A painful topic: what doctors need to know (according to patients)

Ok, so I was wrong. I really liked the RACGP good GP television commercial. It had some flaws but I thought they were small in the grand scheme of things (see my last post). But many patient advocates did not agree and were unhappy about the lack of communication portrayed in the video.

Blogger Michelle Roger commented: “My current GP asks me what I want to do, what I think is most important and together we sort through the problem at hand and potential solutions. I feel valued and heard and trust her more knowing that she listens and knows me and my family.”

“That for me was missing in the video. It was one-sided and the patients appeared little more than props to be talked at. In fact the patients had no voice at all. A problem that still permeates a lot of medicine.”

Crockey health blog posted an article titled ‘The Good GP never stops learning: the RACGP video that made doctors cry – and patient advocates wince’. In a response to this article Irish blogger Marie Ennis-O’connor wrote on her blog: “We can’t just talk about a commitment to patient centred care – we have to live it. It is only by bridging the divide which places patient and doctor expertise on opposite sides that we can achieve more personalized and meaningful care of the patient.”

Patient blogs

I wondered why the patient opinion was so different to mine. On Twitter it was suggested to me that more doctors should read patient blogs to understand their view better. I thought that was a good idea so I asked for some recommendations and started reading.

I can tell you, it didn’t cheer me up but it was enlightening. It felt a bit like a refresher course “do’s and dont’s for doctors”. What I read was that, in the eyes of patients:

  • Doctors often don’t know how to deal with disabilities
  • Doctors sometimes blame patients for treatment failures
  • Some doctors find it hard to accept patients as experts
  • Doctors don’t always communicate well.

Now that I’ve read the blog posts I feel that I can better appreciate the patient response to the RACGP video – and I learnt a lot more along the way.

I have been given permission to share parts of these blogs and I recommend anyone who works in healthcare to read on. It may help to bridge the divide. Doctors beware: don’t expect flattery.

Empathy towards disability

Carly Findly
Carly Findlay: “Doctors need to move past the textbook and immerse themselves in the disability community to truly learn and empathise with our experiences.” Source: Carly Findly

In one of her posts writer and speaker Carly Findlay tells the story of how doctors gave up on her and told her parents to prepare for her death, and how she later met one of these doctors.

(…) “Over the Christmas holidays, I introduced myself as an adult to the dermatologist who gave me a pretty dismal prognosis as a baby. He pretended not to remember me until he told me I always had blocked ears. I think he was surprised to see me. I told him some of my achievements including how I am now educating dermatologists about my condition (something he needed when he treated me).”

(…) “Other people with Ichthyosis tell me that doctors didn’t give them a chance either. My friends have said that their parents were told they wouldn’t make it into mainstream school, that they wouldn’t have relationships or children, and that they would be social outcasts.”

(…) “The political models of disability can determine a person’s compassion and empathy towards disability. And so a doctor’s low expectations for a baby born with a disability can set the scene for their attitude through the lifespan of that patient.” (…) Doctors need to move past the textbook and immerse themselves in the disability community to truly learn and empathise with our experiences.”

Read the complete post here. Follow Carly on Twitter

Blaming patients

Caf
Caf: “I’m not sure that I truly trust any doctors, despite having a lovely GP.” Source: Rellacafa

Blogger Caf explains how doctors told her to see a psychiatrist when their attempts to treat her chronic pain failed.

“I had arrived at the appointment of the reveal, hobbling with a pair of forearm crutches. I could hardly bear any weight on the offending ankle. It didn’t take long for him to deliver his message, laced with condescension and arrogance. ‘There’s nothing wrong with your ankle. Why are you on crutches?’”

(…) “Chronic pain has been misunderstood and stigmatised for so long that many people probably don’t know what to believe. Even patients themselves often wonder if they’ve just gone crazy because their symptoms are so utterly illogical.”

Caf says that her experiences have affected her trust: “I’m not sure that I truly trust any doctors, despite having a lovely GP.”

Read the complete post here. Follow Caf on Twitter

Michelle also writes about pain in this post: “And there is a pervasive idea of the drug-seeker, seen in every patient who has chronic pain. That those who simply don’t get over pain and require ongoing pharmaceutical management are weak.”

“Friends who have used pain clinics tell stories of dismissal and blame. That they are not trying hard enough when they don’t recover, when I know the lengths they have gone to to try and alleviate their pain. And compassionate pain doctors who become the exception not the rule.”

