r/medicine • u/Peaceful-harmony- MD • 11d ago
Thyroid med adjustments: office visit or portal message?
It seems silly to drag in a patient for a thyroid med adjustment when I only ask them a few questions and then prescribe their meds. But for me it’s about 7min of work—review lab, open chart, review dosing hx, use MD brain to see if they need an adjustment, e-prescribe meds, write an order for their 6w lab check, set a auto-reminder for them to return in 6w for said blood draw, and communicate with them. How do you manage this?
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u/basar_auqat MD 11d ago
Can you make it a televist?
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u/Peaceful-harmony- MD 11d ago
Yes
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u/basar_auqat MD 11d ago
Perhaps schedule as a televist and at least get paid something. I'm pretty sure it shouldn't be more than a 10 minute visit.
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u/NoCake4ux2 Nurse 10d ago
It should be a level 4. Chronic condition w progression due to need to adjust meds, and moderate risk for prescription management. As long as it isn't Medicaid a level 4 can be billed regardless of in office or tele health
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u/theenterprise9876 MD 10d ago
This is correct. Chronic condition not at goal w/ rx management = level 4.
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u/CalmAndSense Neurologist 10d ago
I think physicians need to take a page from the lawyers and bill for every tenth of an hour that we spend.
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u/seekingallpho MD 11d ago
Things sounds like a completely reasonable in-person follow-up visit. A lot of what you do could probably be handled via the portal if you knew what it was before someone showed up. I think the fact that you're wondering means you aren't the type to call someone back for something that really doesn't require it.
Also, if 7min visits are too short to require someone to come in then what is Derm doing?
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u/deadpiratezombie DO - Family Medicine 10d ago
Look, you have to SEE the rash. Touch it. Experience the texture. Marvel at the play of light over the surface. Examine from EVERY angle. Maybe use a woods lamp for the special effects. The full photographer session.
And then maybe…just maybe…take a sample. For collection.
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u/Plenty-Serve-6152 MD 11d ago
If they visited recently and we discussed it as a possibility, I just send it in. Otherwise it’s a telephone visit if that’s all we are doing. Just ime
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u/janewaythrowawaay PCT 11d ago
My preference as a patient is to have the labs done before the visit like hematology does, then go in and discuss results and the treatment plan.
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u/maydaymayday99 MD 11d ago
It is practical(and correct imo) to do it via portal. If you have a job that measures your visit volume, you may be forced to make other decisions
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u/Peaceful-harmony- MD 11d ago
I’m not on salary. I eat all of this. And if I have 4 a day then it really adds up…
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u/themiracy Neuropsychologist (PhD/ABPP) 11d ago
From the other end as a patient usually we discuss thyroid management, the lab is ordered, and a change is made via the portal when needed when the lab comes back, and I’ve always been happy with this.
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u/ExtremisEleven DO 10d ago
Offer both. I haven’t had my routine endo visits because I just can’t get out of work for them and to be honest I have been titrating my own meds. I’m a physician. I’m perfectly capable of doing that. A good chunk of my patients are not. I don’t see why this needs to be restricted to one type of visit when people are so wildly different.
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u/thepriceofcucumbers MD 11d ago
“Use MD brain” - sometimes docs have a bad habit of downplaying the amount of training, time, and experience required to get to the point that it takes you 7 minutes to adjust a medication for a condition which, if left untreated, carries a hazard ratio for all-cause mortality of 1.8 compared to euthyroid individuals.
It’s easy to you because you’re a physician.
How to deliver that care (your original question) depends on your reimbursement models. Traditional FFS needs to generate visits for any and all medical decisionmaking and time on your part so you can make payroll. Direct primary care has opposite pressures - you start the day with as much revenue as you’ll make, and every patient you see is “losing” some amount of revenue via overhead. Risk-based VBC is another model where asynchronous treatment makes more sense for something like this, so that you have more access for patients who need to see you in person quickly to avoid higher cost avenues for healthcare.
If you’re doing this to save the patient time, great - incentives are aligned all around. If you’re doing it to save them a copay - now you’re falling into the trap of carrying the weight of our broken healthcare system on your back.
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u/compoundfracture MD - Hospitalist, DPC 10d ago
I’m DPC so I just handle all of that through messaging since I’m getting paid either way.
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u/The_best_is_yet MD 10d ago
Don’t fall down this slippery slope. If it’s worth your time, it’s worth the patients time. We get better communication with the patient, and we don’t want to gib up primary care.
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u/meowed RN - Infectious Disease 11d ago
Do you have a smart phrase to speed up your review process?
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u/Peaceful-harmony- MD 11d ago
Sure for communicating with patients. I wish I could set up a template that would auto-generate the lab order and reminder. But no EMR does that… (edited to change to my EMR doesn’t do that)
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u/meowed RN - Infectious Disease 11d ago
I would want a dot phrase that pulled in labs, dosing hx, previous appt date and next appt date.
Do you have to make the reminder for yourself to message them or can you schedule-send portal messages?
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u/Peaceful-harmony- MD 11d ago
That sounds nice but it’s not an option for me. The reminder is actually the easiest part of all of it. Text goes directly to the patient at 6w.
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u/janewaythrowawaay PCT 11d ago edited 11d ago
You can order a test to be done a year out. Essentially when you see the patient for their 2025 visit, you can order the 2026 labs then.
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u/redlightsaber Psychiatry - Affective D's and Personality D's 6d ago
I adjust lithium dosages according to labs over email all the time.
I'm not saying you should do this, I'm not in the US so the "liability issues" you ahve to contend with don't apply to me, thankfully.
But regarding the economics, which is what I think you asked you, I'm in private practice, and charge enough per visit that doing quick adjustments (or even reports) doesn't bother me, even if it takes a few minutes of my time.
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u/terracottatilefish MD 11d ago
in a productivity model I would say that this is an ideal telehealth/video visit, especially if you need to clarify adherence, timing of dose, use of other medications or supplements that might interfere, etc.
I would say that probably 40% of the time when I start asking people about an abnormal TSH after being on a stable dose it turns out that they’re forgetting to take it or have just started an iron supplement or something, and that pretty quickly turns into a 10+ minute discussion.