1
What is outpatient medicine?
Outpatient medicine (or ambulatory medicine) refers to medical care that is delivered without admission to the hospital. The patient enters the facility where care is provided and then leaves once care is delivered.
2
What types of patients should not receive outpatient care?
Outpatient care is NOT appropriate if the patient is unstable and requires close monitoring or if subsequent treatment for the patient cannot be delivered at home (e.g., intravenous [IV] fluid or medications).
3
Where is outpatient care delivered?
Outpatient medical care is delivered in a number of settings. The most common site is the outpatient clinic (e.g., a doctor’s office). There are several types of outpatient clinics including primary care clinics, specialty clinics, and urgent/emergency care clinics. Outpatient care can also be delivered in surgical sites and procedural offices/suites.
4
What is primary care?
Primary care is the act of a healthcare provider that serves as the initial assessment of care for a patient. Primary care clinics are conducted in the outpatient setting and involve family physicians, internal medicine physicians, pediatricians, and some obstetrics/gynecology physicians.
5
Who should receive care at a primary care clinic?
All individuals should establish care in a primary care clinic. If possible, the clinic should be conveniently located and easily accessible.
6
Why do patients come to a primary care clinic?
Most new medical complaints are first evaluated at a primary care clinic. The complaint may be addressed within that clinic or the patient may be referred to a specialized clinic. However, if the patient is having severe symptoms that suggest an acute life-threatening process, the patient should present to the nearest emergency department.
Patients with previously presented complaints or chronic diseases may receive follow-up care in a primary care clinic if the healthcare provider at that clinic is comfortable managing the patient’s illness. For example, a diabetic patient may visit a primary care physician every 3 to 6 months to assess hemoglobin A1c and glucose levels.
Patients who originally presented to the emergency department or were recently admitted to the hospital usually follow up in a primary care clinic once their more immediate concerns are addressed and they have been discharged from the hospital. For example, an 85-year-old man admitted to the hospital with lobar pneumonia would be seen by his primary care provider after discharge from the hospital to ensure proper recovery.
A patient may also receive heath maintenance examinations at a primary care clinic. For example, a healthy teenager may present to the primary care clinic for a physical examination required for participation in athletics.
7
List the types of healthcare providers who deliver care in a primary care clinic
A list of primary care providers along with their required training and medical roles is displayed in Table 11-1 .
| Health Care Provider | Training and Medical Role |
|---|---|
| Internists | These are physicians who have completed a 3-year residency in internal medicine. These physicians will take care of the general health care needs of adults. |
| Pediatricians | These are physicians who have completed a 3-year residency in pediatrics. These physicians will mostly care for individuals younger than age 18. |
| Gynecologists | These are physicians who have completed a residency training program in obstetrics and gynecology (3 to 4 years). These physicians provide routine gynecologic care (Pap smears, breast examinations, birth control care, etc.). They also play the role of a medical specialist and see patients referred by nongynecologic physicians for gynecologic concerns. |
| Family physicians | These are physicians who have completed a 3-year residency in family medicine. They may take care of adults and/or children. They may also provide gynecologic and/or obstetric care. |
| Geriatricians | These are physicians who have completed a 3-year residency in either internal medicine or family medicine and have received additional training in caring for older patients with multiple medical problems (often a fellowship in geriatrics). They serve the general health needs of adults who are usually older than age 65 and often have several complicated medical issues. |
| Med/Peds | These are physicians who have completed a 4-year combined residency in both internal medicine and pediatrics. They care for patients of all ages but generally do not provide gynecologic care. These physicians often care for children with chronic diseases and can remain the primary care provider as the patient becomes an adult. |
| Nurse practitioners and physician assistants | These are individuals who may provide general health care for a variety of patients. They are not licensed physicians and usually provide care under the supervision of an appropriate physician. |
8
List the staff seen within an outpatient clinic along with their roles
The various staff within an outpatient clinic are displayed in Table 11-2 along with their training and role within the clinic.
| Medical Staff | Training and Medical Role |
|---|---|
| Attending physician | A physician who has completed medical school and residency. The attending is ultimately responsible for the care provided to the patient and must agree with the final assessment and plan. |
| Resident physician | A physician who has completed medical school and is currently in a residency program. In most outpatient clinics affiliated with an academic institution, the resident is the initial physician who speaks with and examines a patient, performs a physical examination, and comes up with a preliminary plan. He or she then staffs with the supervising attending. |
| Nurse | There may be a variety of types of nurses with different education training among the various outpatient clinics. A nurse is likely to be the one in charge of tasks such as administering shots, giving intravenous medications, or drawing blood. The nurse in some clinics also does the work of a medical assistant. |
| Medical assistant (MA) | The medical assistant is typically a staff member who transfers the patient into the examination room, obtains and records the vital signs, asks about the chief complaint, and then cleans the room after the patient leaves so that it is ready for the next patient. |
9
Describe a typical day in an outpatient clinic
A typical schedule in an outpatient clinic begins between 7 and 9 am . Daily responsibilities include patient evaluations, which are scheduled back-to-back, and note keeping. In clinics with electronic charts, notes are usually dictated and typed by an outside source. Once typed, they are available to the attending physician to proofread and sign and then become a part of the electronic records. However, in other clinics, notes are hand-written into paper charts. A typical full day ends between 4 and 6 pm .
