, be judicious. Don’t hand your doctor a six-inch stack of papers and expect her to read them in detail. Separate just the important ones and place them on top.)
• If you want an ally in the room with you, make sure that person is able to come with you to the appointment.
• Assemble your meds (including vitamins and supplements). It’s best to bring the actual bottles, but if you can’t, bring your most up-to-date medication list.
• Make sure you have your insurance card with you.
• Some practices will allow you to do the dreaded “paperwork” in advance or online. You can save yourself time on the day of the visit by doing this.
• Finally, bring something to do while you are in the waiting room. I like to take along a mid-sized novel when I go for an appointment, and I’ve seen people doing their taxes and studying sign language (not at the same time though). There’s almost always waiting involved at doctors’ visits, so come prepared with your knitting, sudoku or your Latin verb tables. Doing something fun or productive can make the waiting less arduous. Find out if your doctor’s waiting room offers free wifi, so you can bring a laptop along.

 

On the Day Of

Your appointment day is here: Here’s what to do.

 

IN THE WAITING ROOM

Check in with the front desk. If it’s a first-time visit, arrive at least 15 minutes early to fill out paperwork, if you haven’t done it in advance. Even if you’ve been to the office before, the staff will usually want you to verify your address, phone number and insurance coverage.

Be flexible. We all deserve to be seen on time. But remember that nearly every patient has more issues to discuss than there is time for, so if your doctor is running late for you, he or she is either giving another patient a little extra time or doing the many extra tasks required for documentation (more on this later). There’s not much you can do to make the process go faster so pull out your crossword puzzle or that book that keep meaning to get to and see if you can interpret this waiting time as “found time” to do something you don’t normally have time for.

 

IN THE EXAM ROOM

1. Set your agenda, but also listen to your doctor’s. At the start of the visit let your doctor know the two or three things you want to be sure to get to and make sure you listen to your doctor’s two or three things that she wants to be sure to get to.
2. Focus on the doctor-patient conversation. More than the physical exam, blood tests, X-rays, and M.R.I.s, the doctor-patient conversation is the most powerful tool in medicine. Make sure the majority of your visit is spent in direct communication. (Forms and paperwork should be relegated to the waiting room.)

Luckily, good communication is not as hard as it seems. Sometimes all it takes is one solid minute of focused attention — the doctor’s eyes on you, not on the computer — to get all the important information across.

 

3. Understand the multi-tasking mess that your doctor faces. The number of items that your doctor must attend to during a visit has skyrocketed in the last decade. The advent of the electronic medical record (E.M.R.) has changed the nature of the doctor-patient interaction immensely, and most doctors have no choice but to type during your visit. If your doctor looks like someone in a 1950s secretarial pool, typing nonstop, welcome to 21st century medicine.

Multitasking is not an excuse for poor communication, however, or a feeling of rushing through the visit. You can be aware of and even a bit forgiving of the bureaucratic labyrinth that your doctor has to deal with, but your doctor should make time for direct, face-to-face communication. That is crucial for accurate diagnosis and treatment.

Some doctors can listen well while they are typing, but if your doctor does not appear to be listening to you, you are well within your right to politely acknowledge that. You could say something like, “I know that you have to write all this down in the computer, but if you could give me one minute of your full attention, I’ll tell you the important stuff as concisely as possible.”

 

4. The physical exam. Most doctors’ visits involve some sort of a physical exam. Depending on what part of your body is being examined, you may or may not have to change into a gown. Some medical practices have a “chaperone” present for any physical exam; some offer it only when there will be an examination of breasts or genitalia. But the decision is always yours. You can request that a chaperone be present at any time, and you can also give the chaperone the boot at any time. The same goes for family members or friends who may be with you during the visit. Whether or not to have company during the physical exam is your decision and yours alone.

 

5. If the visit is drawing to a close and your top items haven’t been reached, a gentle reminder is absolutely in order. You could say something like: “I see that time is running quickly, but I want to be sure we get to X, Y and Z that I’d mentioned in the beginning.” If you feel an important question has been left unanswered, or especially if you don’t understand something that was explained to you, don’t be shy about bringing this up before the visit ends.

 

6. But don’t throw in the kitchen sink. Resist the temptation to squeeze in other concerns at the last minute. It is okay, though, to let your doctor know that there are a few things still on your mind. Ask if it’s possible to set up a phone call, or whether you can email follow-up questions through a secure site, called a patient portal. Most doctors offer patient portals that can also be used to check test results or view a short summary of your visit. You might be able to address some of your remaining concerns with the nurse, or you might simply have to schedule another visit so that those issues get their due.

