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Neurology Now:
doi: 10.1097/01.NNN.0000424230.43366.7b
Features: Office Visits

Be Prepared!: How to make the most of office time with your neurologist.

Avitzur, Orly M.D., M.B.A.

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As a neurologist in private practice, I often wish I had more time to spend with each of my patients. But in addition to spending time on their care, I have to make sure that I document the visit accurately in their electronic health record, meet new governmental requirements for record-keeping, and complete a variety of other administrative tasks. I make a big effort not to leave patients feeling neglected, but every once in a while, I fear that I have failed.

A recent Newsweek story, “The Doctor Will See You—If You're Quick” (bit.ly/HIgaEA), summarized troubling health care statistics from a variety of sources. Among the findings: In 25 percent of visits, doctors neglect to ask patients what is bothering them; the average time doctors spend conveying crucial information about patients' conditions and treatment options is 1.3 minutes; and about 30 percent of the time, doctors forget important information their patients tell them.

In spite of the fact that the vast majority of doctors are deeply dedicated to the health of their patients, the growing intrusion of administrative and regulatory demands has whittled down the time physicians can spend with patients. The imposition of governmental mandates has created a distraction from clinical care and forced doctors to divide their attention between patients and computerized checklists.

Documentation of a patient visit, which is important, used to mean maintaining clear notes in a paper chart. Now, it entails the reporting of “clinical quality measures” that may or may not apply to the neurologic problem for which a patient is seeing the doctor. Documentation has also come to require filling out complex lists to meet “meaningful use standards” for electronic medical records—standards that include transmission of electronic prescriptions and the recording of a patient's ethnicity, height, weight, and tobacco history, among other things. Starting this year, doctors must also use electronic prescribing at least 25 times or face a penalty from Medicare.

So if you've ever had the feeling that your doctor is digressing in a seemingly irrelevant direction instead of focusing on your problem, the reason may be the need to check off those little digital boxes.

In a November 2011 story in Neurology Today, the American Academy of Neurology's magazine for health care professionals, a number of neurologists expressed their disappointment about the increasing intrusion of business into the practice of medicine. (“A Sobering View: Young Neurologists Express Career Regret,” bit.ly/rtD4bq.) One newly minted doctor was quoted as saying, “I just want to take care of patients. I didn't expect to be doing so much paperwork.” Even seasoned doctors are distressed by the changes. After 22 years as a practicing neurologist, Daniel B. Hoch, M.D., Ph.D., assistant professor at Harvard Medical School, neurologist at the Massachusetts General Hospital in Boston, and member of the American Academy of Neurology (AAN), is disheartened to witness neurologists engaged in increasingly challenging battles—not with neurologic disease but with paperwork, regulations, and administrative tangles.

In addition to the shrinking face-to-face time available during the office visit, we are experiencing a growing shortage of neurologists in many parts of the United States. A December 2010 Medical Economics survey from the AAN revealed that the average wait time to see a neurologist was 28.1 days. According to a 2009 Merritt Hawkins and Associates survey (bit.ly/19b983), that is almost the double the wait to see a cardiologist (15.5 days), and considerably longer that the average 16.8 days it takes to see an orthopedist, the 20.3 days to see your family doctor, or the 22.1 days to see a dermatologist. (See box, “Get Involved!”)

Since you may have to wait longer these days to get seen for a shorter period of time, making the most of your office visit is critical. That means arriving prepared to your first visit so that office staff won't waste a moment searching for results or reschedule you because vital information is missing and needs to be tracked down.

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Get Involved!

To help ensure that the neurology workforce is sufficient to meet the growing demand for neurologic care, let your members of congress know that you support the Medicare Physician Payment Innovation Act of 2012 (HR. 5707). This bill would reform the way physicians are paid by Medicare and would allow for the complex services performed by cognitive specialists like neurologists to be recognized during a transitional period.

