New patient visits vs. return patient visits

[Celexa]

Hi all,

I'm a resident in a large academic program. Many aspects of our outpatient clinics are frustrating to the residents, but one of the most immediate issues is that there doesn't seem to be a lot of thought put into how many new patients we should see vs. the amount of time we need for our return visits. We are a traditionally structured program, with outpatient starting third year. New PGY3s inherit patient panels from outgoing residents. The default schedule leads to more than 40% of our appointment times being for new patients. We are allowed to convert new patient slots into return visits when we run short, but given our inexperience in the outpatient setting it's hard to anticipate when you need that until it's too late and you have a bunch of patients who need relatively close follow-up and no openings.

I would love to hear from people in all practice settings (private practice as well as academic/teaching environments) how much time you spend with new patients vs. return visits (as a total proportion of your time, not how long the individual visits are), how this changes depending on the age/maturity of a practice, and if there is any standard guidance on this for different patient populations.

thank you!

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[wolfvgang22]

It's tough for the first few months when every patient is new to you, whether it's a follow up or a patient’s first visit to the clinic. For now, focus on staying on schedule and getting your work done each day on time. Typically in most settings follow ups are 30 minutes and new evaluations are one hour. In private practice settings that are trying to make a lot of money or in settings where the clinician is being abused, follow ups are every 15 minutes and new evals are 30 or 45 minutes. I am alloted 30 minutes for follow ups, but in practice my stable patients I'm not worried about take 15 minutes (not counting paperwork) and complex follow ups can take an hour.

Take the time you need to get to know patients over a few visits, as your attendings have already given you that leeway. Don't try to be a super hero and cure all the follow-ups the first time or two you see them. Follow treatment guidelines for each diagnosis and avoid prescribing any new controlled substances or completely changing regimens that patients have been on for years. Pick your spots to address needed changes. Spend most of your time establishing rapport with patients, not reinventing the wheel. Most of your follow up patients will mainly be concerned you are going to swoop in and change everything. Resist the urge to do too much until the patient feels you care about him or her, unless it is urgent.

New patients - similar thing. Focus on making the correct diagnosis by doing a thorough exam, then treat per evidence based guidelines. Focus on giving time for sufficient trials of antidepressants. There will always be pressure from patients for quick fixes. Try to steer them toward therapy rather than changing meds every visit. It will not be more than a few months that there is not a lot of room for new patients in your schedule.

 

[Celexa]

It's tough for the first few months when every patient is new to you, whether it's a follow up or a patient’s first visit to the clinic. For now, focus on staying on schedule and getting your work done each day on time. Typically in most settings follow ups are 30 minutes and new evaluations are one hour. In private practice settings that are trying to make a lot of money or in settings where the clinician is being abused, follow ups are every 15 minutes and new evals are 30 or 45 minutes. I am alloted 30 minutes for follow ups, but in practice my stable patients I'm not worried about take 15 minutes (not counting paperwork) and complex follow ups can take an hour.

Take the time you need to get to know patients over a few visits, as your attendings have already given you that leeway. Don't try to be a super hero and cure all the follow-ups the first time or two you see them. Follow treatment guidelines for each diagnosis and avoid prescribing any new controlled substances or completely changing regimens that patients have been on for years. Pick your spots to address needed changes. Spend most of your time establishing rapport with patients, not reinventing the wheel. Most of your follow up patients will mainly be concerned you are going to swoop in and change everything. Resist the urge to do too much until the patient feels you care about him or her, unless it is urgent.

New patients - similar thing. Focus on making the correct diagnosis by doing a thorough exam, then treat per evidence based guidelines. Focus on giving time for sufficient trials of antidepressants. There will always be pressure from patients for quick fixes. Try to steer them toward therapy rather than changing meds every visit. It will not be more than a few months that there is not a lot of room for new patients in your schedule.

I hear you, but this isn't actually what I'm asking about--apologies if I wasn't clear. Our attendings are pretty good at guiding is through the clinical part of the outpatient transition and we do a decent job of keeping within time in each visit. I don't have an issue with the length of each individual appointment. I'm talking about how many of your actual appointments are new vs return visits. Ie, the problem I'm running into is I see a patient, my attending wants to see them back in four weeks, but oops! my schedule is 100% booked already and literally there are no return visits available when I need them. Meanwhile I have all these new patients scheduled. The default in our clinics is just to keep on scheduling new patients every day without any guidance or assistance in figuring out if that's appropriate given our panel.

 

[Candidate2017]

Anything more than 3-4 new evals a day will run into follow up issues. Let the clinic medical director know you have too many new evals to schedule follow ups within 4 weeks. They may or may not be responsive. If not, oh well, schedule follow ups for whatever slot is available. It's their clinic. Or bring some coffee and donuts for the secretary who fills your schedule

 

[Sushirolls]

I'm in private practice. I set my schedule up for 90 min consults, and 30 min follow ups. Sometimes I go over and take 2 hours on consult (only if nothing following). Or if very straightforward patient I have finished in 40 min, but this is rare. 90 is the norm.

