Excelling in the Clinic: A Concise Guide for Medical Students 3030994147, 9783030994143

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Excelling in the Clinic A Concise Guide for Medical Students Clifford D. Packer

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Excelling in the Clinic

Clifford D. Packer

Excelling in the Clinic A Concise Guide for Medical Students

Clifford D. Packer Louis Stokes Cleveland VA Medical Center Cleveland, OH, USA

ISBN 978-3-030-99414-3    ISBN 978-3-030-99415-0 (eBook) https://doi.org/10.1007/978-3-030-99415-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my friends and family: Bob Packer, Laura Watson, Doug Tursman, Judy Packer, Tom Hornick, Nels Nelson, Lorraine Nelson, and Nenad Trifunovic

Preface

This is not a handbook on how to manage hypertension, diabetes, and heart failure in the clinic. There are many other good sources for that. This one can be thought of as a handbook of humanistic skills for the primary care clinic. These skills are widely taught in medical schools but in a somewhat scattered and disconnected way. My intent was to combine a broad discussion of humanistic patient care with practical points about how to work well in the clinic – how to do chart review, present cases concisely and discuss them thoroughly with the attending, and work with clinic staff in various settings – to create a comprehensive guide to being a thoughtful, sensitive, and capable medical student in the outpatient clinic. The second aim of this book is to challenge some students’ preconceived notions about primary care, and to demonstrate the awesome power of the incremental care we provide in the clinic to improve our patients’ lives and advance public health. I have tried to weave the humanistic thread into every chapter. Topics addressed include the public health implications of strong doctor-patient relationships, how to recognize a good role model and not be harmed by a bad one, how to optimize a telemedicine visit, and how to listen to the stories of homeless patients and understand that the goal is to help and support them as possible, not to redirect their lives. The heart of the book is Chap. 7, with its discussion of the patient-centered interview, motivational interviewing, shared decision-making, and dealing with talkative, angry, and distracted patients. For the sake of modernity, I have also included some discussion of cyberchondriasis (and its cousin,

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cybersomatization), an emerging anxiety disorder associated with repeated online searches for health information. In the last chapter, I make my case for medical students to consider a career in primary care, and describe the wonderful academic lives they can have as clinician-educators. This book is a product of the COVID-19 pandemic. I mention this not to make an excuse for its obvious shortcomings but to explain that it was written over 16 months with many interruptions, including two callbacks to the VA wards to help take care of COVID-19 patients during the surges. On the plus side (to paraphrase Samuel Johnson), there’s nothing like a pandemic to concentrate the mind, and I think it helped me to focus on the task at hand and consider my priorities as to the content and style of this book. I am also very proud of my current group of medical students, who are courageously donning their respirators to help care for so many sick patients during the present Omicron surge. I would like to express my thanks to my Springer editors, Miranda Finch and Dhanapal Palanisamy, for their forbearance and understanding as I went several months past the initial deadline for this manuscript. My gratitude also goes to Dr. Robert Bonomo for his ongoing support of academic endeavors and medical education at the Louis Stokes Cleveland VA Medical Center, and to all of my accomplished colleagues in the Primary Care Clinic. Cleveland, OH, USA January 17, 2022

Clifford D. Packer

Contents

1 The Importance of Primary Care��������������������������������  1 1.1 The Power of Incremental Care������������������������������  1 1.2 Effects of High-Quality Primary Care on Health Outcomes������������������������������������������������  3 1.3 The Long-Term Physician-Patient Relationship ����  5 1.4 Seeing the Big Picture��������������������������������������������  6 References������������������������������������������������������������������������  8 2 Medical Education in the Outpatient Clinic: Benefits and Barriers ���������������������������������������������������� 11 2.1 Benefits: Role Modeling, Mentoring, and One-on-One Teaching�������������������������������������� 11 2.2 Barriers: Stressed Clinical Preceptors and Student Preconceptions������������������������������������ 14 References������������������������������������������������������������������������ 18 3 Clinic Settings, Schedules, and Structures������������������ 19 3.1 Settings�������������������������������������������������������������������� 20 3.2 Schedules���������������������������������������������������������������� 22 3.3 Structures���������������������������������������������������������������� 23 3.4 Other Clinic Experiences���������������������������������������� 26 References������������������������������������������������������������������������ 28 4 COVID-19 and the Rapid Rise of Telemedicine���������� 29 4.1 How COVID-19 Has Changed Primary Care �������� 29 4.2 Telephone and Video Visits: Benefits and Limitations ������������������������������������������������������ 30

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4.3 Student Participation in Telemedicine�������������������� 32 4.4 Telemedicine Is Here to Stay���������������������������������� 36 References������������������������������������������������������������������������ 36 5 Role of the Student in the Outpatient Clinic �������������� 39 5.1 Active Versus Passive Clinic Experiences�������������� 39 5.2 What Your Clinic Attending Is Looking For ���������� 40 5.3 Increasing the Level of Responsibility: The RIME Framework�������������������������������������������� 43 5.4 Working with the Clinic Staff �������������������������������� 45 5.5 Following Up on Test Results and Consults ���������� 45 References������������������������������������������������������������������������ 46 6 Preparing to See the Patient������������������������������������������ 47 6.1 Chart Review and Creating an Agenda for the Visit�������������������������������������������������������������� 47 6.2 More Thoughts on the Agenda: “I Just Want to Know If I’m Healthy Enough for Bacon”���������� 53 References������������������������������������������������������������������������ 55 7 The Patient-Centered Interview ���������������������������������� 57 7.1 Basics of the Patient-Centered Interview���������������� 57 7.2 Greeting and Introduction �������������������������������������� 61 7.3 Begin with an Open-Ended Question, and Listen Carefully to the Answer������������������������������������������ 62 7.4 Look at the Patient, Not the Screen������������������������ 63 7.5 Med Reconciliation������������������������������������������������ 64 7.6 Evaluate New Symptoms with Pertinent Positives and Negatives������������������������������������������ 65 7.7 Review of Systems�������������������������������������������������� 67 7.8 Using Motivational Interviewing for Behavioral Change�������������������������������������������������������������������� 68 7.9 Dealing with Talkative, Angry, and Distracted Patients�������������������������������������������� 70 7.10 Cyberchondriasis���������������������������������������������������� 74 7.11 Shared Decision-Making���������������������������������������� 76 References������������������������������������������������������������������������ 81

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8 The Physical Exam�������������������������������������������������������� 83 8.1 (Lack of) Evidence for the Routine Physical Exam�������������������������������������������������������� 83 8.2 The Irrational Physical Exam?�������������������������������� 86 8.3 Checking Your Exam Findings with the Attending���������������������������������������������������������� 87 8.4 Point-of-Care Ultrasonography in the Primary Care Clinic������������������������������������������������ 88 References������������������������������������������������������������������������ 90 9 The Concise Oral Case Presentation���������������������������� 93 9.1 The SOAP-Style Oral Presentation������������������������ 94 9.2 Schema for the Oral Case Presentation in the Clinic������������������������������������������������������������ 95 9.3 Using the Problem List as a Guide ������������������������ 96 9.4 Examples of Oral Presentations������������������������������ 97 9.4.1 The Routine Follow-Up Visit���������������������� 97 9.4.2 The Posthospital Visit �������������������������������� 99 9.4.3 The Urgent Visit������������������������������������������100 9.4.4 The New Patient Visit ��������������������������������101 References������������������������������������������������������������������������103 10 Discussing the Case��������������������������������������������������������105 10.1 Identifying Key Learning Points from the Case����������������������������������������������������������������106 10.2 Using SNAPPS for Case Presentation, Discussion, and Teaching��������������������������������������108 10.2.1 Standard Case Discussion ����������������������109 10.2.2 SNAPPS-Style Case Discussion (Same Patient)����������������������������������������110 10.3 Researching the Case and Reporting Your Findings��������������������������������������������������������112 10.4 Questioning Dogma in the Clinic ������������������������113 10.5 Responding to Feedback ��������������������������������������119 References������������������������������������������������������������������������120

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11 Writing a Clinic Note����������������������������������������������������123 11.1 The Classic SOAP Note and Its Function������������123 11.2 How Not to Write a Progress Note: Things to Avoid����������������������������������������������������126 11.3 Examples of Concise Clinic Notes ����������������������129 11.3.1 Note #1. 55-Year-Old Woman����������������130 11.3.2 Note #2. 71-Year-Old Man ��������������������132 11.3.3 Note #3. 71-Year-Old Woman����������������134 11.3.4 Note #4. 67-Year-Old Man ��������������������137 11.3.5 Note #5. 74-Year-Old Man ��������������������139 11.3.6 Note #6. 55-Year-Old Man ��������������������142 11.3.7 Note #7. 66-Year-Old Man ��������������������143 11.3.8 Note #8. 92-Year-Old Man ��������������������145 12 Service-Learning Clinics ����������������������������������������������149 12.1 Working in Shelters and Homeless Clinics����������149 12.2 Student-Run Free Clinics��������������������������������������154 12.3 Challenges and Satisfactions of Caring for the Underserved����������������������������������������������������������156 12.4 The Silver Chalice������������������������������������������������157 References������������������������������������������������������������������������160 13 Careers in Primary Care����������������������������������������������163 13.1 Traditional, Nontraditional, and Academic Practice Options����������������������������������������������������163 13.2 Finding Your Niche in Primary Care��������������������167 13.3 Academic Careers in Primary Care: How to Get There��������������������������������������������������170 13.4 The Future of Primary Care����������������������������������174 References������������������������������������������������������������������������175 Subject Index ������������������������������������������������������������������������177 Author Index �������������������������������������������������������������������������181

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The Importance of Primary Care

1.1

The Power of Incremental Care

My patient was in his mid-forties when I first met him. He had a long history of steroid-dependent sarcoidosis that had led to dozens of hospitalizations and a host of complications, including diabetes, hypertension, avascular necrosis of both hips and shoulders, nonalcoholic fatty liver disease, osteoporosis with lumbar compression fractures requiring kyphoplasty, and obesity. He was bedeviled by intractable asthma symptoms and severe chronic pain. He was found to have endobronchial sarcoidosis with obstructing webs that required bronchoscopic dilation. His pulmonologist and I made several attempts to wean down his steroids, but his asthma symptoms inevitably flared up when we dropped the prednisone dose below 40 mg/day. He had poorly controlled diabetes and hypertension despite high doses of insulin and three antihypertensive medicines. His liver function tests spiked alarmingly, and he was found to have severe fatty liver disease on ultrasound. He developed truncal obesity and Cushingoid facies from the steroids, and eventually required bilateral hip and shoulder replacements for the avascular necrosis. He was oxygen-­dependent and used a power wheelchair to get around. I saw him frequently in clinic and struggled to control his hypertension and diabetes. Sometimes we would make progress,

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 C. D. Packer, Excelling in the Clinic, https://doi.org/10.1007/978-3-030-99415-0_1

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but he was hospitalized every few months and treated with huge doses of steroids with very slow tapers, which inevitably set us back. After a couple of years of frustration and worsening polypharmacy with very little progress, I came to see very clearly that most of his medical problems were complications of his long-­ term corticosteroid treatment and that we had to find a way to get him off steroids permanently or he would die. I had a long discussion with his pulmonologist, and we decided to start azathioprine and taper off the prednisone very slowly. After 6 months, he was steroid-free. His truncal obesity and facial puffiness resolved, he lost 40 pounds, his hypertension improved, his liver function tests normalized, and we were able to wean off the insulin and treat his diabetes with metformin alone. Best of all, his intractable wheezing disappeared, and he was breathing comfortably for the first time in years. He did physical therapy and pulmonary rehab and was able to improve his endurance and get around a bit without his wheelchair. He still has chronic pain requiring opioid treatment, and still uses oxygen as needed, but his long-term prognosis is much better and his quality of life has improved dramatically. This patient’s experience shows the power of what Atul Gawande has described as “incremental care,” as practiced in primary care clinics by internists, pediatricians, and family practitioners. Although we primary care physicians may sometimes effect rapid cures, our practices consist mainly of patients with chronic diseases whom we see regularly and treat with incremental adjustments in their medications, along with appropriate screening and preventive measures. We provide this care in the context of a long-­ term doctor-patient relationship where we understand our patients’ preferences and goals of care. Surgeons and interventional radiologists are the “rescuers” who make dramatic interventions with life-changing procedures. We generalists are incrementalists; at every visit we adjust, recalibrate, and try to bend the arc toward better health. Our process is gradual, but our results are no less dramatic. “Primary care,” writes Gawande, “is the medical profession that has the greatest overall impact, including lower mortality and better health, not to mention lower medical costs.” He compares good treatment for hypertension to bridge maintenance: “It requires active monitoring and incremental fixes and adjust-

1.2 Effects of High-Quality Primary Care on Health Outcomes

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ments over time but averts costly disasters” [1]. The same process applies when we treat our patients with diabetes, heart failure, COPD, asthma, and coronary artery disease. We also attend to the underlying problems that are worsening our patients’ chronic conditions. My patient with alcoholic cardiomyopathy will not do well if she continues to drink, however skillfully I manage her heart failure medicines; and the patient with severe peripheral vascular disease who smokes two packs a day will probably lose his leg, even with daily aspirin and a high-intensity statin, unless I can find a way to help him quit smoking. Another trait of incrementalists is that we tend to take a conservative and expectant approach to new symptoms when the cause is not immediately clear. Rather than order a barrage of tests, we wait and monitor and ask our patients to call back in a few days if they’re not doing better. We understand that time is an ally and that nonspecific symptoms often resolve within a few days or weeks. If the symptoms don’t resolve, they usually become more focused and specific, and a potential diagnosis begins to emerge. Then, we order testing to confirm that diagnosis. For every ten patients I’ve seen in the clinic for nonspecific abdominal pain, with no red flags such as fever, weight loss, and blood in the stool, nine have gotten better on their own, either with empiric treatment such as antacids or no treatment at all. It is important for medical students to understand that the incremental care they observe and begin to practice in the clinic is not trivial or marginal, however small the steps that are taken on a given day. Look back in the chart, read the past progress notes. You might find a surprisingly dramatic story of change for the better when you realize where the patient was a few years ago.

