How to Be Awesome in an Ambulatory Clinical Rotation

How can you hit the ground running on your first day when you join an outpatient primary care practice? As a student, you may be eager to have a great educational experience but sometimes it is hard to know where to start and how best to pitch in. In addition, work in primary care is fundamentally different from working in an inpatient setting and it will be important for you to understand these differences. Review these tips and strategies below so that you can become a valuable member of the team, improve the quality of care for your patients, and gain critical experience that will make you awesome.

How Is Outpatient/Ambulatory Primary Care Different from Inpatient Medicine?
In hospital settings most early clinical students will be responsible for a few patients at the most, although you will hear about many more on rounds. In the ambulatory environment, the patient volume is higher, visits are time limited, and the visit types differ between acute/problem-oriented, chronic disease follow-up, procedures, and wellness visits. The core features of traditional primary care practices, particularly family medicine practices, encourage the 4Cs: First Contact, Comprehensive, Continuous and Coordinated.

Primary care is different from the work done in emergency departments or in hospital settings. Pretest probability is different, relationships are fundamental, and approaches to problems differ. In particular, primary care physicians, nurse practitioners, and physician assistants stay mindful of the potentially ominous diagnoses that a presenting complaint may portend, but stay grounded in the more likely diagnoses. In addition, they tend to do more limited initial testing, treat for the most likely diagnoses, and use follow-up visits to gauge the success of treatment and the utility of further diagnostic tools, if needed. This is different from the “if you can think it, order it” approach to problems that is often present in the inpatient setting.

Outcomes for medical problems often play themselves out over a more protracted period of time in ambulatory care settings, highlighting the importance of continuity, one of the core features of primary care. Knowing when to intervene, if at all, understanding that “common things are common,” developing strong relationships, and providing context are critical learned skills for those doing primary care work.

Strategies: What Can I Do to Help?
To begin with, you should become familiar with the objectives of your course leaders and how you will be assessed. You should work to find time to learn from your preceptor(s) what they are most interested in from you, what your role is, and how you can contribute. See if you can get a tour of the clinic by someone. If this isn’t your primary preceptor, then maybe the practice administrator can give you the tour.

Presenting Your Patient Visits
Learn how to present patients to your preceptor. This is a delicate art, differs by setting and by preceptor, and can be challenging to do well. Some patient presentations will be done in the room with the patient (initially intimidating but ultimately this is a very useful skill to learn), and some will be done outside of the room. Each presentation will call for slight differences in approach. For acute/problem-oriented visits consider presenting your patient visit to your preceptor using the SNAPPS model:

a. Summarize briefly the history and findings
b. Narrow the differential to two or three relevant possibilities
c. Analyze the differential by comparing and contrasting the possibilities
d. Probe the preceptor by asking questions about uncertainties, difficulties or alternative approaches
e. Plan management for the patient’s medical issues
f. Select a case-related issue for self-directed learning

Context in primary care is an essential element of the work, and finding ways to incorporate a patient’s unique context into your presentation will win you points with your preceptor. “This middle-aged homeless, jobless, white, father of two” is more contextually rich than “A 53 y.o. man.” Presenting in front of a patient with “This 33 y.o. WF” will feel unnecessarily awkward, but “Julie is here today to discuss the back pain you reviewed at her last visit,” will be better.

Chronic Disease Follow-up
Preparing for and presenting patients who present for chronic disease follow-up is different. In particular, you will want to understand elements of how well the disease (or diseases) under discussion is under control both subjectively and objectively, if there are signs of complications, and how adherence to a treatment plan is proceeding, including plans that call for what can be significant lifestyle modifications. You will want to learn to use evidenced-based guidelines for the diseases under question and tools within the electronic health records that can aid in monitoring progress over time. Electronic health records also often offer suggestions for next steps, based on current guidelines.

Wellness Visits
Wellness visits offer a third and different type of medical visit. These are also called physicals or check-ups. How you prepare, gather information, and share data with your preceptor and patient will also be different from the acute/problem-oriented and chronic disease follow-up visits noted above. You will want to become familiar with guidelines that suggest what anyone of a give age, gender and risk factors should be concerned with. The US Preventive Service Task Force recommendations, https://www.uspreventiveservicestaskforce.org, are an excellent source of information on these topics. The core features of a wellness visit that you should consider can be condensed into a RISE mnemonic:

• Risk factor identification
• Immunization need/review
• Screening tests to consider
• Education

Focused Physicals
In addition, you will want to learn how to do focused physicals on your patients. The examination of a patient with an upper respiratory tract infection is going to be different from someone presenting with abdominal pain or even someone presenting for a physical and you should explore these differences. What is important to examine in the setting of a physical for an adult is also influenced by patient expectations and your provider’s unique practice style. Medicare wellness visits do not require a physical exam at all.