The patient as expert

In another post she writes: “As a patient with an unusual, complex, and poorly understood disorder, 9 times out of 10 when I see a new doctor I am the expert in the room.”

(…) “I spend my spare time researching my disorders on Medline. I flip through Cochrane Reviews, and review consensus statements regularly. I read up on the drugs I’m taking and keep abreast of current research trials. On forums, I can ask questions of other patients.

“The constant fight to be heard is exhausting

Arm rash Michelle Rogers
Michelle Rogers: “I awoke to welts and rashes across my body. My pre-op information met with eye rolls, a sense that I was over-anxious, and thus completely ignored.” Source: Living with Bob (dysautonomia)

(…) “Some doctors are quite happy to acknowledge that I may know more about my disorder than they do. For example, my GP is happy for me to take the lead on my treatment needs. Even my cardiologist is happy to discuss my disorder in more of a collegiate manner, than the traditional doctor-patient relationship.”

(…) “Yet there are many others who are nothing short of dismissive. Should I dare to suggest a potential treatment or line of investigation the appointment can become adversarial. At times what I say is outright ignored.”

“Case in point my recent hospital admission. Despite having a red allergy band on my arm, sharing the information from my Allergist, and speaking to both my neurosurgeon, anaesthetist and senior nurse about my allergy to adhesives, I awoke to welts and rashes across my body. My pre-op information met with eye rolls, a sense that I was over-anxious, and thus completely ignored.”

(…) “The constant fight to be heard is exhausting. We are told that we must be our own advocates. That the future is patient-centred medicine. That rapport and making a patient feel part of the decision-making model leads to more compliance and more successful outcomes.”

New technology

Michelle: “Patients no longer live in a bubble where they are reliant upon their doctors as the only source of information. With the advent of social media and the ease of access to medical journals, patients can be as up to date, and at times, in front of their doctors, with regard to advances within their various disorders. We come empowered and informed to our appointments and have an expectation that our doctors will be equally informed or at the least, willing to listen and work with us.”

“We have an expectation that our doctors will be equally informed or at the least, willing to listen and work with us

“The medical community needs to be aware of the new ways information is being shared, especially the speed at which information can now travel. Instead of criticising patients for researching their ailments, they should instead be working with them, especially to direct them to more appropriate medically sound sources of information.”

“Patients are already distrustful of big pharma and the way research is funded. If their physicians also refuse to help them navigate these areas or are dismissive of their efforts, such distrust will also pass to them, to the detriment of both practitioner and patient.”

Read the complete post here. Follow Michelle on Twitter

Doctors who listen

Carly: “I went to hospital earlier this year. I was so sore, and a bit miserable. I saw a junior doctor, one I had not seen before. I spent an hour in the consult room, talking to her about Ichthyosis, but also my job, blogging, wedding plans, travel and the Australian Ichthyosis meet.”

“Their compassion means I am a human being first

“She said I was the first patient she’d met with Ichthyosis and she wanted to learn more than what she’d seen in the textbook. Her supervisor came in to provide further input into my treatment. Again, we talked about life, not just Ichthyosis.”

“And she told this junior doctor how lucky they are to have me as their educator. What a compliment. I am so lucky to feel empowered as a patient at my hospital. These doctors listen to me. They treat me as a person not a diagnosis. They see my potential and are proud of my achievements. Their compassion means I am a human being first.”

The e-health challenge: an interview with NEHTA Chair Dr Steve Hambleton

In the 2015 Budget the Federal Government has allocated significant funding to improve the electronic health record system for all Australians. The personally controlled e-health record gives patients a lot of control, but many healthcare providers are still concerned about the medicolegal risks embedded in the system.

I had the privilege to speak with Dr Steve Hambleton, former AMA president and Chair of the National E-Health Transition Authority (NEHTA), about some of the concerns voiced by doctors and consumers.

It appears there are various sticks and carrots in the pipeline to get more healthcare providers on board, but there is no sign that for example the heavy-handed PCEHR Participation Contract for providers will be changed.

The good news is that Dr Hambleton expects the current national infrastructure will help other providers and products – different to the PCEHR – to emerge in the near future.

Here is the transcript of our conversation:

Dr Steve Hambleton
Chairman of the NEHTA-Board Dr Steve Hambleton. Image: LinkedIn

Are you enjoying your role within NEHTA?