1.2

 ffects of High-Quality Primary Care E on Health Outcomes

There is compelling evidence that the availability of high-quality primary care correlates with better health outcomes, reduced health disparities across socioeconomic groups, and decreased costs of care. In the United States, states with higher ratios of

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primary care physicians have better health outcomes, including decreased mortality from cancer, cardiovascular disease, respiratory tract diseases, and stroke [2, 3]. Several studies have shown an association between availability of primary care and increased life expectancy. In England, each additional general practitioner per 10,000 population was associated with a 6% decrease in mortality [4]. A county-by-county study of US epidemiologic data from 2005 to 2015 found that adding 10 primary care physicians per 100,000 population was associated with a 51.5-day increase in life expectancy. “The largest decreases in cause-specific mortality associated with increased primary care physician density were for cardiovascular disease, cancer, and respiratory tract disease, conditions with strong evidence of amenability to primary care management or with delayed mortality conditional on early screening through primary care” [3]. Unfortunately, however, the authors noted that the overall density of primary care physicians decreased from 46.6 to 41.4 per 100,000 over that same 10-year period. Another US study found that adding 1 primary care physician per 10,000 patients resulted in a 5% decrease in outpatient visits, a 5.5% decrease in inpatient admissions, a 10.9% decrease in ER visits, and a 7.2% decrease in surgeries [5]. There is also evidence that primary care physicians provide better preventive care and more cost-effective care than specialists. When compared with family physicians, rates of hospitalization were 100% higher with ongoing care provided by cardiologists, and 50% higher when provided by endocrinologists [6]. It has also been found that care for common illnesses such as community-acquired pneumonia is more expensive if provided by specialists rather than generalists, with no difference in outcomes [7]. Furthermore, it appears that increased availability of primary care can compensate to some degree for the negative health effects of income inequality [8]. An estimated 13% of Americans live in an area with a primary care shortage, and without drastic increases in physician supply, this trend is likely to worsen. Despite a 31% increase in US medical school enrollment between 2002 and 2018 [9], a 2020 report from the Association of American Medical Colleges predicts a shortfall of between 21,400 and 55,200 primary care physicians

1.3 The Long-Term Physician-Patient Relationship

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by 2033 [10]. This shortfall will be driven by population growth and aging, and by physician retirements—more than 40% of the physician workforce will be 65 or older by the end of the next decade. Between 2018 and 2033, the US population is projected to grow from about 323 million to 361 million, with a 45% increase in the 65-and-over population by 2033. Nurse practitioners and physician assistants are taking up some of the slack, and osteopathic medical schools, which traditionally produce more primary care physicians, are also increasing enrollment. But we must take steps now to meet the demand for high-quality primary care. A good start would be to matriculate more of the idealistic (and diverse) students who are predisposed to primary care careers, maintain their interest with great mentors and strong primary care rotations in medical school, and incentivize them with better pay, reasonable lifestyles, and academic practice opportunities. The stakes are high: if we fail to meet the demand for primary care physicians, our patients’ life expectancies will continue to fall, spending will continue to rise, and the injustice of healthcare inequities will persist for the next generation of children.

1.3

 he Long-Term Physician-Patient T Relationship

The long-term physician-patient relationship has been described as “an essential element of good primary care” and “the defining experience of generalist practice” [11]. Any experienced primary care physician would agree enthusiastically with these statements; long-term relationships with patients are essential for a satisfying and successful practice. In my own 23-year VA clinic career, I’ve gotten to know my cohort of long-term patients so well that I can anticipate their symptoms and new complaints, and sometimes even respond to their unexpressed anxieties and unspoken questions. I know who likes to tinker with motorcycles, who walks his dog twice a day, who goes to work every day at age 93, and who still mourns deeply for a spouse who died 12  years ago. When they call in with new problems, I generally know when to offer reassurance and when to be concerned. I know most of them well

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enough to have frank discussions about their expectations and goals of care. Knowing patients well, and having their trust, can allow for diagnostic restraint and a careful, measured approach to treatment. The positive effects of long-term physician-patient relationships have been demonstrated in two studies. In an analysis of 6551 primary care physicians and 1.17 million Medicare beneficiaries, Bazemore et  al. [11] found that rates of hospitalization were 16% lower and adjusted expenses were 14% lower for the highest quintile of physician-level continuity of care, as compared with the lowest quintile. Similarly, Weiss and Blustein [12] found that 36% of Medicare patients had ties with their physician lasting 10 years or more and that these patients had substantially lower hospitalization rates and expenses than patients with physician ties of 1  year or less. These results confirm the importance of long-term relationships with our patients, and beg the question of why we are not doing more to make long-term careers in primary care attractive to young physicians. The other part of the solution is to provide stable universal healthcare for patients, without the restrictions and interruptions in their coverage that make long-­ term ties with one primary care physician impossible for so many of them.

1.4

Seeing the Big Picture

The role of the primary care physician vis-à-vis specialists can be understood by revisiting the old Indian folktale of the blind men and the elephant. In the parable, six blind men have a heated argument about what an elephant might be, based on what they have heard and imagined. The villagers tire of their argument and bring them to the Rajah’s palace, where they can examine an actual elephant. Of course, as the story goes, one grabs the trunk and thinks it’s a giant snake, another touches a leg and thinks it’s a tree, a third touches an ear and insists it’s a giant fan, and so forth. The blind men argue even more heatedly until the wise Rajah interrupts them: “The elephant is a very large animal. Each man

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touched only one part. Perhaps if you put the parts together, you will see the truth.” It might be a little unfair to say that the primary care physician is the wise Rajah and specialists are the argumentative and self-­ deluded blind men. After all, we rely on specialists for their expert opinions in complex cases and their technical and procedural skills. Yet when it comes to seeing the big picture and understanding our patients’ perspectives and best interests, we have the advantage of knowing the whole elephant. We’ve known our patients for a long time. Beyond their medical histories, we understand their preferences, their strengths and limitations, their fears and anxieties. We can often predict their compliance with a complex treatment regimen based on what we know of their health literacy and their social situation. We can also ask them the questions that others may be afraid to ask. One of my patients with end-stage heart failure had been receiving hospice care at home until his domineering sister-in-law told him he didn’t need it and was so abusive to his hospice nurses that they refused to return. When he showed up at the ER short of breath, massively volume-­ overloaded and hypotensive, the initial plan was to admit him to the ICU on the cardiology service for pressors and a furosemide drip. I visited him in the ER and asked him what he wanted to do. His sister-in-law tried to answer for him, and I asked her to let him speak. He hesitated for a moment, and then said quietly that he didn’t want any more aggressive treatment for his heart failure— he only wanted to be kept comfortable. This was consistent with what he had told me several times in the clinic over the past few months. It was hard for him to overrule her, and I don’t think it would have happened if I hadn’t asked her to let him have his say. He died a few days later under hospice care, quietly, with no pressors or chest compressions or electrical shocks. It really helped to have somebody there in the ER who knew something about his prior wishes as well as his difficult family dynamics. Primary care doctors provide incremental care that improves outcomes, reduces costs, and helps to correct health inequities. Long-term physician-patient relationships provide long-term benefits. Getting to know our patients well and seeing the big picture

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can help tremendously with treatment decisions and determining goals of care. Good primary care is essential to the health of the nation and the world. We need more primary care physicians. These are important facts to consider as you prepare for your first primary care rotation. When you come to work in the clinic, find a role model and focus on the process of primary care. We listen to our patients, observe and monitor symptoms, treat conservatively where possible, intervene as necessary, use resources wisely, and make it our daily task to relieve pain and reduce anxiety. These are the key skills you need to learn in the clinic.

References 1. Gawande A. Tell me where it hurts. The New Yorker; 2017. p. 37–45. 2. American College of Physicians. How is a shortage of primary care physicians affecting the quality and cost of medical care? Philadelphia: American College of Physicians; 2008: White paper. 3. Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of primary care physician supply with population mortality in the United States, 2005–2015. JAMA Intern Med. 2019;179(4):506–14. 4. Gulliford MC. Availability of primary care doctors and population health in England: is there an association? J Public Health Med. 2002;24(4): 252–4. 5. Kravet SJ, Shore AD, Miller R, Green GB, Kolodner K, Wright SM.  Health care utilization and the proportion of primary care physicians. Am J Med. 2008;121(2):142–8. 6. Greenfield S, Nelson EC, Zubkoff M, Manning W, Rogers W, Kravitz RL, et al. Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA. 1992;267(12):1624–30. 7. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502. 8. Shi L, Starfield B, Kennedy B, Kawachi I.  Income inequality, primary care, and health indicators. J Fam Pract. 1999;48(4):275–84. 9. 2018 medical school enrollment survey. aamc.org/system/files/2019-­08/ resultsofthe2018medicalschoolenrollmentsurvey.pdf. Accessed 2 Aug 2020.

References

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10. The complexities of physician supply and demand: projections from 2018– 2033. https://www.aamc.org/data-­reports/workforce/data/complexities-­ physician-­supply-­and-­demand-­projections-­2018-­2033. Accessed 2 Aug 2020. 11. Bazemore A, Petterson S, Peterson LE, Bruno R, Chung Y, Phillips RL Jr. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16(6):492–7. 12. Weiss LJ, Blustein J. Faithful patients: the effect of long-term physician-­ patient relationships on the costs and use of health care by older Americans. Am J Public Health. 1996;86(12):1742–7.

2

Medical Education in the Outpatient Clinic: Benefits and Barriers

2.1

 enefits: Role Modeling, Mentoring, B and One-on-One Teaching

Over the years, I’ve worked with several MD/PhD students in my primary care clinic and in the ER. Our medical scientists in training are assigned to work in the clinical setting for one-half day per week while they complete their PhD research projects. The purpose is to keep their clinical skills sharp during the long hiatus between the second and third years of medical school. One benefit of this program (both for me and my students) is the wonderful long-term relationship that develops over the 2–3 years we work together, a true apprenticeship in the most positive sense of the word. It begins with the student shadowing me for a couple of sessions as I see patients, and then a gradual increase in responsibility as the student learns to review the chart, take an interval history, perform a focused exam, develop an assessment and plan, and write a concise progress note. After a few months, my students are working semiautonomously, seeing patients, writing notes, and discussing the key points with me. I always see the patient with them and confirm their findings, but more often than not they’re right on target with their assessments. Although mentors are often great role models, mentoring and role modeling are different things. Mentors have long-term rela-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 C. D. Packer, Excelling in the Clinic, https://doi.org/10.1007/978-3-030-99415-0_2

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2  Medical Education in the Outpatient Clinic: Benefits and Barriers

tionships with their students; role modeling can be done once or twice, with no long-term relationship, and still may have profound positive or negative effects on students. I remember quite clearly the fine role modeling of many of my attendings and residents when I was a medical student—the internist who took me on nursing home rounds and explained pharmacokinetics in elderly patients, the plain-spoken attending who rounded on his patients 365 days a year and taught me the basics of diabetic ketoacidosis treatment (“saline, insulin, potassium, glucose…”), and the residents who worked all day and all night and most of the next day to keep their patients alive and as comfortable as possible. I also remember the negative role models—a surgeon who joked “don’t buy any long-playing records” while he was operating on a patient with metastatic cancer and another who continually screamed “too long!” and “too short!” when I was cutting sutures (I found out later that he did this with all medical students as a kind of sadistic standing joke, regardless of how the sutures were cut). These experiences had a definite role in my decision to eliminate surgery as a career option and opt instead for internal medicine. Clinical teachers need to be aware that even brief encounters with students can have profound effects—for better or worse—on their career choices. Benbassat makes the argument that medical students should be warned against “uncritically imitating preceptors who are perceived as role models,” and should instead be taught to make a “reflective assessment of their preceptors’ professional behaviors, especially so that they can better discern those that are worth imitating.” He elaborates: …Although imitation is important for students’ initial adaptation to the clinical environment, sustained uncritical imitation of role models may stifle students’ critical reflection and prevent students from responding to evolving ethical norms and patients’ needs. It may also promote a judgmental right/wrong dualism towards values and behaviors. Therefore, I suggest that faculty should warn students against the tendency to uncritically imitate one or more of their tutors, because none of them is error-proof, and none of them combines, at all times, all of the qualities of the ideal clinician. Rather, students should be encouraged to critically assess the attri-

