Set a policy about extra exams in a single appointment

Maybe you have a name for them, like "two-fers," "freeloaders," or some other term that's probably best kept to the back offices at your practice. If you go a day in primary care without a family asking to get an extra exam out of one appointment, you probably wonder what's wrong.

The requests can happen under many different circumstances: a parent asking you to examine more than one child; a husband and wife who go to an appointment together; or even just friends, if they share the same physician.

Some of the requests, of course, are innocent, like the parent who makes an appointment for one sick child for later in the day, but by the time he or she arrives, another child is showing symptoms as well. There also are those families who, when you see their name on the schedule, you know will be asking you for a favor.

It's a delicate situation. On one hand, you have patients who may have been coming to see you for years just asking for a little extra advice. On the other hand, it's time wasted and revenue lost if you don't pull a chart and charge them for an office visit.

Whatever the circumstances, physicians should be prepared to handle patients asking for quick and seemingly harmless medical opinions. While doctors may hesitate to set ironclad policies, having a protocol in place can prevent them from wandering too far down that free-care road.

"We're torn between wanting to be nice guys and wanting to run a business," said John Sattenspiel, MD, a family physician with Salem Family Physicians PC, a three-physician practice in Salem, Ore. "If you talk to practice management people, they say, 'Pull the chart and make clear it's another appointment,' but if it's just a quick glance, it's hard to justify charging for that."

On the other hand, there are families who try to manipulate their doctors and the system; and the ones who are good at it can find ways to get free examinations the way they might find loopholes to land a free rental at a movie store.

Andrea J. Leeds, MD, a pediatrician in Bellmore, N.Y., says that in her solo practice, she can tell what kind of a co-pay a family has based on the requests they make in the exam room. If they ask her to examine a second child, chances are their insurance company requires a co-pay.

"If they have a plan with no co-pay, they're making appointments for all their kids," she said.

Dr. Leeds said she has decided over the years to set a strict policy that whenever a family asks for her to examine another child, she makes it clear that the chart will be pulled, implying the encounter will be documented and the family will be charged. If it's an honest, innocent request, the family will live with that response. A family looking for a free exam, however, will often agree instead to forget the exam, monitor the child and see what happens, she said.

"Our service is often our diagnostic impression," Dr. Leeds said. "They don't make the connection that our education and experience is what allows us to look at a child and make a diagnosis. Thus, to them, a two-second glance is just two seconds, but in reality, if they could do it, they wouldn't ask us for our two seconds."

Robert D. Walker, MD, a pediatrician with Palmetto Pediatric and Adolescent Clinic, a 16-physician group in Columbia, S.C., said he often decides how to approach extra exam requests based on if he has two seconds to spare. If the day is sticking to schedule and the request is not complicated, he said he may do the family a favor and take a quick look at a second child. However, if it's a repeat offender, or if the family seems to expect the extra care, Dr. Walker said he passes along the reminder that next time, the chart will be pulled.

"Many times, the receptionist is bypassed, and it becomes a physician-to-patient issue," Dr. Walker said. "With the people who work the system, you just have to address with them that you're happy to see both kids, but with separate appointments."

The problem that plagues physicians who agree to a quick glance at a second patient is how far to take the encounter. At this time of year, sore throats and earaches are common, as are requests to check an extra ear or throat. If you make a courtesy check and find nothing, the encounter ends right there. But if you find an infection, the issue then becomes finding a stopping point.

"Sometimes, if you do too much, you encourage that behavior from patients," Dr. Sattenspiel said. "Sometimes, we almost bring it on ourselves when we ask them if there's anything else they want to ask us."

If they agree to look at a second patient, most physicians will make it clear the exam ends with that first glance. Just a peek, however, can ease patient minds and make the visit a less stressful one for the doctor.

"In my earlier years of practice, I tended to be more rigid, and I found myself getting more upset when they brought in a second child," Dr. Walker said. "It would have been easier just to look at the child."