 

7. Don’t leave until you know the plan. Take notes if you can. (Having a friend or family member there to take notes can also be helpful.) Ask your doctor for a list of the medications being prescribed, or tests being ordered. Many doctors will give you a short printed summary of the visit when you leave. Collect any printed orders that you might need for follow up testing and make sure you know how you will be informed of test results and if (and when) you should come for a follow-up appointment. Since most prescriptions are sent electronically these days, check that your doctor has the correct information for the pharmacy you prefer to use. If you are interested in signing up for a patient portal, be sure to obtain instructions about how to enroll, so you can access it from home.

 

HOW MUCH WILL IT COST?

When your doctor recommends a treatment, whether it’s an M.R.I. or an antibiotic or physical therapy, you quite naturally might want to know how much it will cost. And you’d think that the person making the recommendation should be able to tell you. Think again! Strange as it is — we doctors usually have no idea what anything costs. It all depends on your insurance company and what kind of deal they’ve negotiated with the radiology service or what physical therapy benefits they offer.

And as to whether that antibiotic is covered by your insurance — your doctor may not have the answer. Not only do different insurance companies have different formularies (lists of medications that are covered), each formulary has multiple tiers of coverage, and the formularies are constantly changing (again, based on the deals the insurance companies negotiate with pharmaceutical suppliers). Your doctor’s computer system may have the ability to run formulary checks, but these are not always 100 percent reliable.

Are you confused? You’re in good company, because so is your doctor. This is the nature of an opaque medical system with dozens of insurance companies cutting deals with hundreds of hospitals, health systems, pharmaceutical companies and medical device companies.

I always feel like it’s a cop-out when I tell my patients that they may have to call their insurance company to accurately answer cost questions but it’s the reality of the American system. (Make sure you have an extra-large sudoku to do when you make that phone call.)

If you get to the pharmacy and it turns out that your medication isn’t covered, usually the pharmacist will call the doctor’s office. One option is to change the the prescription to a similar medication that is covered. The other — if there isn’t anything comparable — is that the doctor will have to apply for a prior authorization, a process that can be laborious and also delay your prescription. Tip: Ask the pharmacist — before she or he calls your doctor — which are the comparable medications that are covered by your plan.

 

Back at Home

Congratulations! You’ve done the hard part — now it’s time to make sure you reap all the benefits from your visit.

 

REVIEW THE VISIT

Things to consider on your way home from the doctor:

• Did you get your questions answered?
• Did you cover your three most important issues?
• Do you know what you are supposed to do now? (What meds to take? What tests to do? What specialists to see?)

If you have lingering questions, call the office and ask to speak to the nurse. Or ask if the doctor could call you back another time, or send a message through the patient portal. (Remember that these follow ups are just for clarification, bringing up 20 more issues at this time isn’t appropriate. For that, you’ll need to schedule another visit.)

Make sure any follow-up tests and referrals are scheduled and mark all the dates in your calendar, including the follow-up appointment with your doctor.

 

WHEN THINGS DON’T WORK OUT

A relationship with a doctor is like any relationship, and you need to feel that it’s the right one. If something doesn’t feel right, that’s worth paying attention to. After all, you are entrusting this person with your life.

 

A SECOND OPINION

If you are about to undertake a major medical treatment (cancer treatment, heart surgery, lupus treatment), it’s perfectly reasonable — even expected — that you get a second opinion. Your doctor will not be (or should not be) insulted. And insurance usually covers a second opinion for complicated procedures or treatments.

 

CAN WE TALK?

We used to think of communication skills as bonus, something that a few kindly doctors possessed. We used to tolerate those doctors who were supposedly excellent, but had a terrible bedside manner. The research is getting more and more clear that these two things are mutually exclusive: You can’t be an excellent doctor if you don’t have sharp communication skills. Good communication is the foundation of good medicine.

If your doctor isn’t really listening, or if you feel that you are not being heard, it’s time to get a new doctor.

If you feel comfortable, write your doctor a letter and let her know why you are leaving. We doctors rarely get feedback, and it’s really helpful, even if it’s negative feedback. (Here’s a time where I received negative feedback. While it didn’t feel great in the moment, I was really appreciative in the long-run.)

If you prefer to leave quietly, that’s fine. You should request your medical records to bring to your new doctor, but you are not obligated to give an explanation to your old doctor.

 

GOING FORWARD

You’ll want to stick to the plan that you and your doctor agreed upon. If there are reasons that you can’t (maybe the medication doesn’t agree with you, or you’ve changed your mind about doing a test) it’s important to let your doctor know.

Don’t forget to focus on exercising most days, getting enough sleep and eating a healthy diet with plenty of fruits, vegetables and legumes. This may sound like boring, common-sense advice, but these can actually have more of an effect on your overall health than even the best doctor’s visit.