2.1  Benefits: Role Modeling, Mentoring, and One-on-One…

13

butes of their clinical preceptors, with an intention to select those attributes that are perceived useful and worth adopting. [1]

I would argue that mature, thoughtful students do this naturally to some extent, but a self-conscious practice of “reflective imitation” could help learners to get the maximum benefit (and avoid harm) from their role models. Reflection on the role modeling process is also important for clinical teachers. I know that I’m not always a perfect role model myself, but I’m continually conscious of my influence when working with students. This self-awareness, seeing oneself at all times from the student’s point of view, is essential for preceptors who want to be good role models. It has also been recommended that “role modeling should be explicit in clinical teaching, as it is important for teachers to make an ­intentional effort to articulate what aspects they are modeling” [2]. For example, I might listen for a few minutes without interrupting as my patient talks about her pain symptoms, and then take the student aside to discuss the importance of actively listening to patients as a way of building trust and respecting their values and priorities. Or I might say, more proactively, “I’m going to show you my approach now to talking respectfully and constructively with a patient who is frustrated by her chronic pain. We’ll see how it goes and then we can talk about it afterward.” This is an open and collegial approach to role modeling that invites comments and questions from the student. Sitting down with an attending and deconstructing a patient encounter can be a highly formative and memorable experience for a medical student. In their review of the literature on doctor role modeling in medical education, Passi et al. note that “medical students experienced strong feelings of powerlessness and conflict during clerkships between what they had learned about patient-centered care in the first two years and what they saw modeled in the third year” [2]. Negative role modeling happens mostly in the informal or “hidden” curriculum, and often involves such things as derogatory humor, inappropriate discussion of gender and race issues, criticism of departments and institutions, and persistence of hierarchies (the student goes out to get coffee for the team). These should be recognized by students as unprofessional and unaccept-

2  Medical Education in the Outpatient Clinic: Benefits and Barriers

14

able behaviors. Teachers who establish a rapport with learners, assign plenty of patient interactions, and create a positive, supportive educational environment should be looked up to as role models. The key for students is to reflect on their teachers’ attitudes and behaviors and actively seek out the best role models.

2.2

 arriers: Stressed Clinical Preceptors B and Student Preconceptions

Medical students should be aware that primary care physicians often face considerable barriers to teaching in the clinic. A 2016 survey of internal medicine clerkship directors on the state of ambulatory undergraduate medical education [3] revealed that the leading barriers to having learners in the clinic were reduced physician productivity, lack of time for teaching, and inadequate financial support for teaching (see Fig.  2.1). Inadequate space for learners, short patient visits, and lack of ambulatory teaching skills (especially for community physicians) were also common problems. Students heading into their clinic rotations should not expect long sessions of uninterrupted teaching and unlimited Clerkship Directors’ Perceived Barriers for Each Teacher Type Physicians not interested in ambulatory teaching

Inadequate financial support inadequate for teaching

Physicians not skilled at ambulatory teaching Learners add too much work to clinic

Inadequate space in clinic for learners Patient visits are not long enough to accommodate learners Learners add too much time to clinic Learners presence reduces physician productivity 0

10

20

Community Physicians (N=59)

30

40

50

60

Affiliated (N=65)

70

80

90

100

Academic (N=82)

Fig. 2.1  Barriers to teaching medical students in ambulatory internal medicine clinics. (Reproduced with permission from Elsevier [3])

2.2  Barriers: Stressed Clinical Preceptors and Student…

15

time with their assigned patients. Ponderous and exhaustive ward-style patient presentations will not be tolerated—there is no time to waste and concise presentations are essential with a packed schedule of patients. Teaching will be done mostly on the fly, and a typical day’s lessons might include 2 minutes on the distinguishing features of the shingles rash, learning the correct technique for palpating pulses in the feet, discussing the indications for starting a patient on insulin, and learning the lateral approach for a knee injection. In the clinic, where patient care is incremental, learning must be incremental as well. Clerkship lectures, conferences, and independent reading supplement what is learned in the clinic and provide the broad background knowledge that is essential for practice. The importance of reading every day about the patients and diseases that were seen in the clinic cannot be overstated. No one expects medical students to provide financial support for their clinic teachers, but there is a great deal students can do to help them with the productivity and teaching time issues: Get to Know the Clinic and How It Operates  Introduce yourself to the clinic nurses, social workers, and clerks. Learn quickly about the clinic workflow, how to use the electronic medical record, where supplies are stored, and other clinic logistics. Become a useful and efficient part of the clinic team. Review the Chart Carefully Before Each Patient Encounter  Read the latest progress notes and discharge summaries, and know your patients’ major medical problems and recent lab and imaging results before you see them. If your data collection is thorough, accurate, and consistent, your attending will have more time to teach you. Take an Appropriate Interval History and Review of Systems, and Have the Vital Signs and Findings from your Focused Physical Exam Ready When You Present the Patient  Your attending will always review key parts of the history and physical exam with the patient. However, if you can accurately present the relevant H&P findings to the attending beforehand, you will earn their trust and

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2  Medical Education in the Outpatient Clinic: Benefits and Barriers

allow them to spend less time confirming the findings and more time expounding on the case with you. Writing good progress notes that do not require extensive editing and addenda by the attending will also make more teaching time available. Be Proactive About Your Learning and Teaching  Instead of waiting passively for your attending to come up with teaching points after you’ve presented a case, you can immediately bring up one or two questions or discussion points that you’d like to cover. You might even volunteer to read about some aspect of the case (e.g., the new research on the benefits of SGLT-2 inhibitors in the treatment of heart failure) and report back tomorrow with your findings. This absolves the attending of some of the ­responsibility for initiating the teaching, and shows that you are interested, proactive, and motivated to learn. Sometimes, especially in busy community clinics, the barriers to teaching can be very hard to overcome. Students may find themselves in the role of passive observers, “following” the attending rather than seeing patients on their own. This is fine for first-year students, but third- and fourth-year students need to see, present, and discuss patients in order to prepare themselves for residency. It is absolutely appropriate for students to request a more active role if they are asked to be observers. In my experience, most community physicians will allow students to see patients on their own (and enjoy the more robust teaching and discussion that goes with it) once they understand the issue. If not, it’s probably best for students to report the problem to their clerkship director and transfer to a more accommodating clinic if possible. Sometimes a student’s preconceptions about primary care can be a barrier to effective teaching and learning in the clinic. A study of undergraduate premedical students found widespread negative opinions and misconceptions about primary care, even as early as the Freshman year. Primary care physicians were perceived as overworked, poorly paid, lacking in prestige, and unglamorous, and their work was seen as uninteresting, with less autonomy and

2.2  Barriers: Stressed Clinical Preceptors and Student…

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responsibility because they were compelled to refer to specialists. Misconceptions included the idea that primary care physicians treat only “simple” illnesses, that board certification is not necessary, and that “there was only one family practice residency in the United States” [4]. The notion that primary care physicians deal with trivial content and problems is one of the most pernicious and damaging misbeliefs that some students bring to the clinic. The family physician John Geyman has written that: Generalist physicians are attracted to the front-line nature of their work, dealing as they do with a wide spectrum of care spanning the entire life cycle (in the case of family medicine), medical emergencies, screening and prevention, diagnosis and management of acute and chronic illnesses, counseling and long-term care. They are prepared to definitively manage the majority of the problems ­ brought to them, arrange for consultation with appropriate specialists when necessary, and then co-manage many patients with consulting specialists thereafter. [5]

When confronted with the argument that “anyone can do primary care,” Geyman counters that generalist physicians “are willing and able to cope with the intellectual challenges and ambiguity of primary care practice, enjoy working closely with people, and have a mindset looking for patterns of illness beyond the shackles of arbitrary specialty boundaries.” In response to the notion that primary care deals with trivial content and simple problems, Geyman cites a 2011 study that compared the complexity of outpatient encounters in family medicine, cardiology, and psychiatry. The study found that care during family medicine visits was more complex than the care provided in cardiology and psychiatry visits, probably because primary care patients present earlier in the course of their illness with less differentiated disease, which makes the input less clear and the diagnostic process more complex. Shorter visits and time pressure were also found to increase the complexity for family physicians [6]. It is true that primary care physicians work very hard, their lives are not glamorous, and their pay puts them near the bottom

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of the physician food chain. But the work they are doing is incredibly important. They make difficult decisions every day in the face of uncertainty. They deal with diagnostic complexity and figure out the best, safest, and most cost-effective testing and treatment strategies for their patients. They are the champions of screening and preventive care. Most importantly, they know their patients well, understand their preferences, and strive to deliver patient-­ centered care. Medical students need to shake off their preconceptions about primary care and open their eyes to the life-changing work that goes on every day in the clinic.

References 1. Benbassat J.  Role modeling in medical education: the importance of a reflective imitation. Acad Med. 2014;89(4):550–4. 2. Passi V, Johnson S, Peile E, Wright S, Hafferty F, Johnson N. Doctor role modeling in medical education. BEME guide no. 27. Med Teach. 2013 Sep;35(9):e1422–36. 3. Shaheen AW, Alexandraki I, Fazio SB, Lo MC, Packer CD, Jasti H, et al. The state of ambulatory undergraduate internal medicine medical education: results of the 2016 Clerkship Directors in Internal Medicine Annual Survey. Am J Med. 2019;132(5):652–7. 4. Gold JA, Barg FK, Margo K.  Undergraduate students’ perspectives on primary care. J Prim Care Community Health. 2014;5(4):279–83. 5. Myths and misperceptions about primary care. https://pnhp. org/2011/08/22/myths-­a nd-­m isperceptions-­a bout-­p rimary-­c are/. Accessed 17 Oct 2020. 6. Katerndahl D, Wood R, Jaén CR. Family medicine outpatient encounters are more complex than those of cardiology and psychiatry. J Am Board Fam Med. 2011;24(1):6–15.

3

Clinic Settings, Schedules, and Structures

I’ll never forget my first day as a practicing general internist. I had just finished my residency and had been prepping intensively for my internal medicine boards, and felt that I was ready for anything. I was up on all the latest guidelines and treatments for heart failure, diabetes, hypertension, COPD, and chronic kidney disease. I had read the classic articles and reviewed the most recent randomized trials. I had a whole pharmacopoeia of drugs at my disposal, and knew their indications, contraindications, mechanisms of action, and adverse effects. I entered the exam room to see my first patient, a middle-aged man, introduced myself, and asked how I could help him. “Doc,” he said, “I’ve been having this terrible shoulder pain for the past couple of weeks.” My second patient that day had knee pain. My third patient had low back pain and possible lumbar spinal stenosis. By the end of the day, I realized that my musculoskeletal exam skills would need some serious upgrading if I wanted to manage my patients properly. The point of this anecdote is that breadth is at least as important as depth in medical education. In internal medicine (as in other specialties), we need to know a great deal about the disciplines at the fringes of our specialty in order to succeed in our day-to-day practices. I have often wished, for example, that my training in dermatology had been more robust, since itching and rashes are perennial complaints in my daily practice. The same

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can be said for otolaryngology, gynecology, urology, ophthalmology, and orthopedics. For students who will not be specialists in these areas, most of the practical teaching and learning takes place in outpatient clinics. Non-orthopedists will not need to know how to do hip replacement surgery, but they will definitely need to know how to use the hip exam to differentiate between trochanteric bursitis and osteoarthritis. Most primary care physicians will never perform a tonsillectomy, but they must be able to distinguish between a case of bacterial pharyngitis and a potentially life-threatening peritonsillar abscess. In other words, many of the things that every medical student should know are best taught in outpatient clinics. To achieve the necessary broad preparation for their future practices, medical students will need to adapt to a variety of clinic settings, schedules, and structures.

3.1

Settings

Most medical students will spend the bulk of their outpatient clerkship time in the classic primary care clinics: internal medicine, family medicine, and pediatrics. OB/GYN, general surgery, and neurology clinics are also mainstays of outpatient clerkship training. Medical and surgical subspecialty clinics are sometimes offered to clerkship students, although in-depth clinic experiences in such areas as cardiology, rheumatology, or plastic surgery are generally deferred until fourth-year electives. For medical students, there are generally three options for outpatient clinical teaching: academic clinics, affiliated clinics, and community clinics. Each setting has its advantages, disadvantages, opportunities, and challenges. Academic Clinics  These clinics are usually at or adjacent to a major teaching hospital. They are staffed by experienced clinician-­ educators who are given protected time (and full pay) for their clinic teaching. Academic preceptors typically do not see their own patients (or see fewer patients) during their assigned teaching hours, which frees them up to focus on teaching and encourages

3.1 Settings

21

vigorous case discussions. In the academic setting, students often work alongside interns and residents and learn from them as well. Reading assignments, daily or weekly conferences, and other curricular activities such as quality improvement projects are common in academic clinics. The educational strengths of academic clinics are obvious, but there are also limitations. Community clinics often have more sociodemographic diversity than academic clinics and give students insight into “real-world” issues such as short appointments, high patient volumes, and administrative challenges. Affiliated Clinics  These are clinics that maintain an affiliation with a university teaching hospital; they can be either clinics within affiliated hospitals or freestanding clinics. In Cleveland, for example, both the Cleveland Clinic (Lerner College of Medicine) and University Hospitals of Cleveland (Case Western Reserve University School of Medicine) have extensive networks of satellite hospitals and clinics where many medical students do their outpatient rotations. In terms of teaching activities, affiliated clinics fall somewhere in between the academic and community teaching models. Affiliated clinic preceptors often have academic appointments (e.g., clinical instructor or assistant clinical professor) and are motivated to teach. They may also have reduced patient schedules on teaching days. Clinic conferences and other formal curricular activities are less likely to happen in affiliated clinics, but the teaching is often rigorous and systematic. Community Clinics  Freestanding, unaffiliated community clinics are not as common as they used to be, with large hospital networks buying them out and taking them over. In general, rural and inner-city clinics are more likely to be unaffiliated than suburban clinics. As noted in Chap. 2, the leading barriers to teaching in community clinics are reduced physician productivity, lack of time for teaching, and inadequate financial support for teaching. Busy community clinic preceptors are rarely allowed to reduce their clinic schedules to increase teaching time. It follows that the teaching in community clinics, while often excellent, is more epi-

3  Clinic Settings, Schedules, and Structures

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sodic and ad hoc than in academic settings. This kind of teaching can be highly effective, but it requires that students take the initiative to ask questions, initiate discussions, and research questions that come up during patient care. For students, the rewards of working in community clinics include more diverse patient populations, a broader scope of practice (especially in rural clinics), and insight into the challenges and pleasures of primary care practice.