“I think I am now!”

I assume you are happy with the allocated funding of $485 million for e-health over 4 years in the latest budget?

“Yes absolutely. I think it does two things: It restarts the momentum of e-health in this country, and the Federal Government has now sent a signal to the State Governments and the e-health community saying: ‘we are serious about e-health and we want to get an outcome; we want to get some returns.’ If you think about it, we’ve really had no momentum since about September 2013.”

The budget indicated that NEHTA will cease to exist as suggested in the Royle report – what will your role be after the transition?

“I hope to be able to contribute in some way, but there are no announcements about it as yet. NEHTA can now complete its task of setting up the infrastructure and I guess the Australian Commission for E-Health, if it goes forward as proposed, can take it to the next step of more meaningful and better use of e-health.”

What is the difference between NEHTA and the proposed Australian Commission for E-Health?

“I think the main difference will be in the governance, not so much the strategic direction. We recommended in the Royle review to put users and people who can meaningful influence the direction of e-health on the governance board, so the influence is there at the highest level.”

According to the PCEHR Act 2012 the PCEHR has four purposes: to help overcome fragmentation of health information, improve the availability and quality of health information, reduce the occurrence of adverse medical events and the duplication of treatment, and to improve the coordination and quality of healthcare provided to consumers by different healthcare providers.

It appears however there are least 5 other purposes of the PCEHR spread out throughout the Act:

  1. Law enforcement purposes
  2. Health provider indemnity insurance cover purposes
  3. Research
  4. Public health purposes
  5. Other purposes authorised by law 

Especially the last one seems a catch-all category. There seems to be a lack of information about what happens with our patients’ health information in the PCEHR. What are your thoughts on this?

“We should probably engage with the minister now to gain a better understanding of where they want to go with e-health, but if we simply mechanise what we’re doing with paper records we really can’t reach the benefits of electronic health. We have to analyse the data we’re creating and use that to improve care and understand outcomes.”

“For example, when a new drug is released into the community we want to know: does it actually deliver the same outcomes as when the drug trials were run? We need to make sure that the healthcare we are providing does make a difference and does get an outcome, so we do need to analyse the data. Whichever way we go, the performance of the system is going to face more transparency as time goes on, and I think the profession is beginning to understand that.”

“We need to analyse individually what we do in our practices; all the colleges are now saying: ‘as part of continuous professional development we want you to reflect on your activities within your practice and show us how you modify your activities to get a better outcome.’ That will apply to GPs, specialists, hospitals, and the systems need to be analysed as well. We can’t do that unless we have a common dataset and I think that’s what e-health gives us.”

We need more information about what the government will and won’t do with the data because the PCEHR act 2012 seems to allow for almost anything. 

“I think that’s probably a question we should put to the minister. We need to hear what’s in their heads. I don’t have any knowledge about what’s in the government’s mind.”

The data is kept by the government for 130 years, is that right?

“My understanding is that’s correct yes.”

Do you think patients are aware of this?

“I can’t answer that question, I couldn’t tell you what patients are thinking but certainly from the day-to-day interaction with patients it’s surprising to see how many people think we’re already sharing information about them and use that to try and improve the situation.”

Even if healthcare organisations or practices cancel the PCEHR Participation Agreement, 7 of the 14 clauses contain paragraphs that survive termination, including liability. Although practices may have signed up to access the incentive payments, they may be concerned about the fact that the contract has clauses that, once signed, will be perpetually binding. It makes sense to adjust the contract to entice clinicians to participate, doesn’t it?

“My comment would be that we’re bound by good medical practice in any case, no matter what we do in relation to our patients. Decisions that we make are expected to be in their best interest. And putting my AMA-hat on, our interaction with e-health should be no different and shouldn’t require any different concept than when we are interacting with patients in other ways.”

“E-health is a different way of interacting and recording data and I guess that’s why we’re well-educated and insured and act in the patient’s best interest. If you look at good medical practice and say well that’s the guidance that we’re all subscribe to, than this should apply to any interaction including e-health.”

But 130 years seems like a long time.

“We’re expected to keep paper records for a period of time and every time I try to get information about this, you know, nobody will give you a clear answer when you can dispose of them. Theoretically it might be seven years since you last used them but if you talk to a medical defence organisation they say: ‘well if you keep them longer that would be good.'”