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WHAT TO BRING FOR YOUR DOCTOR

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List of Top Three Things You Want to Discuss

One of my patients has a habit of voicing his new and often worrisome symptoms just as he is leaving my office. Recently, he confessed, “Oh, by the way, I've been passing out behind the wheel of my car…. See you in a few months.”

It's important to plan what you want to tell your doctor. If possible, let your physician know at the start of the office visit (or even before the visit, such as by phone) about changes in your health. Make a list of the top three things you want your neurologist to know and bring it with you to your visit. Order it in terms of priority with the symptoms that you consider most urgent first. As in any other encounter with time constraints, the first item is more likely to get the most attention. If you feel that not enough time has been spent covering all your health issues, ask your doctor if it would be best to schedule another appointment to discuss your additional concerns.

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Symptom Diary

If you have a chronic condition, one of the most effective measures you can take to assist your neurologist in the evaluation of your condition is to record a symptom diary prior to your visit. This is particularly helpful if you have condition with symptoms that come and go over time, such as Parkinson's disease (PD), epilepsy, sleep apnea, or headaches.

Alexander Mauskop, M.D., the director of the New York Headache Center and a Fellow of the AAN, asks all his patients to download and complete an online symptom diary as part of their new patient questionnaire.

“It's best to do this at home rather than waiting until you come to the office when you may feel rushed, distracted, or stressed out,” Dr. Mauskop advises. The diary he created includes a log of headache frequency, severity, duration, triggers, and response to medication (including side effects).

“The record provides me with a fuller picture of the problem at a glance and allows me to concentrate on management with the patient, rather than spending the time documenting that history when the patient is in front of me,” Dr. Mauskop says.

Diaries and disability scales completed before follow-up visits offer valuable data to determine if medications and other interventions have been effective.

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A Friend or Relative

It's easy to get flustered when seeing a doctor, especially if the news is worrisome or the instructions are complex. If you bring a friend or relative with a pen and paper, you'll have another set of eyes and ears to confirm what the doctor said about your condition, how to take your medication, what side effects may occur, and which tests need to be scheduled before you return. That person can also ask questions to help carry through the doctor's orders.

What's more, a friend or relative can help the doctor take a better history.

Kenneth A. Gaddis, M.D., a general neurologist and AAN member practicing in Baton Rouge, LA, in the Ochsner Health System, previously worked in a small town “down the Bayou” in Thibodaux, LA. “In that part of southern Louisiana, family responsibility is huge,” he observes. The waiting room might have three patients and 25 supporting family members, Dr. Gaddis says—while in the big city of Baton Rouge, accompanying family “historians” are not nearly as common.

“When a patient with ‘spells’ comes to see me without an observer of the events, that person is clueless as to what may or may not have happened,” Dr. Gaddis says. When he attempts to diagnose a seizure or state of altered awareness, the presence of a family member or third party is critical to a good history, he stresses. “Having a family member with the patient is not just important,” Dr. Gaddis says, “it's necessary.”

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Test Results (Including CD of Images)

It's wise to bring copies of any test results or laboratory work ordered by other physicians involved in your care. Unless you receive care at a multispecialty group in which all your doctors are networked through a common electronic records system, your doctor may not have easy access to test results. If your doctor doesn't have a test result, essential treatment may be delayed or overlooked. Moreover, unless you track your tests, you may risk unnecessary duplication of procedures.

Aurora K. Pajeau, M.D., M.P.H., a neurologist and AAN member practicing at the Boice-Willis Clinic in Rocky Mount, NC, says that patients are typically referred to her after an abnormal computed tomography (CT) scan or magnetic resonance imaging (MRI) study. Often, the primary care doctor has ordered this imaging because of a suspected abnormality. However, says Dr. Pajeau, “primary care doctors often forget to tell patients that they must bring a CD of their scans. It is essential for me to review the images for diagnosis, treatment, and counseling.”

Dr. Pajeau routinely reviews scans to make sure the report was correct. If she disagrees with the conclusion, she will call the radiologist to discuss the discrepancy.