3.2

Schedules

Students may find themselves scheduled for half-day, full-day, or evening clinics, and sometimes for weekend clinics as well. Daily schedules vary, but as a general rule, academic clinics allow more time for patient visits (20–30 minutes) compared with community clinics (15–20  minutes). Sometimes, depending on the practice setting, new patient visits may be scheduled for 30–60 minutes, but in my experience these longer appointment slots are the first thing to go when practices start to grow and get busy. Overbooks are common, especially in community clinics. In my early days as a community internist, my Saturday morning schedule would start at 9:00 AM (with overbooks often scheduled at 9:01 and 9:02), and then 9:15, 9:30, and every 15 minutes until noon. This meant that I was almost always behind schedule and rarely finished with note-writing and other paperwork before midafternoon. Overbooks and unrealistically short appointment times are less common in academic outpatient clinics, where teaching time is a priority and same-day patients can often be seen in other venues, such as dedicated urgent clinics. Students typically see, present, and write progress notes on 2–3 patients per half-day. This works out to seeing one of the 3–4 patients on the attending’s schedule per hour. Let’s say that you’re scheduled to see the 9:15, 10:15, and 11:15 patients in your morning clinic. You see the 9:15 patient while your attending is seeing the 9:00 and 9:30 patients, then take 5  minutes to present the patient around 9:45, and then finish your write-up from 9:50 to 10:15, when your second patient is scheduled. Meanwhile, the

3.3 Structures

23

attending sees the 9:45 and 10:00 patients. This means that you actually have up to 30 minutes to see your patient, 5 minutes to present, and 25 minutes to write the note. This will obviously vary depending on the flow of the clinic, but the point is that even in a very busy clinic, you will always have more than 15 minutes to see and present a patient and write the progress note. As a student assigned to a busy community clinic, one way to increase efficiency is to arrive early enough to do some chart review on the 2–3 patients you will be seeing that day. Chart review helps you to set priorities and create a checklist for the visit: 1. How is the diabetes control since empagliflozin was added last month? 2. Is the tremor responding better to primidone than it did to ­propranolol? 3. The patient will need his flu shot and Tdap, and we should also discuss PSA testing and lung cancer screening. This will give you a running start on the visit and also help you to organize your oral presentation and progress note—all of which can increase efficiency and make your attending’s day a little easier. A little preparation can make a huge difference in a busy clinic.

3.3

Structures

Outpatient clinical rotations can be set up as either continuity clinics or block clinics. In the continuity clinic model, students spend 1  day or a half-day per week in the same clinic for an extended period of time (typically 8–12  weeks, sometimes longer). In the block clinic model, students work for a shorter time (typically 1–4 weeks) in the same clinic every day. Each model has its strengths and weaknesses. The strength of the continuity model is that patients can be followed over a longer period of time, which allows for better understanding of the natural history of disease and chronic disease management. The disadvantage of

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this model is that students are pulled every week from their inpatient ward rotations, which can be inconvenient and disruptive. The block clinic model offers a briefer but more concentrated and immersive clinic experience, with no other obligations or distractions, but does not allow for long-term follow-up. Optimizing student-preceptor continuity in traditional block clerkships leads to more meaningful feedback and evaluation for students, and increased satisfaction for both students and preceptors [1]. A newer and increasingly popular model for clinical education is the longitudinal integrated clerkship (LIC). In one version of this model [2], all of the third-year clerkships (including both inpatient and outpatient rotations) are integrated into a weekly schedule that runs for the entire academic year (Table  3.1). Students in LICs are often assigned a cohort of patients to follow as they progress through their hospitalizations, surgeries, and clinic visits. This may also involve hospital rounds with medical or ­surgical teams before morning clinics. Students generally rate their LIC experiences as excellent and perform well on standardized exams, but LIC programs require highly motivated students, and the administrative costs for these complex schedules can be daunting. This has limited the number of LIC students at many medical schools. Another popular—and perhaps more broadly practicable— version of the LIC is the longitudinal ambulatory block (LAB) model, which combines the benefits of the longitudinal model (more continuity, working with one preceptor in each discipline) and the block model (a concentrated experience without competing demands or distractions). This is essentially a set of longitudinal ambulatory rotations and didactics that are joined together into a single 8–12-week ambulatory block. Note that the LAB model keeps inpatient ward and outpatient clinic activities separate but allows for broad integration in the ambulatory setting, where it is probably most useful in terms of preparation for future practice. A good example of a successful LAB is the Cleveland Clinic version (Table 3.2), which offers 12-week outpatient longitudinal experiences with the same preceptors in internal medicine, family medicine, pediatrics, women’s health, geriatrics, and emergency medicine [3].

Sunday ER ER ER

Monday Psychiatry clinic Conferences OB-GYN clinic

Tuesday KLIC KLASSa Conferences Medicine clinic

Wednesday Neurology clinic Conferences Independent learning Reflection sessionb

Thursday Family medicine clinic Conferences Independent learning

Friday Saturday Surgery OR day Surgery OR day Surgery OR day

Reprinted with permission from The Permanente Press ER emergency room, KLIC Kaiser Longitudinal Integrated Clerkship, OB-GYN obstetrics and gynecology, OR operating room, blanks free time a A weekly didactic seminar with lectures from each discipline and interdisciplinary lectures b A faculty-facilitated monthly session where students reflect upon topics such as challenging patients, transitions of care, and medical errors

Time Morning Lunch Afternoon Evening

Table 3.1  Example of weekly student schedule for a longitudinal integrated clerkship (LIC) [2]

3.3 Structures 25

3  Clinic Settings, Schedules, and Structures

26

Table 3.2  A 12-week longitudinal ambulatory block (LAB) rotation at Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine [3] Time Monday AM Internal medicine PM

Tuesday Wednesday Thursday Pediatrics Family Women’s medicine health

Palliative FLEX Med or ER time

Family medicine

Geriatrics

Friday Rotation or longitudinal didactics SAMI (science and art of medicine integrated)

Some students in LIC or LAB rotations may find the daily discontinuity to be challenging and even disorienting (e.g., psychiatry in the morning, OB/GYN in the afternoon), while others thrive on variety and enjoy finding the connections that unify all medical disciplines. Students who prefer to take a deep dive into one subject area for an extended time may struggle. Most schools offer students a choice between traditional clerkships and the LIC or LAB models. Self-reflection about one’s personal learning style, flexibility, and ability to accept uncertainty can help students decide which learning model would be best for them.

3.4

Other Clinic Experiences

Students may have the opportunity to participate in a variety of clinic experiences that go beyond the traditional student-­preceptor office model. Shared medical appointments (SMAs) are group clinics where patients with the same medical condition—typically hypertension, diabetes, or heart failure—are seen first in a group setting for teaching, and then individually for case management. Students assigned to SMAs may find themselves participating in both the group teaching and question-and-answer sessions and the individual check-ins that follow. SMAs are often run by clinical pharmacists and/or nurse practitioners, and students can learn a

3.4 Other Clinic Experiences

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great deal about the importance of interdisciplinary collaboration in chronic disease management. There is evidence that patients who participate in SMAs can have significant improvement in important biomarkers such as hemoglobin A1c and systolic blood pressure [4], and it seems very likely that these cost-effective group sessions will continue to gain traction in both primary care and subspecialty clinic settings. Participation in SMAs can help students to prepare for what may be an important part of their future practices. Other clinics that students may encounter in the primary care setting include mental health or behavioral medicine clinics, pain clinics, and urgent clinics. Primary care mental health clinics are generally staffed by psychologists, who guide students in the evaluation of both scheduled patients and “warm hand-offs” with such problems as anxiety, depression, and substance use disorders. This can be a great opportunity for students to learn about assessment and mitigation of suicide risk, cognitive-behavioral therapy, interpersonal therapy, assessment of capacity, and practical approaches to smoking cessation and alcohol use disorder. Outpatient pain clinics may include training in pain psychology, pain pharmacology, and adjunctive treatments such as chiropractic, acupuncture, biofeedback, and therapeutic massage. Urgent clinics, which may be staffed by various combinations of physicians, nurse practitioners, physician assistants, and registered nurses, can be great places for students to see large numbers of undifferentiated patients with everything from minor musculoskeletal complaints to serious illnesses. In our era of interprofessional medical education [5], students working in urgent clinics, SMAs, and the other primary care clinics described above can also learn important lessons about interprofessional cooperation and the roles, responsibilities, and limitations of all members of the care team. For future primary care physicians, learning to work well with the full spectrum of health professionals is just as important as learning the essential skills from across all medical disciplines.

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References 1. Biggs JL, Sutherell JS, Remus R, Armbrecht ES, King MA. Positive outcomes of optimizing student–preceptor continuity in a traditional block clerkship. Teach Learn Med. 2018;30(2):202–12. 2. Poncelet AN, Mazotti LA, Blumberg B, Wamsley MA, Grennan T, Shore WB.  Creating a longitudinal clerkship with mutual benefits for an academic medical center and a community health system. Perm J. 2014;18(2):50–6. 3. https://case.edu/medicine/sites/case.edu.medicine/files/201907/ CWRU%20School%20of%20Medicine%20Student%20Handbook%20 v7.19.pdf. Accessed 30 Nov 2020. 4. Edelman D, Gierisch JM, McDuffie JR, Oddone E, Williams JW. Shared medical appointments for patients with diabetes mellitus: a systematic review. J Gen Intern Med. 2015;30(1):99–106. 5. Interprofessional Education Requirements at US Medical Schools. https:// www.aamc.org/data-­r eports/curriculum-­r eports/interactive-­d ata/ interprofessional-­education-­requirements-­us-­medical-­schools. Accessed 29 Dec 2020.

4

COVID-19 and the Rapid Rise of Telemedicine

4.1

How COVID-19 Has Changed Primary Care

The COVID-19 pandemic of 2020 has caused rapid, drastic, and possibly permanent changes in the way we deliver primary care to our patients. On March 12, 2020, I saw a full schedule of patients face-to-face in my VA primary care clinic. On March 13, in-­ person visits were suspended, and all of my future appointments were changed to telephone or video visits. Everything changed for us and our patients, literally overnight. Although we physicians had dabbled in virtual visits (some more than others—I had done very few), telemedicine was suddenly the only option. We had all become participants in a huge, real-time experiment in the virtual delivery of primary care. Gradually, over a few months, as we reconfigured our clinics, waiting rooms, and schedules, we were able to accommodate some patients who needed to be seen face-to-face, including hospital follow-ups, urgent visits, and patients with complex problems. As it stands now, in the first week of January 2021, I’m seeing about 25–30% of my patients in person, and I continue to work doing telemedicine from home at least 1 day per week. This has been the pattern, with variations, for primary care physicians and specialists across the globe. Before COVID19, telemedicine services were mostly restricted to rural areas

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and other locations with poor access to care. By April 2020, 44% of Medicare primary care visits were provided via telemedicine, compared with 0.1% 1 year before [1]. Similarly dramatic changes were also seen in subspecialty practices. By March 30, 2020, 75% of all cardiology outpatient encounters had been converted to telemedicine; the shift occurred over 2 weeks [2]. Despite large increases in the use of telemedicine, US primary care visits decreased overall by 21% in the second quarter of 2020 compared with 2018, and there were substantial decreases in blood pressure and cholesterol level assessments as well as new medication visits [3]. These data raise questions about the availability, content, and overall utility of telemedicine as opposed to traditional in-person visits. What are the risks and benefits of telemedicine? How will it affect care of the elderly, the poor, and the disenfranchised? Will we want to continue with virtual visits when the pandemic is over?

