Tomorrow I will see a patient who has been on a stable treatment regimen for years. Tomorrow someone else who wants that appointment will wait.
Sometimes I think the hardest part of my job as a PA in endocrinology is convincing patients that they don’t need me anymore. In specialty medicine, we take pride in getting to a diagnosis, helping a patient understand what is happening, and outlining a treatment plan. In some instances, changes only happen after months or years of trial and error together, building what feels like a vital relationship between patient and clinician. Each step of the way, we celebrate symptoms improving and lab values normalizing. But the quiet paradox of specialty medicine is that successful treatment often makes us unnecessary for ongoing patient stability. We teach and practice patient assessment, plan development, and approach to treatment adjustments, but less talked about is the ending of the therapeutic relationship, the de-escalation, transitioning back to primary care. Although it’s satisfying for me to tell a patient that they don’t need me anymore — that their regimen is stable, their labs are boring, the goal has been met — it’s also often fraught. Patients, it seems, don’t want to hear that it’s time to move on.
The uncertainty of how to end the therapeutic relationship is a common experience for clinicians. And there are myriad reasons that having that conversation with patients feels challenging. Patient comfort, defensive medicine, and system incentives for a full clinic are just a few of the friction points that drive clinicians back to the comfort of “see you in six months.” In specialty medicine, appropriate endings should be identified by stability and the ability of another clinician, generally in primary care, to carry forth the treatment plan with equal effectiveness. But just because something is appropriate doesn’t mean it always happens.
On the surface, it’s easy to identify the patients who are ready to graduate from specialty care. The challenge comes when these identified patients are not in alignment with their clinician on their readiness to move toward a plan of graduation. Or when primary care teams are overwhelmed and push back, requiring specialty involvement in their mutual patients’ care. Or when systems overload clinicians with overbooked schedules that beg for the break of an easy, stable follow-up over a potentially complex new patient evaluation.
From the patient perspective, there is an overwhelming theme of not wanting to leave specialty care because their condition only improved when they came to see a specialist. They identify the relationship itself as a part of the successful treatment. Patients worry that it will all fall apart when they leave. They are holding onto a fear of fragility, despite all the evidence of stability. For clinicians, letting go can feel risky too. Despite all confidence, there is a shadow of liability fear. If it does fall apart, am I liable for sending them away? And how many new patients can a clinician really see safely in a day? If all stable patients are sent away, will clinician schedules be overburdened with new, complex patient cases that overwhelm and result in errors? Thinking financially, reimbursement structures reward new patient visits, but systems volume expectations reinforce return patient visits.
So, when my schedule is full, who deserves the appointment more?
In a system with limited specialty clinicians, follow-up is not neutral. There is a fixed clinician capacity and steadily growing demand for timely patient encounters. When appointment wait times are months long, every stable patient scheduled means a new consult will continue to wait. When appointment slots are consumed by patients who may not truly need to be seen in that clinic, we are inadvertently withholding medical care from other patients. Yet often, we give them “just one more year” anyway — perhaps out of desire to avoid patient pushback or due to the subconscious discomfort in releasing patients and shifting strain back to our already overloaded primary care colleagues.
I would love to conclude that I mastered the graduation conversation with patients and streamlined the workflow of shifting patients smoothly back to primary care. Or that the system strain naturally resolves itself if you follow a well-defined sequence of steps. In reality, I am still a part of the patient access traffic jam, I still have a six-month wait list, and I am still testing out the language to use with patients to help them understand why letting go is not abandonment, but a marker of success.
But every day I am doing my best to maintain clearer graduation criteria for patients and care teams, recognizing that these conversations work best when they are not surprises. I am trying to set expectations early for time-limited follow-up and normalize the idea that specialty care is often temporary. I teach that the goal is stability and independence and help patients focus on their success, not mine. My hope is that with this framing, when the time comes that the active goals are achieved and the plan is to maintain, it feels less like a rejection of or indifference toward the relationship and more like a success. But just in case there is any lingering hesitation, I remind patients that the door is not closed. Returning is always an option if things change.
I love my stable, well-controlled patients. They are living proof that our work matters and makes a difference to people’s lives. But truly caring for them means recognizing when holding on serves neither them nor the system they rely on. Helping patients transition smoothly back into the care of their primary care clinicians and ending the therapeutic relationship is not failure, it is what happens when medicine works.
How do you set expectations with patients around follow-up? Share in the comments!
Carrie Keyes, PA-C, is a physician assistant in endocrinology based in Winston-Salem, NC, where she champions tech-forward diabetes care. She is passionate about advancing clinician education and shaping the future of diabetes management through research and advocacy. She is also involved in PA education and a strong voice for clinician well-being and safe, effective patient care. She is a 2025–2026 Doximity Op-Med Fellow.
Illustration by Diana Connolly
