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Patient Expectations for Primary Care

Dear Patients,

I want to provide you with the best possible primary care services and for us to have a good long term relationship. 

A good primary care relationship is a two way street. I can take my best care of you when we work well together and you understand what I need as a provider to take good care of you. 

I also would be unable to run on time and complete everything needed for all my patients on a daily basis in a sustainable way if we don’t have shared expectations. Setting boundaries and expectations allows me to run on time and maintain a sustainable workload that allows me to give your concerns my undivided attention and maintain my capacity to troubleshoot complex issues. Providers who are burned out and don’t care usually are not able to maintain the boundaries they need to maintain their curiosity and ability to think deeply and critically, and remain invested professionally and emotionally in their patients.

I completely understand there are financial and logistical challenges that limit how often people can seek healthcare such as expensive copays, deductibles, needing to take time off work, arranging childcare etc. that lead people to wanting to have many issues addressed at each visit or try to address issues between visits with portal messages.

I also understand that if it's been a long time since you’ve seen a healthcare provider or seen one who you feel cares or listens to you, you may feel like you need to get everything out and want it addressed all in one visit, or you may be afraid I’ll stop caring after the first visit. These are normal and understandable reactions.

The expectations below are not about me wanting to turn every health concern into money and profit, but ensuring I have adequate bandwidth and time to fully address your concerns in the detail they deserve, am able to run on time, and have a sustainable workload in the long-term. Your time is just as important as my time, and not running 60+ minutes behind schedule is one way I respect both of our time.

Here are some expectations that will allow me to take best care of you and maintain my capacity to take good care of you in the long term. 

1. I can usually address two issues in a 30 min established patient appointment. I am happy to change our agenda for the day if there is something pressing you would like me to address than what we scheduled the appointment for, but we typically do not have time to address additional issues. You are welcome to schedule additional appointments to address additional concerns. If an issue is one that I judge as potentially life threatening including a mental health emergency or requires I coordinate urgent imaging or labs, that is the only issue I am able to address at that visit. 

2. If you send me a portal message about a new issue, meaning one we haven’t addressed in an appointment, or there has been a significant change since I last saw you, I will ask you to schedule an appointment so we can address it together so I can get all the information I need to address your issue and have the dedicated space and time to process your concerns fully. 

3. If you send me a question that I can’t address in one or two sentences or requires additional information, I will ask you to schedule a follow up appointment for us to discuss the issue

4. If you have lab or imaging results that are abnormal and require follow up, we will need an appointment to discuss them and discuss the pros and cons of different approaches to addressing them

5. If I don’t have an appointment available for a time sensitive issue such as chest pain, shortness of breath, stomach pain, infection etc. I will probably ask you to go to urgent care and schedule a follow up with me. I am not brushing you off, downplaying your concerns, or not wanting to address them, but rather making sure that you get the level of care you need within a timeline that the issue requires. Also, I do not have the ability to get a CT done on the same day or get back blood test results on the same day in outpatient primary care, and if you have a condition that requires that level of investigation, I will be referring you to a facility that has the capacity to get that information to you, which may be an emergency department. I know the emergency department, is expensive and you may have to wait for hours, but I do not have the ability to order and get back same day lab results or a CT scan. If you do not want to go to the emergency department, I will need to inform you of the consequences of not doing so. I am not shaming you because I know there are many factors that may go into this decision, but I also have a legal obligation to inform you of those consequences. 

6. If I haven’t prescribed a specific medication for you before, I will need an appointment to discuss it. Prescribing a medication is not simply sending an electronic order, but it legally entails me agreeing it is medically necessary and developing a plan to monitor it for safety and effectiveness 

7. Controlled substance prescriptions such as stimulants, benzodiazepines like Xanax or clonazepam, opioids, certain sleep aids, and other controlled substances are only filled at scheduled appointments which are every three months. If you are overdue for a followup appointment for one of these medications, I will likely either decline the prescription or write a small quantity until an appointment is scheduled depending on the situation. I typically try to schedule follow up appointments before you leave your last appointment. Furthermore, if there is a legal or safety concern with a controlled substance prescription, I may have to decline that prescription until the issue is resolved, and this does not mean I don’t care about you, our relationship, or the symptoms you are experiencing. In the strict medico-legal environment of healthcare practice in the United States, there are some situations in which my hands are tied no matter how I feel. 

8. Paperwork such as disability paperwork, work or school accommodations, etc. requires its own appointment. There are many ways I can fill that paperwork out, and I want us to be sure we are on the same page and you know exactly what information I am sharing with your school, employer, etc. 

9. I do not have the resources to check your insurance benefits and tell you how much you will have to pay prior to labs, imaging, or other specialty services. 

10. I do not have the resources to figure out which specialists or imaging facilities are in your insurance network. While I generally do my best to have some working knowledge of resources in the area, I may need your help identifying specialists or imaging facilities that are in network with your insurance from time to time. 

11. There are some medications and treatments that are outside my scope of practice as a family nurse practitioner, even if they have been working for you previously or you have been taking them for a long time. Scope of practice refers to what regulatory and licensing bodies have decided is safe for me to offer in terms of diagnosis, medications, and other treatments on the basis of my education and training. I cannot go outside of my scope of practice without incurring substantial risks that are not sustainable for my practice. I work hard to offer as many different treatment options as I can as a family nurse practitioner because I know how hard it is to get healthcare services. An example of a common request I get that is outside my scope of practice is to prescribe ketamine for mental health conditions. 

Sincerely,

Natalie Paul FNP