4.2

 elephone and Video Visits: Benefits T and Limitations

Telemedicine offers many potential benefits. Obviously, it’s safer to stay home during a pandemic than to sit in a crowded waiting room and have close contact with nurses and doctors. The inconveniences and costs of travel to the clinic, which can be considerable barriers for many patients, are completely eliminated. People with limited mobility and work-related time constraints clearly benefit, and telemedicine also meets the needs of patients in remote and rural areas (where it has been widely used for many years). For the most part, the technology works well, and we’re able to meet patients where they are, with efficiency and cultural sensitivity. It has also been argued that telemedicine can allow for a more comprehensive team-based approach to maintain wellness and put clinical data at the patient’s fingertips, which could increase patient engagement and autonomy. Patients may also benefit from reduced co-pays and other costs. In fact, telemedicine could, according to Poppas et al., provide a method to “reduce

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health disparities and improve health equity by decreasing barriers and increasing access” [2]. Telemedicine can’t be a viable option without technology. Both reliable telephone and broadband Internet access and the equipment for accurate data collection are essential. Telemedicine without data is little more than a speculative doctor-patient conversation. Safe and effective medical treatment requires specific, objective information. Data collection, both in real time and between visits, requires devices ranging from the most basic— scales, glucometers, blood pressure cuffs, and pulse oximeters— to more advanced technologies such as ECG monitors, wearable activity sensors and fall detectors, smartphone-linked electronic stethoscopes, and implantable pulmonary artery pressure monitors for advanced heart failure patients. As these technologies are refined and become more user-friendly and less expensive, they’ll be widely adopted for use in telemedicine. Despite the optimism expressed by many telemedicine advocates, there are significant concerns across health professions that the rapid adoption of telemedicine may exacerbate health disparities [4]. Broadband access reaches 97% of people in urban areas, but drops off to 65% in rural areas and 60% in tribal lands. Lower broadband access is associated with age over 65, lower educational levels, African-American or Latino race/ethnicity, and lower socioeconomic status. For people with incomes under $30,000 per year, 29% do not own a smartphone, 44% have no access to broadband, and 26% depend on their smartphone for Internet access [1]. Thus, a substantial segment of high-risk patients are unable to connect with their physicians for virtual visits. Telephone visits can be a viable option for patients who don’t have smartphones and lack broadband access; some disease management can be done over the phone, and face-to-face follow­up visits can be arranged when a diagnostic physical exam is needed. However, video visits enhanced with real-time data collection are the gold standard and should be available to all patients. Key actions that must be taken to reduce health disparities in telemedicine include mitigation of barriers to digital literacy, broad access to devices, and advocacy for policies and infrastructure that facilitate equitable telemedicine access [5].

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One important question about telemedicine is how the quality of diagnosis and management compares with traditional face-to-­ face visits. Straightforward and common problems, such as simple rashes and hypertension, might be safely evaluated with a virtual visit [6], but patients with fever, chest pain, or abdominal pain will usually need to be seen in person for accurate diagnosis and optimal care. Testing diagnostic hypotheses can be difficult or impossible without laying hands on the patient, and there are (and should be) limits to the amount of diagnostic uncertainty that physicians can accept.

4.3

Student Participation in Telemedicine

As a third-year medical student, it’s very likely that you’ll be expected to participate in virtual patient care during your clerkships. As in any patient encounter, a few minutes of chart review and preparation are essential (see Chap. 6 for details on how to prepare for patient visits). Your preceptor will help you with the technical aspects of the call (or you might end up helping your preceptor, if he’s anything like me!) and hopefully allow you to observe a couple of video visits before you strike out on your own. Remember as you get started that patient consent is doubly important in virtual visits; in addition to discussing the benefits and limitations of telemedicine, you need the patient’s approval to speak first with a medical student, which is in essence asking them to participate in a teaching activity. When asking for consent, it’s important to be matter-of-fact rather than apologetic (there’s nothing to apologize for); don’t hesitate to mention the importance of what you expect to learn from the encounter, and also reassure patients that they’ll be speaking with their physician at the end of the call. A template for the initial consent might go something like this: Hello, Mr. John Smith? This is student-doctor Jones – I’m a third-­ year medical student working with Dr. Johnson. I was wondering if it would be okay with you if I speak with you first and find out how

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you’ve been doing, and then get Dr. Johnson on the line a little later to answer your questions and go over the treatment plan. I also want to be sure that you’re okay with the plan for a video visit today rather than a face-to-face appointment.

In addition to obtaining consent, beginning the call this way can help to build the rapport and trust that are necessary for a useful and productive encounter. In their excellent article “Telemedicine in the Time of Coronavirus,” Calton et al. [7] describe ways to create a therapeutic telemedicine environment and provide effective virtual care: • Choose a space that is quiet, is private, and has good lighting. When possible, choose a space with a professional, neutral, and uncluttered background. • Use a laptop or desktop computer whenever possible; avoid using a handheld smartphone, which can be distracting or even nauseating as the phone moves around. • Look at the camera (not your electronic medical record) to ensure good eye contact and foster rapport and trust. • Clinicians should orient the patient to where they are sitting and who else is in the room to reassure them the conversation is private; ask the patient to do the same. • Look for unique opportunities to learn more about patients by telemedicine and use the technology creatively. • On many platforms, multiple clinicians and/or family members can participate in the visit from separate locations. • By way of example, ask for a tour of the patient’s home, meet their pet virtually, or have them share family photographs. • Perform accurate medication reviews by having your patient hold up each medication to the camera. • Brainstorm what parts of the physical examination can be performed by video (it is surprising to most clinicians how much is possible). • Pay even closer attention to subtle comments made by patient and caregivers and their body language. The clinician should ask clarifying questions if they are not sure if they heard the

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patient correctly or are having difficulty interpreting body language by video. • Many clinicians note telemedicine visits are shorter and more focused than in-person visits. While this can increase efficiency, creating space for patients and families to share their thoughts and feelings is arguably even more important than it was before the COVID-19 pandemic. A simple question early in the telemedicine visit like, “I know we are facing really scary, uncertain times right now. How are your spirits?” can be effective. • Do not shy away from having sensitive and emotional conversations over telemedicine. Key communication principles like asking for permission and attending to emotion should be relied upon when discussing sensitive topics by telemedicine. • Finally, it is important to be patient. Occasional technological difficulties are inevitable, and the tech literacy of your patients will vary [7]. A great deal of useful clinical information can be gleaned from a video visit. We can observe the patient’s facial expressions, mannerisms, and postures as they respond to questions. We can see what they are wearing, who is with them, and the appearance of their room, car, or workplace, depending on where they’re taking the call. This kind of context is unavailable with a regular clinic visit or a telephone visit. One of my patients with anxiety went outside and circled his back yard while he spoke with me via his laptop, which gave me insight into the depths of his restlessness (as well as a mild case of vertigo). Another had just moved Cleveland to have his health problems addressed, and was very worried about losing the longtime teaching job he had enjoyed in Japan; the empty room in the background brought home the loneliness and depression he was struggling to describe to me. On another call, I was reassured by the comfort and safety of my frail elderly patient’s living room, and the presence of his daughter, who spoke affectionately with him and asked me excellent questions about his health status.

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When it comes to the physical exam, telemedicine can provide a surprising amount of useful data, even without smartphone-­ linked stethoscopes, otoscopes, or other such devices. Tachypnea, dyspnea, accessory neck muscle use, and even jugular venous distention can easily be discerned on a video call. Many elements of the neurologic exam can be done, including most of the cranial nerves, assessment of weakness (arm drift, resistance to gravity), gait, cerebellar function (finger-to-nose), and evaluation of resting or intention tremors. Rashes and other skin lesions can be diagnosed with confidence; just yesterday I verified a diagnosis of shingles by video in a man with a painful vesicular rash affecting his right upper arm. Leg ulcers, cellulitis, diabetic foot infections, gout, DVT, rheumatoid arthritis, ascites, jaundice, temporal wasting, eye disorders such as esotropia, facial plethora, acromegaly, hyperpigmentation of Addison’s disease, thenar atrophy associated with carpal tunnel syndrome, and dozens of other conditions can be diagnosed (at least provisionally) by means of video assessment. Sometimes it can be difficult to coordinate with the patient to get the right camera angle and focus; it took at least 5 minutes of dizzying and blurry views of clothing and skin until I got a brief but sharp view of my patient’s shingles rash yesterday. It helps to be encouraging, positive, and persistent. Patients and family members can also assist with the video exam. A family member might point out a skin lesion on the patient’s back, or hold the camera and adjust the light to optimize viewing. A family member can even be asked to perform certain physical exam maneuvers while the physician watches, such as gently palpating different areas of the abdomen, flexing the patient’s knee and rotating the hip, or moving the electronic stethoscope to specific auscultation points on the back or chest. With patience and a little ingenuity, much can be accomplished with telemedicine. Remember that all relevant observations need to be documented in the note. Templated telemedicine notes will generally have a “Clinical Observations” or “Video Observations” section instead of the “Physical Exam” that is part of the traditional clinic progress note. You will not be expected to document a complete physical exam in a telemedicine note (this is not possible), but any

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relevant observations should be carefully described. For example, in a video note I completed earlier this week for a patient who had been on long-term corticosteroids for possible pyoderma gangrenosum, I documented his Cushingoid facies and described the depth, color, and size of his leg ulcer. Images of any kind from a telemedicine encounter should not be saved to the note without specific consent from the patient.

4.4

Telemedicine Is Here to Stay

There is every reason to think that telemedicine will persist even after the COVID-19 pandemic is over. Telemedicine is cost-­ effective, convenient, and secure. Comfort levels—both for patients and physicians—are increasing as we use it more and more, and the technologies to support and enhance it are developing rapidly. Governments and insurance companies have shown that they are willing to pay for it. As long as clinical outcomes, quality measures, and patient satisfaction scores are acceptable, I suspect that we will continue to see high levels of telemedicine in both primary care and specialty practices. This means that today’s medical students will participate in telemedicine now—in their clerkships and clinic rotations—and also in their future careers. In fact, today’s students will likely become tomorrow’s leaders and innovators in virtual medical care. It follows that medical schools must integrate telemedicine into their current curricula [8, 9], and teach—in addition to the required tele-clinical skills and technologies—the broader public health issues of access, privacy, limitations, costs, health equity, and long-term sustainability.

References 1. Brotman JJ, Katloff RM.  Providing outpatient telehealth in the United States: before and during COVID-19. Chest. 2020;S0012-3692(20):35302. 2. Poppas A, Rumsfeld JS, Wessler JD. Telehealth is having a moment: will it last? J Am Coll Cardiol. 2020;75(23):2989–91.

References

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3. Alexander GC, Tajanlangit M, Heyward J, Mansour O, Qato DM, Stafford RS.  Use and content of primary care office-based vs telemedicine care visits during the COVID-19 pandemic in the US.  JAMA Netw Open. 2020;3(10):e2021476. 4. North S.  Telemedicine in the time of COVID and beyond. J Adolesc Health. 2020;67(2):145–6. 5. Nouri S, Khoong EC, Lyles CR, Karliner L. Addressing equity in telemedicine for chronic disease management during the COVID-19 pandemic. NEJM Catal Innov Care Deliv. 2020;1(3). 6. Romanick-Schmiedl S, Raghu G.  Telemedicine  – maintaining quality during times of transition. Nat Rev Dis Primers. 2020;6(1):45. 7. Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. J Pain Symptom Manage. 2020;60(1):e12–4. 8. Iancu AM, Kemp MT, Alam HB. Unmuting medical students’ education: utilizing telemedicine during the COVID-19 pandemic and beyond. J Med Internet Res. 2020;22(7):e19667. 9. Jumreornvong O, Yang E, Race J, Appel J. Telemedicine and medical education in the age of COVID-19. Acad Med. 2020;95(12):1838–43.

5

Role of the Student in the Outpatient Clinic

5.1

Active Versus Passive Clinic Experiences

For third-year medical students, the days of “observing” and “shadowing” in the outpatient clinic should be over. It’s time to take an active role in patient care. Third-year students should be seeing patients first, collecting data, and working on developing their skills as reporters and interpreters of clinical information. This is an exciting time because it marks an important transition point in the journey from student to physician. From here on, more will be expected. Your clinic attendings will look to you for accurate data collection, concise presentations, and some tentative efforts to develop a differential diagnosis and treatment plan. Your patients will begin to see you as a doctor-in-training. There can be no backsliding to a passive role once this transition process has begun. Building the skills that will be needed for residency requires a gradual layering-on of responsibilities, clinical skills, and professional expectations. This is not to say that you should never be an observer in the clinic. When I work with new third-year students in my office, I always ask them to observe my interactions with one or two patients before they strike out on their own; this helps them to understand how a clinic visit should be conducted and structured. I also bring them to my exam room to see interesting physical

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exam findings; sometimes (to make it a more active experience), I ask them listen to the heart sounds or percuss the liver first, and tell me what they think. This is a good opportunity to help them sharpen their physical exam skills. In the more procedural outpatient clinics such as otolaryngology and dermatology, students can learn a great deal from observing a fiber-optic laryngoscopy or a punch biopsy of a skin lesion. However, they should also be taking interval histories, doing physical exams, and working actively on developing a differential diagnosis, just as they would in the primary care clinic. No clinic, no matter how specialized, should ever become a 100% passive affair for a third-year student. Asking to see patients first and to assist or even perform procedures where possible is absolutely acceptable for students who feel they are not getting the hands-on experience they need.