Starting a fresh practice whether in a Big Box shop or in a private practice there is the growth stage, where you are doing as many new evals to increase the patient panel size as possible. This phase 1 is exciting with new patients but also draining as new consults take more time, more record gathering, and issues pop up with treatment plan before folks get dialed in. Personally, I've lost my gusto from earlier years where I didn't care how many new evals a day I did and now if I do more than 2 I feel drained. Depending on your practice style of when you do follow up visits (4 weeks? 6 weeks? 8? 12?). You'll start to notice an oscillation to your schedule as patients pile up one week but empty the following week based on how the follow ups fall. Having a full time schedule permits more flexibility as the schedule jams happen on a week per week basis.

Phase 2 is where the follow ups are getting an increased level of schedule time and its harder to squeeze in the consult blocks and even getting harder to get follow ups scheduled exactly when you want. Time to get patients in shifts from days, to now 1-2 weeks. At this stage you'll want to start thinking about the pros/cons having designated consult slots.

Phase 3 is where you are simply just full, and consults now can only happen if added on at end of the day outside routine hours, or truly in blocked designated time slots way in advance. You'll likely want to review your practice attrition rate, how many people are on panel, and how many drop of each quarter. How many consults are needed to replace the normal rate of attrition? Perhaps 2 per week? 1 per every 3 weeks? who knows.

Residency clinics, and Big Box shops typically just don't care. You are a miner, and if there is idle time where you aren't shoveling coal then they view it as lost money. Residency clinics are bouncing around between phase 2 and 3, but if you have the misfortune of picking up a large panel and already in phase 3, and you happen to have a schedule gap, Admin won't care. They aren't conceptualizing the stage of a practice and population management and the work/life balance of the doctor. Rarely you might find a place the respects the input of the Doctor if they say they are full, but count on this less and less.

Nuances for you to look for in your resident clinic is typically how often are patients being scheduled out? The bulk of my patients are in 4-6 weeks, and stable are 12 weeks out. So if for some reason 90% of your patients are in the 4-6 week time frame, admin will see lots of gaps 8 weeks out and turn it into a consult - which only further serves to congest your scheduling as you just added another 4-6 week patient. What happens, from my observations in Community Mental Health clinics is every just gets scheduled monthly or in some Big Box shops, every gets scheduled every 3 months. By having all patients on a single follow up schedule, this makes it harder for admin to squeeze in the consults. But as we know, not all patients fit to a single follow up time schedule, some in CMHC can be seen at longer intervals, and some in the Q3 month clinics do need to be seen sooner.

In grand summary, good luck navigating this headache, set your hopes low that any real change will happen, but high five for seeing this issue and thinking about the clinic flow and logistics. Take note of these variables, headaches, and inefficiencies so when the day comes you open up your own shop you can do it better.

*I made up this whole phase 1, phase 2, phase 3 nomenclature.

 

[romanticscience]

Hi all,

I'm a resident in a large academic program. Many aspects of our outpatient clinics are frustrating to the residents, but one of the most immediate issues is that there doesn't seem to be a lot of thought put into how many new patients we should see vs. the amount of time we need for our return visits. We are a traditionally structured program, with outpatient starting third year. New PGY3s inherit patient panels from outgoing residents. The default schedule leads to more than 40% of our appointment times being for new patients. We are allowed to convert new patient slots into return visits when we run short, but given our inexperience in the outpatient setting it's hard to anticipate when you need that until it's too late and you have a bunch of patients who need relatively close follow-up and no openings.

I would love to hear from people in all practice settings (private practice as well as academic/teaching environments) how much time you spend with new patients vs. return visits (as a total proportion of your time, not how long the individual visits are), how this changes depending on the age/maturity of a practice, and if there is any standard guidance on this for different patient populations.

thank you!

I have a micro-solo private practice. I was very cautious about burn-out and over-filling. Initially, I thought of having a traditional psychodynamic practice, where every patient has therapy with me for ~50-min. I soon found out that private practice patients GET BETTER and that not everyone wants analytic therapy with their meds (I felt super odd keeping people in weekly dynamic therapy when I knew they just wanted a prescription). In the beginning, I had pretty much all therapy patients. Being flexible to the patient's goals and becoming more structured in my therapeutic philosophy, I started transitioning people to less intense follow-up.

This was ideal because I started to do "med management" with people who graduated MY therapy. So, I saw more people (= more $/hour) who felt "known," and were ok with less time. Since I've actually started seeing more people for sx/med-focused appointments from the start who may have other therapists.

At this point in my practice, I only have space for 1-3 new patients per week. New consults are 1-hour. Follow-up appointments are 30-min, 45-min, 60-min. As an example, this past week, I had 22 (30-min appts), 13 (60-min appts), and 20 (45-min appts).

I also only schedule 1-week out at a time to ensure room for existing patients. A low frequency (e.g., monthly) person may decompensate and need weekly for a time. If you come to an appointment, I can guarantee the length of your choice. If you miss or cancel, it is up to you to reschedule from my online portal, which has slots of 30mins. Incentivizes the people who follow-up well and it also helps fill the cracks in my schedule.