Dr. Pajeau also likes to review the images with patients, identifying specific part of the brain and spinal cord and demonstrating how the abnormality could explain their symptoms. “I can tell the patient that [the abnormality] is minimal, or I can let the patient know it is significant by showing the scan,” she explains.

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Medication List

One of my favorite patients, a gentleman who just turned 95, brings a computerized print-out of all his medications to every visit. It never fails to bring a smile to my face.

An updated record of medications likely tops your physician's wish list for the most valuable information you can bring to the office. I advise all my patients to maintain a list of their medications—prescription, over-the-counter, vitamins/supplements—and carry it in their wallets or pocketbooks. A small index card will do the trick, and as a patient once taught me, it can be laminated easily with double-width packing tape to make it waterproof.

If you're tech-savvy, iTunes apps like “My Medications” allow you to keep your list on your iPhone or other devices.

James R. Storey, M.D., a neurologist and Fellow of the AAN, prefers that his patients bring all their prescription bottles to his office so that he can verify drug names, dosages, and schedules.

“Now and then, I see some people taking medications that are working against each other,” he says, recalling one patient who was prescribed a drug for bladder-retention problems by his urologist and an anticholinergic, which exacerbated the bladder problem, by a different doctor.

Dr. Storey also recalls a patient with PD who was referred for orthostatic hypotension (blood pressure that drops when the person stands up), which can be a symptom of PD. However, the patient's cardiovascular medications aggravated the hypotension.

Bringing a complete list of medications—as well as a record of allergies and previously poorly tolerated drugs—will help your doctor avoid duplicating your medication or prescribing a drug that caused side effects in the past.

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Previous Medical Records

In my solo practice, I ask patients to request that their records be faxed to me but follow it up with a call asking my staff if they received the information. Your involvement in your own care will help ensure that all your doctors have access to your health information and help them provide you with the best care possible.

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WHAT TO BRING FOR THE DOCTOR'S STAFF

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Insurance Information

Before you hang up the phone after making your appointment, be sure you know what you should bring to the office. Ask the staff if the office has a website that lists instructions for new patients, and make sure to review and comply with its requests.

David A. Evans, M.B.A., chief operating officer of Texas Neurology in Dallas, requests that patients bring their insurance card; a government-issued ID; a referral (if required); and any deductible, co-pay, or co-insurance amounts to the office.

“We also advise them to verify benefits and coverage limitations with their insurance company, and we request that patients notify us if any changes in insurance have occurred prior to the appointment,” Evans says.

The biggest misconception Evans encounters? Patients' beliefs that their financial responsibility is limited to a co-insurance and deductible, he says. “We advise patients that some services may not be covered by their carrier due to limited benefits or coverage. For example, they may exceed insurance allotment of maximum units for nerves in nerve-conduction testing or need to cover a repeat of such studies at the request of referring neurologists,” Evans explains.

Bring up financial concerns prior to your appointment, before you incur any fees. Most practices are willing to discuss payment plans or fee reductions if the patient is unable to meet the fees.

“We have a social worker on staff who can assist patients who are un- or underinsured or have limited financial resources,” Evans says, noting the variety of governmental programs for low-income patients who do not qualify for Medicaid. “For example, Dallas County has a program called ‘Project Access’ which offers a large network of providers who have agreed to see a specified number of patients per year for free,” he says.

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List of Other Health Care Providers

If your medical care is not coordinated under one health care system with universal access to your health records, it behooves you to help coordinate your own care. Bring a list of all your physicians, along with their contact information, to office visits.

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For More Information

For more on preparing for an office visit, download “Working with Your Neurologist,” a new patient brochure from the AAN, at patients.aan.com/go/brochures, or visit patients.aan.com/go/workingwithyourdoctor.

To find a neurologist, use the AAN's online “Find a Neurologist” tool at patients.aan.com.

©2012 American Academy of Neurology

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