5.2

What Your Clinic Attending Is Looking For

Most clinic attendings get involved in teaching because they like to teach, either as clinician-educators whose primary job is teaching or as hospital or community physicians who volunteer their time as teachers and role models. They are looking for students with curiosity, enthusiasm, and a passion for medicine. When teachers who like to teach meet enthusiastic and well-prepared students, great things can happen. For students, good preparation and a clear understanding of their teachers’ expectations are the keys to a positive experience in the clinic. What specifically will your clinic attending be looking for? Table 5.1 gives a reasonable list of expectations in five key areas: professionalism, preparation, basic skills, clinical judgment, and enthusiasm for education. Enthusiasm is more than expressing excitement and positive thoughts about medicine; it is demonstrated in specific behaviors such as accepting challenges (calling consultants, performing procedures), asking good questions, participating vigorously in case discussions, and looking up guidelines and articles to help with patient care. Preparation means reading up in advance on practice guidelines, immunization schedules, screening recommendations, and relevant anatomy,

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Table 5.1  What clinic attendings are looking for Professionalism

Promptness Professional appearance and demeanor Respectful and effective communication with patients and clinic staff Honesty and integrity at all times Preparation Evidence of specific pre-reading to enhance knowledge in clinic subject area Ability to access and apply basic science knowledge (e.g., anatomy, physiology, pathophysiology, pharmacology) Familiarity with important treatment guidelines (e.g., JNC-8 Hypertension Guidelines, 2021 ADA Standards of Medical Care in Diabetes) Ability to access clinical data in real time to assist with patient care (e.g., use of UpToDate, PubMed, MeSH search, and other electronic databases) Basic skills Ability to perform an accurate and appropriately focused history and physical exam Ability to present a case confidently and concisely, with all essential data Ability to write a concise SOAP-style progress note with a reasonable assessment and plan Understanding of technique for basic clinical procedures (e.g., pelvic exam, knee injection) and willingness to perform procedures under supervision Clinical judgment Understanding of potential risks and benefits of tests, treatments, and medications Willingness to consider the patient’s preferences and values in the treatment plan Willingness to accept ambiguity and uncertainty in clinical decision-making Understanding of the elements of high-value care Ability to see the “big picture” Enthusiasm for Energy and passion for medicine education Willingness to accept new challenges Scholarly approach to clinical work Asks good questions, reports back with answers

physiology, and pharmacology. For example, a student preparing for a general surgery clinic might review the surgical anatomy of the biliary tract, learn the difference between direct and indirect inguinal hernias, check the latest wound care guidelines, and read

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Cope’s Early Diagnosis of the Acute Abdomen, the classic text on the difficult art of evaluating abdominal pain [1]. Preparation for an OB/GYN clinic might involve a review of cervical and breast cancer screening recommendations, contraceptive pharmacology, prenatal care guidelines, and textbook chapters on pelvic pain, menorrhagia, menopause, and infertility. Another good approach is to ask the clinic attending on the first day for a reading list that will cover the most essential material. Students who ask for recommendations and then show in their patient care that they have done the reading will be appreciated and rewarded with high marks by their attendings. Clinical judgment develops over time, with experience, but there are ways to help it along. Let’s say that you’re seeing a 35-year-old woman with recent onset of sharp left-sided chest pain that has been occurring at rest. Your attending asks if you think a nuclear stress test would be helpful. If you have a basic understanding of Bayes’ theorem and know that the pretest probability for coronary artery disease is very low for a 35-year-old woman with atypical chest pain, you will know that stress testing would have a low positive predictive value and therefore a high false positive rate, which could lead to unnecessary invasive testing. The best option would be to hold off on stress testing for this patient. Conversely, if you’re seeing a 65-year-old man with hypertension, diabetes, and hyperlipidemia who has new-onset exertional chest pain associated with nausea and diaphoresis and relieved with rest, you will know that stress testing a patient with a very high pretest probability would result in an unacceptably high false negative rate; the best course of action for this patient would be to skip the stress test and refer him to cardiology for a heart catheterization. Thus, extensive clinical experience is not necessary to make a reasonable decision on stress testing in these two cases, as long as Bayes’ theorem can be applied correctly. Clinical experience comes into play when the attending notes that the 35-year-old woman with chest pain is taking an oral contraceptive and has a family history of venous thromboembolic disease, and orders a chest CT that reveals a pulmonary embolism. One thing that never fails to impress me as an attending is when students discuss their patients’ preferences, values, and

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social issues in the assessment and treatment plan. When a student tells me that her patient with poorly controlled diabetes is only taking his insulin twice a week because he can’t afford the prescription, and says she wants him to see a social worker to get him on food stamps so he can afford the insulin, that’s superb work. When a student tells me that his patient with stage IV colon cancer might be ready to stop chemotherapy and think about hospice care, I’m pleased that he was able to see the big picture and ask some difficult but important questions. “Going deep” in this way, even if it’s the only time you will ever see the patient, is a fine thing to do, provided that it’s done with humility and respect for both the patient and the attending physician.

5.3

I ncreasing the Level of Responsibility: The RIME Framework

Once you’ve shown that you can see a patient, collect the relevant data, and report your findings concisely to the attending, you are at the “Reporter” level of the Reporter-Interpreter-Manager-­ Educator (RIME) evaluation framework, which has become a useful tool for monitoring student progress in clinical medicine. Louis Pangaro, who developed the RIME framework, describes it in the following terms [2]: Reporter  Consistently good interpersonal skills; reliably obtains and communicates clinical findings Interpreter  Able to prioritize and analyze patient problems Manager  Consistently proposes reasonable options incorporating patient preferences Educator  Consistent level of knowledge of current medical evidence; can critically apply knowledge to specific patients For third-year medical students in the clinic, the primary goal is to become a superb Reporter. This means performing a thor-

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ough, accurate, and appropriately focused history and physical, delivering a concise oral presentation of the case, and writing a suitable SOAP note. The secondary goal is to take the first steps in becoming an Interpreter. This means learning the cognitive processes of a diagnostician: identifying the pertinent positives and negatives, producing a broad differential diagnosis, narrowing it, making a case for the likeliest diagnosis, and proposing a testing strategy to confirm it. Medical trainees are generally not expected to become full-fledged Interpreters until intern year; however, third-year students should be working hard on their differential diagnosis skills and showing progress over time in their clinical rotations. Less is expected of students as Managers, but efforts to produce evidence-based treatment plans are encouraged and appreciated. Paradoxically, early third-year students can be ­effective Educators, especially when they look up and report on articles and guidelines that can help with specific questions that arise in the course of patient care. These helpful student talks prove the point that you can be a teacher without necessarily being an expert. I can’t overstress the sense of accomplishment and fulfillment that my students have expressed to me over the years as they grow more confident with their diagnostic skills. Becoming an Interpreter is a huge milestone in becoming a doctor. Many students feel that they have reached that milestone in their primary care clinics, where diagnostic challenges are constant and endlessly variable. Progress as measured by the RIME framework seems to correlate well with the level of responsibility students are given in the clinic. When students show repeatedly that they are reliable historians, their histories will be accepted without hesitation. When they present thoughtful and logical differentials, their diagnostic reasoning will be considered in the discussion. When they come up with reasonable testing strategies and treatment plans, they can begin to manage their patients. As I mentioned in Chap. 2, strong medical students with good basic clinical skills can learn to work very effectively as apprentices after a couple of months in the clinic.

5.5 Following Up on Test Results and Consults

5.4

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Working with the Clinic Staff

Introduce yourself to the clinic staff, which may include nurse practitioners, physician assistants, nurses (RNs and LPNs), clinical pharmacists, receptionists, therapists, psychologists, social workers, scheduling clerks, and janitors. Learn their names, and ask them what they do in the clinic. Ask the nurse if you can assist with finger-stick glucoses, blood draws, or vaccinations. Volunteer to help out with taking vital signs, asking screening questions, and doing diabetic foot exams. Learn the workflow. Nonphysicians do lots of patient care and teaching. Who handles the phone calls and triages the walk-ins? Who does the blood pressure checks and diabetes teaching? Who runs the shared ­medical appointments? How do doctors and nurses communicate? It’s easy to stay in that comfortable bubble with your attending physician and the nurse checking in your patients, but taking a few minutes each day to explore the interprofessional dynamics of the clinic is time well spent. In terms of your future contributions to public health, it’s just as important to know how to lead an effective healthcare team (and understand the team dynamics) as it is to know how to diagnose lupus or evaluate abdominal pain.

5.5

Following Up on Test Results and Consults

As a medical student, it’s important to develop the habit of following up on your patients’ test results and consults. As a physician, you will be morally and legally obliged to follow up on all of the tests you have ordered and notify your patients of their results in a timely manner. If you slip up and miss a low potassium level, a new microcytic anemia, or a slowly enlarging lung nodule, your patient could suffer or even die. My approach is to keep a running list of test results that need follow-up and result letters that need to be written and sent out. I keep the list in my shirt pocket, and work on it whenever I have a few minutes during the day or at home in the evening. As a hospital peer review committee member, I can vouch that failure to follow up on test results is a leading cause of adverse outcomes for patients.

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Students are not technically responsible for following up on their patients’ test results. Students do not have the legal authority to practice medicine, nor do they have the clinical management skills (at least early on in the third year) to respond to an elevated calcium level or an abnormal head CT. But following up on test results and discussing ongoing management issues is a great way to learn about the incremental care (see Chap. 1) that we champion in the primary care clinic. You can learn a lot about patient management by seeing how your clinic attending responded to the abnormal liver function tests and worsening thrombocytopenia in the alcoholic patient you saw together last week. If you want to be more proactive, you can review the test results from the patient you saw yesterday, read independently about the abnormality, and propose a follow-up plan to your attending. “I see that Mr. Hill’s potassium from yesterday was low again at 3.3, even though he was taken off diuretics two months ago. Do we need to work him up for hyperaldosteronism?” You might also volunteer to call the patient to discuss his or her results, or write the results letter. So keep a list of the test results and consults that were ordered for your clinic patients, follow up on them, and read about the management questions that arise. The results list in your pocket marks you as a conscientious student who is serious about learning the professional responsibilities of a physician.

References 1. Silen W. Cope’s early diagnosis of the acute abdomen. 22nd ed. New York: Oxford University Press; 2010. 2. Pangaro L.  A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. 1999;74:1203–7.

6

Preparing to See the Patient

6.1

 hart Review and Creating an Agenda C for the Visit

I don’t recall that anyone ever taught me how to properly review a patient’s chart when I was a medical student back in the 1980s. Nor does anyone seem to be teaching the art of chart review to medical students today, at least not in a classroom setting. I think it’s one of those skills that educators (if they think about it at all) assume will be assimilated by students during their clinical years. This casual, hit-or-miss approach to chart review is surprising given its critical importance in providing safe and effective medical care. Careful and thorough chart review is essential for identifying important trends, following up on test results and treatments, reconciling medications, monitoring health screenings and immunizations, and creating an agenda or checklist for the visit. Chart review properly done can reduce the likelihood of medical error and improve the quality and cost-effectiveness of care. Lawrence L.  Weed developed and championed the “problem-­ based medical record” and the SOAP-style progress note in the 1960s [1, 2]. Thanks to Weed’s work, and the subsequent computerization of the medical record, reviewing our patients’ charts these days has become a fairly simple task. We now have easy electronic access to updated problem lists, flow sheets with vital signs and lab

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results over time, medication lists, discharge summaries, radiology reports, and immunization records. All of these data can be captured with a couple of mouse clicks. Yet, as Weed observed about data collection, “among physicians there is a remarkable spectrum of behavior from the compulsively elaborate to the sketchy and haphazard” as work pressures build up [1]. What we need is a consistent, quick, and repeatable chart review process that can be taught to trainees, so it becomes second nature. The 5  minutes spent reviewing a patient’s chart before a clinic visit is time well spent. It allows us to create an agenda for the visit, a short list of high-priority items that need to be addressed; these items may include reassessment of past symptoms, medication adjustments, worrisome trends like unexplained weight loss and uncontrolled blood pressure, discussion of goals of care, and so forth. Of course, the patient will have his or her own agenda for the visit that is often not congruent with the physician’s agenda—a patient with uncontrolled hypertension and diabetes might be primarily concerned about her back pain and want to discuss a supplement she’s been taking to prevent gout. The trick is to take on both agendas and reconcile them so that the priorities of both parties are addressed. This isn’t easy, especially for a student just starting out in the clinic. Here are the important elements of a 5-minute pre-visit chart review, in the order I have been doing them for many years, to maximize efficiency: 1. Review the problem list and the medication list. 2. Review the most recent primary care and subspecialty progress notes. 3. Review the most recent lab and imaging results. 4. Check alerts or reminders for immunizations and screening tests. 5. Check today’s vital signs and note recent vital sign trends. Consider this example of a 69-year-old man coming in to the primary care clinic for a routine follow-up visit: 1. Problem list and medication list: (a) Hypertension

6.1 Chart Review and Creating an Agenda for the Visit



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(b) Gastroesophageal reflux disease (c) Hyperlipidemia (d) Chronic nephrolithiasis, lithotripsy in 2006 (e) Chronic left flank pain (f) Smoker (g) Impaired fasting glucose (h) Lichen simplex chronicus, forehead (i) Tubular adenomas on colonoscopy in 8/19; repeat in 3–5 years (j) Prostate cancer, diagnosed 10/14, status post brachytherapy 2/15 Active outpatient medications