“I’ve got electronic health records in my practice dating back to 1995 and you wouldn’t think of destroying any of those. I think it’s one of those areas that you think: is this information permanent? I mean, in 130 years is it going to be in a form that’s usable? I guess it’s one of these things we don’t know the answer to.”

How do we get doctors to use the PCEHR?

“Doctors have been sitting back asking: ‘well why should I engage with e-health when it’s not certain if the government is actually going to support it?” There has been a lot of uncertainty. We now have a strong signal from the government that e-health has a future and that we have a national infrastructure that we’re going to use.”

“Then we need to say to doctors: ‘well what is the benefit here?’ The primary beneficiary is the patient. The information collected that they can manage will provide the next doctor they see with accurate and up-to-date information. Specialists and public hospitals can get quick access to the curated information.”

“The reality is it’s going to make our lives easier and make our search time shorter and provide us with rapid access to accurate information. Opt-out ofcourse means that when you look for a PCEHR there’s one there; if the patient has been in hospital there will be a discharge summary; if you want to upload something it’s not complicated and you don’t have to sign people up. It will be more efficient.”

The budget mentioned revised incentives, can you tell us more?

“Nothing specifically, but I have no doubt that the practice incentive payments program will look at incentivising doctors to use electronic health records. Their software has to be SNOMED compliant, they need to have secure messaging protocols and be able to send messages between doctors and patients and utilise the e-health infrastructure. I think that’s going to happen.”

A problem with practice incentive payments is that they go to practices, not to doctors who are interacting with the PCEHR.

“It depends on how practices have set themselves up but you’re quite right. The Royle review recommended that there should be a link between annual health assessments, care plans and utilisation of e-health. This would be a direct reward for doctors if they interact with the e-health infrastructure. The government has indicated that it is going to try and implement the major recommendations of the Royle review.”

GPs could interpret a link between care plans and e-health as the government forcing them to use the PCEHR, because if they wouldn’t their income drops.

“It is by no means a definite outcome. It is something the PCEHR review commission thought would be worthwhile. The Primary Health Care Advisory Group [of which Dr Hambleton is chair as well] will consult with senior members of the profession to see what they think. I think it is pretty clear that people with high needs and chronic diseases would benefit from better electronic communication.”

I agree that certain people with chronic diseases could benefit from e-health. Many GPs however are weighing up their own risks of participating against the benefits to their patients, and that’s where some of the concerns come from.

“Yes, I think we should all look at issues like that. I suppose we will be looking to our indemnity providers to give us some guidance. The AMA has put out a guide for the use of the PCEHR which gives pretty good guidance. But if e-health reduces the risks for our patients and improves the care to our patients everybody is going to support it; if it does the opposite then they won’t.”

“I just want to make one more point. We focus on the PCEHR, and I understand why, but so many people have called me out and said: ‘we’ve spent a billion dollars on the PCEHR!’ but actually we haven’t. The national infrastructure that underpins the PCEHR is really critical for a successful e-health strategy.”

“Think about the individual health identifier, the individual practitioner identifier, practice identifier, SNOMED CT, Australian medicines terminology, secure messaging protocols and also a national product catalogue plus a national health services directory.”

“All of this basic infrastructure is built and can be used by other providers, different to the PCEHR, and that’s the exciting future. I think other products will emerge, which of course doesn’t mean that we shouldn’t make the PCEHR easier to use. We should. We’ve got to make it easier.”

Tricky medicolegal cases

I asked Dr Hambleton to comment on a few real-life cases. In some instances the doctors involved contacted their indemnity insurers but unfortunately insurers were not always able to provide advice. In his comments Dr Hambleton refers to the ‘AMA guide to using the PCEHR’ which can be downloaded here.

A patient saw another doctor in the same practice who did not upload the latest information to the PCEHR, and the patient subsequently complained to their own GP.

“There is no compulsion to upload anything to the PCEHR. A patient can ask the doctor to upload something but the doctor is not required to do it. The doctor may say: ‘I’m not your nominated healthcare provider but you need to see your own doctor to get another shared health care summary uploaded’. These sort of things need to be talked about in practice protocols and discussed with the patient.”

There was a practice that accessed the PCEHR when the patient was not present, and the patient threatened to sue the practice.