Outpatient clinical practice can provide great opportunities to develop common physical exam and procedural skills. Once you have the basics down, you may want to consider focusing on special exam skills that you feel you would like to improve upon. For example, ophthalmologic exams, shoulder exams, or monofilament exams for loss of protective sensation of the feet for patients with diabetes are all core clinical skills that you could focus special attention on developing skills in. If you have difficulty seeing the fundi in patients without dilation you may want to ask each patient you see in a given patient care session, if, in addition to whatever reason they are seeing you for today, you could also examine their eyes. When you think you have improved the skill through your practice, ask to be examined by your preceptor and solicit feedback.

Tips for Maximizing Your Learning Each Day
Below are particular ways in which you can add to your learning and make yourself useful.

1. Before the visit, you can:
   • Help with pre-visit planning, put in orders for preventive services where appropriate, pend orders for medication refills, determine what labs are needed, and call patients in advance of visits to discuss any pertinent issues. In addition, reading about your patients before their visit can provide critical contextual background that will help maximize your time with the patient.
   • Meet patients in the hospital prior to discharge, then see the patients during their outpatient visits post discharge.
   • Conduct concurrent visits with the preceptor. Your preceptor can complete one or more visits while you conduct basic components of another visit.
   • Give common patient education talks such as upper respiratory tract infections, constipation, etc. Ask your preceptor where they get their educational information from.
   • Participate in goal setting in advance of patient visits, for example, what will we ask and how? What is the anticipated outcome of the visit?
   • Review social histories and participate in care team huddles (often a feature of primary care) in order to understand patients. This often provides both the context and the planning needed to make patient visits successful.
     
     
2. During the visit, you can:
   • Room patients with the help of nursing staff.
     • Help patients and families complete developmental screening questionnaires, school physical forms, etc.
   • Perform medication reconciliation.
     • Assess for medication compliance, or adherence, a common issue
     • Assess for drug interactions.
     • Discuss medication side effects with patients.
     • Review
   • Help document care in EHRs.
     • Update problem lists and medication lists.
     • Write and pend orders and prescriptions.
     • Complete after-visit summaries and review them with patients.
   • Write encounter notes—(N.B. Your office may restrict if, how and where you can document in the health record, influenced by Medicare billing rules.)
   • Give immunizations.
   • Draw blood.
   • Find and review quality patient education materials with patients.
   • Create collaborative care plans or visit summaries with patients.
   • Perform scribe functions with your preceptor
   • Practice shared decision making and/or motivational interviewing with the patient
     
     
3. After the visit, you can:
   • Answer patient questions, with supervision, in EHR/patient portal “in basket” and communicate lab results to patients.
   • Call patients several days after visits. This provides an opportunity for you to ensure patients understand and are adhering to their treatment plans.
   • Provide care coordination by accompanying patients to specialty care visits, the hospital, the pharmacy, and/or their homes. This is especially good for complex patients. You can bring information back to the practice and share it.
   • Make calls to coordinate specialty visits, social work assessments, and/or referrals to other resources.
     
     
4. At the end of the day:
   • As you conclude your work for ½ or full day it can be extremely valuable to review what you learned and to discuss patients or experiences that left an imprint in you, or on your preceptor. Seek out this conversation if you can, while of course, always being attentive to timing and the mood/fatigue of your preceptor at the end of the day.
   • You can work with team members to help manage the care of populations by:
     • Following a panel of patients during the rotation (and possibly transitioning the population to the next student).
     • Work with front desk staff, lab techs, nurses, social workers, care managers or other staff who work as part of the health team. You do not need to be with physician preceptors throughout the day; others on the team have a lot to teach.
     • Set aside time to perform pre-visit planning and after-visit care.
     • Proactively reach out to patients who need care, for example, patients who have gaps in care, such as high A1c’s and those who haven’t received flu shots. Registries within electronic medical records can help with this.
     • Help teams meet quality metrics by working with patients and learn how to document this care in the health record.
       
       
5. You can also contribute to the team by:
   • Creating patient handouts that list reliable patient education websites.
   • Bookmarking quality patient education sites on office computers or within the health record.
   • Sharing information about high quality medical apps with preceptors and the practice team.

Look interested, stay curious, show initiative, and find ways to be amazing!

References

1. Society of Teachers of Family Medicine. Strategies to Ensure that Students Add Value in Outpatient Offices. https://stfmwebsite.azurewebsites.net/media/1348/studentsasaddedvalue2018.pdf
2. Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893-898.
3. Huffman, MM. Working in an Ambulatory Care Office. In Essentials of Family Medicine, 7th ed. Smith, Schrager, WinklerPrins, eds. Wolters Kluwer, 2019.

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