It is not uncommon for physicians to work half-days, such as 8 am to 12 noon or 1 to 5 pm .
10
How long are patient visits within the outpatient setting?
The length of a patient visit depends on the reason for the evaluation. Yearly health maintenance examinations are usually scheduled for 45 minutes to 1 hour. Return visits for a chronic condition, such as diabetes, are usually scheduled for 15 minutes. New patient consultations at specialty clinics are usually scheduled for 30 or 60 minutes depending on the clinic.
11
What is a medical student’s role in the outpatient clinic?
In most clinics, after the patient has been transferred to the clinic room, the medical student will first see the patient alone. The student should introduce himself or herself as a medical student working with the patient’s physician, and then inform the patient that the attending will later be in to see the patient as well. The medical student should gather the history and conduct a physical examination. The student will then present the pertinent history and physical examination findings to the attending physician. Most attendings will also expect the student to provide an assessment and plan.
12
Describe the evaluation of a new patient with a new complaint
A new patient encounter should begin by obtaining a full history and performing a full physical examination. Key elements of the history include history of present illness, past medical history, family history, social history, current medications and dosages, and drug allergies. A full physical examination should be performed to establish a baseline examination for future visits and future complaints. These visits are typically scheduled for 45 minutes to 1 hour.
13
Describe the evaluation of an established patient with a new complaint
Although it is important to obtain a thorough history, it should be focused around the patient’s new complaint and previous medical conditions. A focused physical examination should be performed to further assess the differential diagnosis that was formed while the history was taken. These visits are commonly scheduled for a little as 15 minutes.
14
Describe the evaluation of a patient returning for follow-up care of a previous complaint
Before seeing a patient for a return visit regarding a chronic condition, the student should read the most recent follow-up note and in particular the plan stated at the end. Then the student can ask the patient if the plan was followed. The visit should focus on new developments since the most recent visit. These include control of symptoms, any interim exacerbations of the condition or related hospital visits, any changes in medications, medication compliance, and any relevant changes in social or family history. A focused physical examination should be performed. If laboratory tests or studies are generally used to assess the patient’s progress, the student should check the patient’s record for the results. If they are not in the chart, ask if they have been performed. If the laboratory results have not been obtained, include this information in the patient’s plan when presenting the patient to the physician.
15
What is a health maintenance examination (HME)?
An HME is typically conducted annually and involves an overall assessment of a patient’s health history, medical risk factors, physical examination, and required laboratory or diagnostic testing. Appropriate patient education is also provided to encourage patients to be aware of their health status and methods for improvement.
16
Describe the evaluation of a patient presenting for a regular check-up (HME)
For an HME, a complete history and physical examination should be conducted. In this case, having the patient’s previous medical record is helpful so that while in the patient’s room, the student can simply review and confirm the previous data. If this information is not available, the student should ask about the patient’s past medical history, medications, and allergies, and then ask if there have been any changes to other parts of the history. A complete history of present illness should be obtained if the patient has a new complaint at the time of the HME. For female patients, reproductive/gynecologic issues should be addressed including description of menstrual cycles, number of gestations, number of live-birth pregnancies, number of abortions, most recent Pap smear, and any previous abnormal Pap smear results. A complete review of systems should be obtained. The student should also determine whether the patient is up to date with his or her vaccines and age-appropriate screening studies. In addition, patients should be asked about general safety practices, such as seatbelt usage and sunscreen protection. These visits are typically scheduled for 45 minutes to 1 hour.
17
Describe the way in which a patient presenting for follow-up from an emergency department or hospital discharge should be addressed in the setting of a primary care clinic
The medical record from the hospital should be reviewed, including the discharge summary if available. Note the symptoms with which the patient presented at admission, the clinical course, discharge medications, the discharge diagnosis, and whether any issues were unresolved. Focus the medical history on current symptoms and medication compliance. Check the discharge instructions to determine whether any follow-up care such as suture removal is required.
18
What is a specialty clinic?
This clinic is for patients whose problems require the expertise of a specialist in a specific area of medicine such as cardiology or rheumatology.
19
Describe the pathways in which patients might arrive at a specialty clinic
Patients can be referred to a specialty clinic through several pathways, including from a primary care physician, from the emergency department, after discharge from the hospital, and from another specialty clinic.
20
Provide examples of specialty clinics
Specialty clinics tend to follow the organ systems. A list of common clinics is provided in Table 11-3 .