“Patients do provide standing consent for access to their records by registered healthcare providers, so they can assist with their healthcare.”

“I think we have to talk to the AMA or the indemnity providers, but accessing the PCEHR for reasons other than the patient’s healthcare probably is not appropriate access.”

One patient demanded that the GP did not mention essential information available in the PCEHR for a report to an insurance company. The GP was unsure what to do.

“That’s very clear. If you have to write a medicolegal report it would not be appropriate to access the PCEHR, as it’s the patient’s record. If you’re writing a medicolegal report doctors can only access their own records, unless the patient has given permission to access their PCEHR. Practices need to think about protocols that describe who accesses the PCEHR and why, and have systems in place to make sure this happens.”

Misleading, missing or incorrect information causes mistakes or harm. Many doctors are unsure how they can assess if information available in the PCEHR is reliable or not.

“I think this is a really important comment as well. You can’t assume that any information in the PCEHR is absolutely accurate. If you are using that information you often have the patient in front of you so when you are taking a history, check if the information is accurate or not. No information is ever going to be complete and we shouldn’t expect that the PCEHR contains complete information.”

“Patients have the right to say, for example, ‘please don’t upload the fact that I had a termination’. Patients should understand that we don’t have to use the PCEHR and if we do, it should be weighed up like any other object of information we get.”

By looking at the PCEHR billing information providers can find out where patients have been, eg other doctors, even if a patient has asked the other doctor not to upload anything to the PCEHR. Are we supposed to have access to this information?

“Well, supposed to and allowed to are two different things. When patients consent to the PCEHR use, they are basically providing standing consent for access to the information that’s there. They have given consent but they also need to understand what consent means.”

“Patients have a lot of control: You can shut it down to one doctor or you can shut it down to only the doctors you give the access code to, and patients can switch the controls on and off.”

Some doctors are concerned that information they upload may be deemed not 100% accurate, in which case they would be in breach of the PCEHR Participation Contract.

“We are trying to provide the best available data. We will be judged by the standard of what a colleague reasonably would have done in the same circumstances. The intention of a shared health summary is to provide the next practitioner with a guide to manage the patient. If you think about it: there is not much difference between uploading a health summary to the PCEHR and writing a referral to a colleague using that exact information.”

“It is part of good medical practice to continually review the information that’s there, and for example delete previously prescribed antibiotics from the current medication list, and look over the past medical history we’re providing to other doctors to see if it is still relevant and useful to the patient’s medical care. It is certainly true that if you upload reams of information you may confuse the next provider.”

6 key conditions for private health insurance in in general practice

Private health insurers are gearing up to enter the general practice market. But it appears their plan is a copy of the dreaded US-style ‘managed care’ approach.

It’s best to keep health funds at arm’s length or else they will decide what care can, and can’t be given – instead of the patient and the healthcare provider. Therefore, I suggest that six conditions must be met before private health insurers can engage with general practice:

#1: Universal access

Every Australian should have equal access to a GP, independent of insurance status.

#2: Freedom of choice

People should have the option to choose their GP and private specialists; this cannot be dictated by health funds. Patients together with their doctors are best at deciding which tests and treatments are appropriate, not third parties like insurance companies.

Patients should always be given the option to choose and change health funds and insurance products.

#3: Transparency 

Health funds must provide a straightforward package covering GP and/or basic private hospital care – as well as more comprehensive packages. Exclusions should be kept to a minimum. Health funds should make patients aware of exclusions and any other limitations before they buy a product.

To assist consumers choosing the best health insurance that suits their circumstances, an independent Government website should monitor, compare and publicise all available insurance packages.

#4: Professional autonomy

GPs and practice staff need support to be able to provide good care; this also means they should not be overloaded with red-tape, reporting requirements and KPIs. For the same reason health funds should not cause delays in treatment. GPs have the right to set fees to ensure practice viability.

#5: Evidence-based care

Only proven, appropriate, and cost-effective care should be covered.

#6: Stakeholder involvement

Health consumer organisations and the medical profession need to be engaged, as this will likely lead to better outcomes. New regulation should be put in place to safeguard compliance by all parties.

Is the new eRx electronic prescription service beneficial to consumers?

About ten years ago I did a locum in an innovative GP practice in The Netherlands. When prescribing medications, the computer system allowed me to either print the script and hand it to my patient, or send it electronically to the pharmacy. Consumers who elected the second option, were able to collect their medications at the pharmacy twenty minutes later.

