1. When a presentation stops fitting
Clinicians with complex patients Planned episode, outlier patients in primary care. How a clinician recognizes that a presentation has stopped fitting the usual categories, and what changes after that.
Listener title: When a presentation stops fitting the usual categories
Listener description: An anchor physician from a direct primary care or concierge practice talks about the point at which a presentation stops fitting the usual categories: what prompts the rethinking, where the time for it comes from, and what to write down for the next clinician. For physicians and advanced practice providers who carry complex patients over years.
Run of show (about 40 minutes)
| Time | Segment | What happens |
|---|---|---|
| 0:00 to 2:00 | Opening | The host introduces the theme and the guest's role. The guest states any industry relationships. The host notes that no patient information is discussed and that the guest speaks for themselves, not for the network. |
| 2:00 to 6:00 | The guest's practice | The guest describes the practice model in general terms: visit length, how patients reach them between visits, and how that shapes what they notice. If prices come up, they are discussed as method only. |
| 6:00 to 15:00 | The moment of rethinking | What made you stop and rethink, the last time it happened? The guest describes the signal without the patient: a finding that didn't match, a treatment response that wasn't expected, a pattern over time, something the patient said. The host asks whether it is usually one finding or an accumulation, and how the guest checks their own anchoring on an earlier label. |
| 15:00 to 24:00 | Where the time comes from | How much visit time does that rethinking take, and where does it come from? The guest explains how they schedule it: a dedicated long visit, two shorter visits, chart review between visits. The host asks how the practice model makes room for it and what gets displaced. |
| 24:00 to 31:00 | Composite scenario, not a real patient | A patient whose problem list has grown over several years across several specialists, each answer reasonable on its own, with prior labels from different clinicians and nothing objective tying them together. The host and guest talk through the next visit: rebuilding the illness timeline, listing each prior label and what it rested on, and deciding whether to look further or to watch. |
| 31:00 to 37:00 | Writing it down for the next clinician | What do you write down so the next clinician starts ahead of where you did? The guest explains what goes in the record and where it sits: the timeline, the pedigree, what has been excluded and how, the open question. The host asks what a referral to a structured multidisciplinary evaluation, such as the Undiagnosed Diseases Network evaluation described in Splinter 2018, needs from the primary care record. |
| 37:00 to 40:00 | Closing | Takeaway: keep a one-page summary at the top of the chart with the illness timeline, each prior label and what it rested on, what has been excluded, and the open question. Listeners reach the network at coloradocarenetwork.com/join/ or hello@coloradocarenetwork.com; podcast topics go to the same address, and members can post them in #podcast on Slack. |
Guest prep questions (sent to the guest a week ahead)
- Think of the last time a presentation stopped fitting for you. Without any patient details, what was the signal that made you stop: a finding, a pattern over time, a treatment response, or something the patient said?
- How do you make time for that rethinking in a direct primary care or concierge schedule: a dedicated long visit, chart review between visits, or something else? Roughly how much time does it take?
- How has your practice model (membership, visit length, panel size) changed what you notice compared with your earlier practice? If prices come up, please keep to method.
- What do you put in the chart, or give the patient to carry, so the next clinician doesn't start over? If you use a template, please bring a blank copy.
- How do you decide between referring to genetics or a multidisciplinary evaluation and continuing to observe, and what do you send with that referral? Please send any sources you plan to mention before recording.
Show notes
An anchor physician from a direct primary care or concierge practice describes how they recognize that a presentation has stopped fitting the usual categories. The conversation covers what prompts the rethinking, how much visit time it takes and where that time comes from, and what to document so the next clinician starts further along. A composite scenario, not a real patient, is used to walk through the next visit. The episode closes with one change to the chart that any practice can make.
- Sources:
- Splinter K, Adams DR, Bacino CA, et al. Effect of genetic diagnosis on patients with previously undiagnosed disease. N Engl J Med. 2018;379(22):2131-2139. doi:10.1056/NEJMoa1714458
- No patient information is discussed on this episode.
All planned episodes. To be the guest for this episode, email hello@coloradocarenetwork.com with the episode number.