(a) ALBUTEROL 90  MCG (CFC-F) 200  D ORAL INHL INHALE 2 PUFFS BY MOUTH FOUR TIMES A DAY AS NEEDED. (b) AMLODIPINE BESYLATE 10  MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY. (c) CALCIUM 500 MG/VITAMIN D 200 UNT TAB TAKE 1 TABLET BY MOUTH TWICE A DAY WITH MEALS. (d) POTASSIUM CITRATE 10 MEQ SA TAB TAKE ONE TABLET BY MOUTH EVERY DAY. (e) SILDENAFIL CITRATE 100  MG TAB TAKE ONE-­ HALF TABLET BY MOUTH AN HOUR_BEFORE SEX. (f) TAMSULOSIN 0.4  MG CAP TAKE TWO CAPSULES BY MOUTH AT BEDTIME. (g) VARENICLINE 1  MG TAB TAKE ONE TABLET BY MOUTH TWICE A DAY. 2. Recent primary care and subspecialty progress notes: 10/20 PCP note:  Assessment: • Hypertension, controlled • Smoker, continues to work on quitting. Not fully committed to the idea of quitting yet, but will continue to work on it

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• History of nephrolithiasis and lithotripsy, no current symptoms. On chronic potassium citrate for stone prevention • Hyperlipidemia, working on lifestyle modifications. Might want to consider starting a statin depending on repeat lipid panel results • Prediabetes, due for hemoglobin A1c check  Plan: • • • • •

Fasting lipid panel, hemoglobin A1c, LFT. Patient will get flu shot when he comes in for lab testing. Nicotine patch prescription. Chest CT for lung cancer screening. Follow-up with me in 6 months. 7/20 urology note:   Impression/plan: ureteral stone, T2c prostate cancer

• PSA stable now 5 years out from brachytherapy. Will continue to monitor. • UA unremarkable 2 years ago—no signs of hematuria. Will repeat today. • No back pain—no evidence or stone recurrence. • He will follow up here in about 1 year with another PSA prior to visit. • Patient will notify me should he have any problems prior to that time. 3. Recent lab and imaging results: Recent lab data: From 7/20, urinalysis negative, CBC normal, creatinine 1.3, EGFR 66, potassium 3.6, glucose 109, cholesterol 170, LDL 116, HDL 41, triglycerides 64, PSA 0.6. From 12/18, PSA 0.4 Screening chest CT:  Impression: • Mild emphysema with scattered sub-5 mm pulmonary nodules

6.1 Chart Review and Creating an Agenda for the Visit

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• Atherosclerosis with coronary artery disease • Lung-RADS 2, Solid nodule(s) =140/90. • Pneumococcal (PPSV-23) vaccination. 5. Today’s vital signs and recent vital sign trends: Today’s VS (03-15-21): 97.7 100 18 162/84 Weight: 178# BMI: 28.3 Recent BP trends: 04-29-19 04-29-19 06-03-19 12-02-19 12-02-19 12-02-19 07-09-20 03-15-21

177/96 158/88 117/84 148/85 138/80 125/82 140/90 162/84

Recent weight trends: 04-29-19 06-03-19 12-02-19 07-09-20 03-15-21

156 159.7 168.4 167 178

Here is a list of priorities for the visit from the physician’s standpoint: 1. BP is high today, previously well-controlled. 2. Weight is up 11# in the past 8 months.

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3. Readdress smoking cessation; offer nicotine replacement or varenicline. 4. 10-year CV risk score [3] is 42.9%, and can be reduced to 32.1% by adding a statin and to 23.5% by both adding a statin and stopping smoking. 5. Prediabetes; need to recheck HA1c. 6. Due for alcohol and HIV screening and pneumococcal vaccination. It might turn out that the patient’s blood pressure is high because he stopped taking amlodipine due to ankle swelling, or because he has been eating lots of salty lunch meats lately. Maybe he’s gaining weight because he was divorced a few months ago and is living mostly on fast food; or it might be that he developed dyspnea, orthopnea, and paroxysmal nocturnal dyspnea recently and now has new-onset heart failure. The point is that reviewing the chart and having an agenda helps the physician to ask the right questions and make the incremental changes and course corrections that are so important for optimizing health and improving outcomes. If we miss the weight gain, fail to address the smoking, and forget to order the pneumococcal vaccination, we are failing our patient. So take a few minutes to review the chart, and remember (or jot down) your priorities for the visit. The physician’s agenda will vary depending on the focus of the visit. The agenda for a patient seen for diabetes follow-up might look like this: 1. How are the fasting and postprandial glucoses running at home since I added empagliflozin and increased the glargine insulin 2 months ago? 2. Any recent hypoglycemic symptoms? If so, are they recognized and treated appropriately? 3. Any signs or symptoms of dehydration, UTI, or perineal infection on the empagliflozin? 4. Due for a repeat HA1c and urine microalbumin/creatinine ratio today.

6.2 More Thoughts on the Agenda: “I Just Want to Know If I’m…

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And for a patient seen for heart failure follow-up: 1. Any weight gain or weight loss since I increased the furosemide to 80 mg BID at the last visit 3 weeks ago? 2. Any improvement in the PND, orthopnea, dyspnea, and leg edema since then? 3. Is she taking the liquid potassium supplement (the pills were too big for her to swallow)? 4. Is she ready to consider ICD placement as recommended by her cardiologist? 5. Due for a repeat renal panel and echocardiogram to reassess LV function. In some cases, such as well-child check-ups [4], prenatal visits [5], and geriatric assessments [6], there are well-established templates that cover developmental milestones, immunizations, screening, nutrition, exercise, home safety, and other basic checklist items. These templates provide a basic agenda for the visit, although individual patients will always have their additional problems and concerns. Even for these checklist-type visits, careful chart review is essential. Chart review is not a burden for physicians; in fact, it’s a huge time-saver. There is nothing more distracting and inefficient than scrolling through the chart while you have the patient in front of you. It’s hard to take an interval history or perform a physical exam while simultaneously trying to dig up the details of the last visit. Also, patients feel more confident and secure about their care when their physician walks into the exam room with a good grasp of their current medical issues, treatments, and test results. Careful and thorough pre-visit chart review makes for a more efficient, effective, and purposive patient encounter.

6.2

 ore Thoughts on the Agenda: “I Just M Want to Know If I’m Healthy Enough for Bacon”

One of my favorite patients was a lovely lady in her mid-eighties who had hypertension, diabetes, chronic kidney disease, and advanced heart failure. As her heart failure worsened, her man-

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agement became more and more complex. My agenda was to adjust her diuretic and ACE inhibitor doses to optimize preload and afterload and find that elusive sweet spot on the Starling curve where she would perfuse her kidneys without going into ­pulmonary edema. I remember that she listened politely to my explanation of her precarious state and the medication adjustments that I thought might help her. Then, she gave me her agenda: “Doctor, I only have one question for you. Can I eat turkey bologna?” This question is a variation on the theme of the classic New Yorker doctor-patient cartoon, where the patient (sitting undressed on the exam table) says to the doctor, “I just want to know if I’m healthy enough for bacon.” Dr. Claus Pierach, a great mentor during my residency at Abbott-Northwestern Hospital in Minneapolis, wrote a wonderful piece about a conversation he had with one of his elderly patients: Is life still a pleasure? With a little chuckle: “Yes.” What is pleasure? Oh, not much. She loves sweets and chocolate. Her daughter went all over town to find diabetic Easter eggs. They are okay but not for real. And the cooking? All the fat is trimmed or replaced by something of lesser taste. No salt. And if we don't pay attention her diabetes gets quickly out of control, especially when we have to give her a short course of corticosteroids. I imagine her food if properly prepared must taste like wet paper hankies. What is left? Heaven forbid, no more smoking. A glass of wine? It's not on the hospital's menu. A hike in the woods? Dancing? A long, long time ago. Is this what medicine is all about? Are we too shy or too strict to allow our patients the freedom to decide and indulge what they really like? Must we make them feel guilty when they enjoy life's little pleasures? Are we too busy postponing death and adding years to life rather than life to years? I hope I find a heretic when my time comes and I need medical help with some long lasting incurable illness, someone who lets me enjoy my pleasures without making me feel guilty and miserable [7].

Listen carefully and your patient, like mine and Dr. Pierach’s, will give you her agenda. If not turkey bologna or Easter eggs, it might just be to have a doctor who is willing to listen and really hear what they have to say. One of my elderly patients asked if he could hug me, explaining that he hadn’t had physical contact with

References

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any other person since his wife died 2 years ago (I hugged him). That might have been more therapeutic than the change I made in his blood pressure medicine. So review the chart and prepare your agenda for the visit, but remember: your patient’s agenda is also very important. Work on reconciling your patient’s needs with your goals of care for them. Be prepared to modify or even scrap your plans for the visit if necessary. Flexibility is a big asset in the primary care clinic; prioritize, accommodate, adjust. And listen.

References 1. Weed LL. Medical records, patient care, and medical education. Ir J Med Sci. 1964;462:271–82. 2. Weed LL.  Medical records that guide and teach. N Engl J Med. 1968;278(11):593–600. 3. ASCVD Risk Estimator Plus. American College of Cardiology. http:// tools.acc.org/ASCVD-­R isk-­E stimator-­P lus/#!/calculate/therapy/. Accessed 20 Mar 2021. 4. American Academy of Pediatrics. Periodicity schedule. https://www.aap. org/en-­u s/professional-­r esources/practice-­t ransformation/managing-­ patients/Pages/Periodicity-­Schedule.aspx. Accessed 28 Mar 2021. 5. APEC guidelines for routine prenatal care. http://apecguidelines.org/wp-­ content/uploads/2016/07/Routine-­P renatal-­C are-­6 -­3 0-­2 015.pdf. Accessed 28 Mar 2021. 6. Elsawy B, Higgins KE.  The geriatric assessment. Am Fam Physician. 2011;83(1):48–56. 7. Pierach CA. Misery versus pleasure. BMJ. 2000;321(7262):693.

7

The Patient-Centered Interview

In the clinic, the patient interview is more than history taking and data collection. In our increasingly patient-centered world, it’s about listening to the patient, connecting with the patient, motivating the patient, and incorporating the patient’s goals and values in testing and treatment decisions. It’s also about hypothesis testing, probabilistic reasoning in uncertain situations (which are common), and understanding one’s own limitations and biases. Mastering the social and cognitive skills needed to become an efficient and patient-centered interviewer is not easy, and there are as many interviewing styles as there are physicians. Ultimately, medical students will need to find their own way to a comfortable and repeatable interviewing style.

7.1

Basics of the Patient-Centered Interview

The patient-centered interview has its roots in the work of George Engel, who first proposed to replace the traditional biomedical model of illness with a biopsychosocial model in 1977 [1]. According to Engel, the biomedical model “assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological, and behavioral dimensions of

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 C. D. Packer, Excelling in the Clinic, https://doi.org/10.1007/978-3-030-99415-0_7

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illness.” The biopsychosocial model corrects this reductionist viewpoint by taking into account “the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system.” Engel elaborates: The doctor’s task is to account for the dysphoria and the dysfunction which lead individuals to seek medical help, adopt the sick role, and accept the status of patienthood. He must weight the relative contributions of social and psychological as well as of biological factors implicated in the patient’s dysphoria and dysfunction….[1]

With increasing acceptance of the biopsychosocial model, the concept of patient-centered care has gained widespread currency in medical education and some acceptance in medical practice, especially in psychiatry and family medicine. Much work has been done to develop protocols and techniques for the patient-­ centered interview, which generally involve agenda setting, open-­ ended questions, allowing the patient to tell the story, giving empathic responses, and then transitioning to a “doctor-centered” process with more directed questioning from the physician (see Table  7.1) [2]. Medical students and physicians may see this framework for the medical interview as impractical and excessively time-consuming, and argue that in any case patients expect a more disease-centered or physician-centered approach. In their article “Tell Me about Yourself: The Patient-Centered Interview,” Platt et al. counter that: Growing evidence suggests that physicians who focus on the patient as well as the disease obtain more accurate and thorough historical data, increase patient adherence and satisfaction, and set the stage for more effective patient–physician relationships. Although concerns are often raised that practice conditions may not allow clinicians the time to give attention to these issues, clear evidence indicates that interviews that attend to patients’ feelings, ideas, and values actually save time…The resultant patient-­ centered interview increases both patient and physician satisfaction. [3]

7.1 Basics of the Patient-Centered Interview

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In my own practice over more than 30 years, I have come to agree that the patient-centered interview increases efficiency, saves time, and probably leads to more effective care and better patient outcomes. It has certainly strengthened my relationships with patients and increased my satisfaction. This is not a new concept; as Sir William Osler said more than 100  years ago, “The good physician treats the disease; the great physician treats the patient who has the disease” [4]. The keys to success with patient-centered interviewing are to ask open-ended questions at the beginning, find out the patient’s agenda, and then transition at some point to the doctor-centered process described in Table 7.1, Step 5. The time in the interview to make this transition varies from patient to patient. Some patients are more passive about their healthcare and prefer to have their physician take the lead, or may be feeling well and have very little by way of an agenda. With these patients, I move on early to the review of systems questions and use “focusing open-ended skills” (listening and prompting where necessary) to get more information on any positive responses. With patients who have many complaints and an overflowing agenda, I listen briefly to all the complaints and questions, prompting where more information is needed, and triage according to the urgency of the complaint. For instance, if a patient is complaining of his usual low back pain, a sore knee, and an episode of chest pain last week, I might ask a quick series of questions to triage the chest pain (Where exactly did you feel the pain? Was it sharp or dull? What were you doing at the time? Did you break into a sweat, get nauseated, or short of breath? Did it hurt more when you took a deep breath or coughed, twisted, or turned? Did it radiate to your arm, neck, or jaw? How long did it last? What made it better? Have you had any more episodes since then, or any prior episodes?). If the pain was clearly atypical and likely noncardiac, I might offer immediate reassurance and move on to the rest of the list. This process of listening, prompting, triaging, and using brief bouts of more directed (doctor-centered) questioning as needed works well for the initial phase of the interview. Later, the patient will expect you to sum things up and give your assessment and recommendations.