 

[Armadillos]

IMO from an education standpoint you 100% need the schedule space to bring intakes back for first follow up in 2-6 weeks depending on clinical situation and should be loudly complaining if not possible.

However I disagree on the fix, you shouldn’t be cutting down new intakes, your clinic directors should be referring out (or taking on their personal panels) some these patients passed down for years between residents to free up more opportunity to manage your “own” patients from the intake.

Edit- noticed you didn’t actually say if you all inherited patients when starting the year so that’s just an assumption based on what happens several places.

 

[kopftonmd]

I also only schedule 1-week out at a time to ensure room for existing patients. A low frequency (e.g., monthly) person may decompensate and need weekly for a time. If you come to an appointment, I can guarantee the length of your choice. If you miss or cancel, it is up to you to reschedule from my online portal, which has slots of 30mins. Incentivizes the people who follow-up well and it also helps fill the cracks in my schedule.

How do you finagle scheduling just one week out with the online portal? Is there a setting that only lets patients grab a slot within the next week?

 

[hamstergang]

I've worked outpatient C&A at a hospital run clinic for the past 4 years. There are a few complications in the details here, but I essentially started with a partially full caseload of follow ups and had 1 evaluation per day. As I started not to have slots for follow ups, I converted 1 eval slot per week at a time to follow ups. If I ever then had extra space (say due to kids aging out/going away to college) I could convert the follow up slots back to evals.

I don't think there's a good general rule. You can basically just do this organically, adjusting as the need arises, instead of aiming for a preset ratio of evals to follow ups. But to work well, you need the following:
1) You can't be scheduled with new evals too far out. If you already have 6 months of new patients, then any change you make will be too late. If this is the case, then it is more important for you to be more conservative up front so you don't overfill by as much.
2) Your admin/management responds right away to your requests to cut back on evals in order to accommodate the follow ups. They have to be ok with limiting access for new people to the system.
3) You have to be ok with some patients getting seen a little less frequently than you'd like. Because this model has you responding only once you discover you're already too full and then there's a delay in response, it will require you to be too full for a while. Management likes that as it's preferable to being too empty. It also hasn't been as bad as it may seem so long as you have some support staff.

All that said, I don't believe that a new 3rd year should be starting off this full. You should spend some time learning how to operate as an outpatient psychiatrist before upping the volume to the limits.

 

[adiradirim]

I had the same problem in residency. I had the biggest panel of patient compared to any other resident and I still kept getting new patient evals. I sent an email to the program director, office manager, scheduling supervisor, and chief resident telling them about this problem and I framed it as a patient safety issue. They were able to help me by offloading my large panel to other residents and decreased the amount of new evals so I could actually schedule them back within 2-4 weeks if needed. It worked pretty well for me. Start my reaching out to your chief and the office manager (or equivalent) person. Good luck!

 

[romanticscience]

How do you finagle scheduling just one week out with the online portal? Is there a setting that only lets patients grab a slot within the next week?

I meant I only schedule new consults 1-week out. At the end of the week, I look at my consult requests and see how they would fit.

The initial consultation is always scheduled on my end. New people don't have access to the portal.

 

[FlowRate]

Sounds like poor planning on the part of the clinic. I think we had a 50% proportion of follow-up and "new" (all transferred from prior residents) patient slots for residents for the first few months and then they all eventually convert to 30 minute slots except for the one new patient per week.

 

[clausewitz2]

Sounds like poor planning on the part of the clinic. I think we had a 50% proportion of follow-up and "new" (all transferred from prior residents) patient slots for residents for the first few months and then they all eventually convert to 30 minute slots except for the one new patient per week.

Our clinics differed a bit but in the one where residents were flying solo most of the time we had the luxury of new appointment slots of 60 minutes for every single patient who was new to us, regardless of whether they were new to the clinic. This kept things humane for the first couple months of getting to know a new panel. I am also fairly certain that the scheduling people were not allowed to give us more than two new evals per half day, so usually had follow-up slots when I needed them. We also could do our own scheduling for follow-ups and one learned quickly how to strategically schedule follow-ups to preclude new evals being booked for certain times.

 

[FlowRate]

Our clinics differed a bit but in the one where residents were flying solo most of the time we had the luxury of new appointment slots of 60 minutes for every single patient who was new to us, regardless of whether they were new to the clinic. This kept things humane for the first couple months of getting to know a new panel. I am also fairly certain that the scheduling people were not allowed to give us more than two new evals per half day, so usually had follow-up slots when I needed them. We also could do our own scheduling for follow-ups and one learned quickly how to strategically schedule follow-ups to preclude new evals being booked for certain times.

All of that except for managing our own scheduling sounds identical to my residency program as well.

The self-scheduling thing is available in my attending job and I definitely don't actively try to pack my follow-ups together. Seeing 6 news + 2 follow-ups in a day is a bit much.

 

[Celexa]

Thank you to everyone who replied, very helpful perspectives and I feel like I understand better why my clinic's scheduling feels so broken. As multiple of you have alluded to, my ability to change these things as a resident is going to be limited but at least now I understand why the structure that I'm working in fundamentally isn't set up to work well.