I’m not sure how secure the system was, but it was easy to use, saved a lot of paper, and prevented lost scripts and medication errors.

ePrescribing in Australia

Here in Australia doctors are printing or handwriting scripts. This month however I noticed a little QR code in the top right corner after printing a script. It took me a while to figure out what it was for: Patients can scan this code with a mobile device, submit the information electronically to the pharmacy of their choice and pick the script up on a preferred day and time.

eRx express
Source: erxexpress.com.au

The app, developed by the Fred IT Group, is called eRx Express. It can be downloaded for free on mobile devices. It seems that the benefit for health consumers is reduced waiting time at the pharmacy – which is great, especially if people have already been waiting to see their doctor.

I also have a few reservations…

First of all, consumers have to scan and send information via their smart phones, and they still need to bring in the paper script when collecting their medicines at the pharmacy. So it involves a few more steps and we’re not yet saving trees.

Second, as always, I would like to know what happens with the data during and after scanning, transmission over the internet and on the servers of the Fred IT Group and others. Is the information sold or disclosed to third parties?

It would be good if consumer details and their prescription history would not be collected or used for other purposes. But usually, when something is free, we become the product. In other words, there is often a price to pay with regards to our personal data.

The small print

So, after a little search I found this information in the patient terms and conditions and the privacy policy:

You agree that we may disclose your de-identified prescription data to selected third parties for the research and marketing purposes of those third parties.

We do not warrant (…) that any data transmissions between you and us will be secure and that any data you send us shall at all times remain secure.

We reserve the right to (…) charge for the App or service provided to you at any time and for any reason (whether stated or not).

Conclusion

As long as private or governmental organisations want control of our health data for other purposes than patient care, eHealth initiatives will not take off. Of course health consumers are free to use this service, but at the moment the benefits do not seem to outweigh the risks.

6 issues that need to be addressed to make the PCEHR a success

Have you made up your mind? Are you going to sign up for the personally controlled e-health record (PCEHR)?

I believe six issues need to be sorted out as soon as possible to make it easier for consumers to take part:

  • Confidential patient data is potentially unsecure in the PCEHR Govt cloud
  • Too much risk & liability for health professionals
  • Uploaded PCEHR data will be used by Govt for other purposes incl data mining
  • Up to 5 minutes extra per patient is needed to upload and manage online PCEHR data
  • Longer consults create higher fees & increased costs for patients
  • More red tape, difficult to understand rules and regulations

It’s got a lot of potential, but the devil is in the detail.

PCEHR

5 things to remember before a doctor’s visit

It happens regularly: people visit a doctor but have difficulty providing essential details about their health.

Sometimes people incorrectly assume that all information is always at my fingertips. I don’t blame them; the healthcare sector is complicated and going to the doctor is understandably not everybody’s cup of tea.

And in all fairness, it’s not easy to remember when we had our last tetanus vaccination or in which year we were in the local hospital.

I hope the following five tips will help to make the most of your doctor’s visit.

1. Gather information

Write facts down, together with your questions. The doctor may ask a few things such as: when you first noticed the problem, what made it better or worse, and what your main concerns are. Make sure you know what your questions and expectations are.

  • Tip: Feel free to do your research on the Internet and check your findings with the doctor. Remember that online health information may not be applicable to you.

2. Allow enough time

If you want to discuss a complicated issue or a few problems, consider booking a long appointment to avoid running out of time.

3. Ask a friend or family member to join you

Having someone with you is helpful in many ways: to ask questions, to remember what has been discussed, for support and to give you a lift to and from the clinic if you are unwell.

4. Keep a record of all your past and present health problems

This is important. Doctors always need background information about your health. Don’t automatically assume the doctor always has all the required information.

  • Tip: Your own record could include a list of your medical problems, diagnoses, hospital admissions, operations, medications, vaccinations, allergies to or side effects from certain medications, products or food. Outcomes of important tests are always helpful. Keep a paper record or store the information in a safe place on your computer, phone or preferably electronic health record.

5. Never leave things to the last moment

A doctor’s visit just before a holiday trip, or on a Friday afternoon may cause problems – for example if your doctor needs to do more tests or the recommended medications are not available in the pharmacy. Sometimes a last-minute visit is unavoidable but often good planning goes a long way!