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Table 7.1  Patient-centered interviewing method (5 Steps. 21 Substeps) Step 1—Setting the stage for the interview  1. Welcome the patient  2. Use the patient’s name  3. Introduce self and identify specific role  4. Ensure patient readiness and privacy  5. Remove barriers to communication  6. Ensure comfort and put the patient at ease Step 2—Chief complaint/agenda setting  1. Indicate time available  2. Indicate own needs  3. Obtain list of all issues patient wants to discuss; e g., specific symptoms, requests, expectations, understanding  4. Summarize and finalize the agenda; negotiate specifics if too many agenda items Step 3—Opening the HPI  1. Open-ended beginning question  2. “Nonfocusing” open-ended skills (attentive listening): silence, neutral utterances, nonverbal encouragement  3. Obtain additional data from nonverbal sources: nonverbal cues, physical characteristics, autonomic changes, accouterments, and environment Step 4—Continuing the patient-centered HPI  1. Physical story – obtain description of the physical symptoms [focusing open-ended skills]  2. Personal story—develop the more general personal/psychosocial context of the physical symptoms [focusing open-ended skills]  3. Emotional story—develop an emotional focus [emotion-seeking skills]  4. Empathic responses – address the emotion(s) [emotion-handling skills: name, understand, respect, support (NURS)]  5. Expand story and responses—expand the story to new chapters (focused open-ended skills, emotion-seeking skills, emotionhandling skills) Step 5 – Transition to the doctor-centered process  1. Brief summary  2. Check accuracy  3. Indicate that both content and style of inquiry will change if the patient is ready Republished with permission of Elsevier Ireland Ltd., from Hesson et al. [2]

7.2 Greeting and Introduction

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This is where you can present your own agenda—better blood pressure control, more exercise, and starting a statin for cardiovascular risk reduction—and reconcile it with your patient’s agenda. Let’s consider some approaches to specific parts of the patient interview, from greeting and introducing yourself to the patient to summing up the visit.

7.2

Greeting and Introduction

Don’t forget to introduce yourself. This can easily happen if you are running through a mental checklist for the visit, or if the patient immediately engages you in conversation about a symptom and the visit begins in medias res. Give your full name, not just your first name, and identify yourself as “a medical student working with Dr. ________.” You should also obtain the patient’s consent to be seen by a medical student: “Is it okay if I see you first today? Dr. ______ will come in after we finish and check you over as well.” In my experience patients very rarely object to having a student see them first, as long as they know their physician will be in to see them eventually. After introducing yourself, it’s a good idea to start off with a friendly comment or question that’s not any part of the agenda for the visit, just to set the patient at ease and establish some rapport. It might be a comment on the weather, or sports (“I see that you’re wearing a Cleveland Browns T-shirt—did you watch the Steelers game yesterday?”) or anything else you notice about the patient (“I noticed the angler’s hat you’re wearing: are you headed out to the lake for some fishing today?”). In their article, “The Virtues of Irrelevance,” Wolpaw and Shapiro comment: Through irrelevant, friendly comments or questions, physicians can establish key connections with patients. Such small talk conveys physicians’ recognition of patients’ individuality and their own shared experiences, observance of details, and openness to conversation. [5]

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Breaking the ice in this way humanizes the encounter and (I believe) helps with motivational issues such as smoking cessation, medication adherence, and vaccine acceptance, where success often depends on the strength of the physician-patient relationship.

7.3

 egin with an Open-Ended Question, B and Listen Carefully to the Answer

In a 2019 analysis of recorded clinical encounters published in the Journal of General Internal Medicine, Ospina et al. [6] found that clinicians interrupted their patients after a median of 11 seconds! Older observational studies (from 1984 and 1999) revealed that patients who were asked to tell their stories were interrupted after 18–23 seconds. It seems that our capacity to listen to our patients is going from bad to worse! Ospina also found that clinicians elicited the patient’s agenda in only 36% of encounters. Discovering the patient’s agenda is the sine qua non of the patient-centered interview. If the patient is consumed with worry about a nagging pain in her right flank, and her concerns are not discussed or addressed, the visit is a failure. So why not leave it up to the patient to say what’s on her mind? Some patients will come in with a list of symptoms and air their concerns right at the start of visit, but many will not. Anxiety, fear, denial, forgetfulness, and polite submission to the physician’s paternalistic control of the encounter can all be factors in the suppression of the patient’s agenda. Also, it has been shown that patients often lead off with more trivial complaints and save their most pressing concerns for later in the visit—sometimes as they’re heading out the door! This makes it all the more important to allow some open time and space at the beginning to allow the patient to express his or her thoughts and concerns without interruption. A little gentle prompting and encouragement can also go a long way: Doctor: Patient: Doctor: Patient:

Hi, Mr. Jones. How have you been doing? Fine, doctor. I’m feeling well. Any new concerns or problems you’d like to discuss? Well, nothing much. My left knee has been acting up a little more lately. It gets pretty sore and swells up if I do

7.4 Look at the Patient, Not the Screen

Doctor: Patient:

Doctor: Patient:

Doctor:

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too much. It gets very stiff when I sit too long. I took that naproxen you prescribed a couple of times and it seemed to help. I’ll take a look at your knee when I examine you in a few minutes. Anything else going on? I’ve been taking a new supplement for my prostate. It has saw palmetto in it, which I hear is good for prostate symptoms. It seems to be helping—my stream is stronger, and I’m only getting up once at night now. I’m sleeping better. Great! There are some studies that show saw palmetto is effective for prostate symptoms. I’m glad it’s working for you. Anything else? Well, one other thing. I’m concerned about my breathing. I’ve been getting short of breath just walking down the driveway to take out the garbage, which never bothered me before. I’ve also noticed some tightness in my chest when I climb the stairs or take a walk with my wife, and I have to stop for a while to make it go away. I just don’t feel right anymore. Okay, let me ask you a few more questions about that, and then I’ll examine you and we’ll do an EKG.

Note that the patient’s third complaint was the most significant and worrisome issue for him. This is a very common scenario in the patient interview. It’s almost as if the patient is testing the waters with the first couple of issues, assessing the physician’s level of attention and concern before trusting him to handle the most pressing complaint. If physicians fail this listening test, their patients may continue to deny or rationalize their serious symptoms, which can lead to bad outcomes.

7.4

Look at the Patient, Not the Screen

“Turn away from the computer and look at your patient.” This sign should be posted on every computer in every medical office on the planet. Tapping away at the keyboard while staring at the screen and half-listening to your patient does not meet the defini-

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tion of a patient-centered interview. Look at the patient; have a real conversation. If you need to check a test result or renew some prescriptions while you’re speaking, that’s fine; but trying to input all the data and write the whole note while you’re speaking is too much. My method is to jot down a few notes as I interview the patient, and then do the note-writing between patients or at the end of the session. Some practices are hiring scribes to write the notes and free doctors to focus completely on their patients. I’m open to this concept, although I wonder about the effects of putting a third person in the room, and also worry that secondhand notes might miss some of the important nuances and connections that would have gone into the physician’s firsthand note.

7.5

Med Reconciliation

Med reconciliation means verifying with patients that they are taking their medicines and that they know which medicines they are supposed to be taking. It also involves asking patients if they are taking any over-the-counter medicines or supplements, or any medicines prescribed by other physicians. Med reconciliation is usually done by the nurse before the visit, often with the help of a printout listing all of the prescribed medicines that the patient can review while waiting to be checked in. Sometimes patients bring in all of their medicine bottles in a big plastic bag, which can be a real eye-opener when you discover that they are taking cancelled medicines, expired medicines, medicines from unlabeled bottles, or the same medicine from two different bottles. Even if the nurse is doing a med reconciliation before each visit, it’s a good idea for the medical student or physician to review the medication list with the patient at some point in the encounter. A convenient time to do this is while scanning the chart to see which medicines need to be renewed. If the patient says he is taking his insulin every day but the prescription expired 6 months ago, that’s a contradiction that needs to be investigated. I commonly find that my patients have stopped one or more of their medicines, often months ago, because of side effects or uncertainty about the duration of treatment or (very often) simply

7.6 Evaluate New Symptoms with Pertinent Positives…

65

because they are tired of taking so many medicines. I once forgot to do med reconciliation for one of my elderly patients, probably because he was a very conscientious and intelligent man, and I assumed he would be on top of things. Unfortunately, he had run out of his levothyroxine 6 months before and never renewed it; he was admitted to the hospital with severe hypothyroidism (TSH 70) complicated by a large pericardial effusion that led to a long and difficult hospitalization with two pericardial window procedures. This experience taught me the importance of doing a med reconciliation at all visits for all patients.

7.6

 valuate New Symptoms with Pertinent E Positives and Negatives

This is a skill that takes many years to develop. It boils down to careful listening, asking the right questions, and testing various diagnostic possibilities with different lines of questioning. For students, the hardest part may be to decide which symptoms should be evaluated with further questioning, and which are less significant and can be acknowledged without further investigation. Another challenge for students is to learn the questions to ask that confirm a particular diagnosis (the pertinent positives) or rule out other diagnostic possibilities (the pertinent negatives). To take the common clinic scenario of a patient complaining of chest pain, the pertinent positives for angina pectoris are chest pain that is substernal, exertional, and relieved with nitroglycerin; other symptoms that support the diagnosis include diaphoresis, nausea, shortness of breath, and radiation to the arm, neck, or jaw. Pertinent negatives might be chest pain that occurs only at rest or after meals, pleuritic pain, pain brought on by bending or twisting, pain relieved with antacids, or pain lasting only seconds at a time. If the patient’s pain is sharp, is pleuritic, and occurs at rest, the line of questioning might turn to pertinent positives for pulmonary embolism: any recent travel, trauma, surgery, or immobilization? Any history of malignancy? Any arm or leg swelling? Any personal or family history of blood clots? Any smoking, use of oral contraceptives, or estrogen replacement? The line of ques-

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tioning might take another turn if the pulmonary embolism responses are all negative, but the patient mentions that she was lifting and placing heavy flagstones all day yesterday while working on her new patio. With repetition and experience, these questions come to mind quickly and effortlessly for a broad range of patient symptoms and complaints. For me, recalling these key questions feels exactly the same as calling to mind other things I’ve memorized and internalized over the years, such as this quote from Shakespeare’s King Lear (it also applies rather eerily to the COVID-19 ­pandemic): The weight of this sad time we must obey, Speak what we feel, not what we ought to say. The oldest hath borne most: we that are young Shall never see so much, nor live so long.

Pertinent positives don’t generally rhyme, but they do have a certain air of aphoristic authority that makes them memorizable. Here are a few of the many that I can call up from memory: Biliary colic is right upper quadrant pain that is colicky and radiates to a point just below the right scapula. It often occurs after a fatty meal and wakes the patient up at night. Secondary syphilis can cause fever, malaise, lymphadenopathy, sore throat, patchy hair loss, abnormal liver function tests, and a generalized rash that involves the palms and soles. Asthma is reversible, responds to bronchodilators, and can be triggered by cold, exercise, allergies, and environmental factors. Kidney stones cause colicky back, flank, or groin pain, hematuria, dysuria, nausea, and vomiting; 80% are radiopaque, and stones >5 mm are unlikely to pass spontaneously. Celiac disease is associated with chronic diarrhea, weight loss, gluten intolerance, dermatitis herpetiformis, iron deficiency anemia, and tissue transglutaminase antibodies.

The goal for a medical student is to walk out of the exam room with either a provisional diagnosis or a ranked list of diagnostic possibilities. This goal can be reached only if the student understands how to evaluate symptoms and test hypotheses using pertinent positives and negatives. Letting the patient talk (he will tell you the diagnosis if you let him!), memorizing the pertinent posi-

7.7 Review of Systems

67

tives for common diseases, reading, participating in case discussions, and seeing as many patients as possible will help you to become the kind of in-the-room diagnostician you’ll need to be as a primary care physician.

7.7

Review of Systems

There are two ways to approach the review of systems at a clinic visit. One is to perform a full review of systems, which is generally done for new patient visits and annual checkups. The other option is a focused review of systems, which means focusing on the patient’s active medical conditions. For example, if a patient with hypertension, heart failure, COPD, BPH, and gout comes in for a follow-up visit, a focused review of systems might include the following questions: 1. Hypertension. How have your home blood pressures been running? Any stroke or TIA symptoms, headache, chest pain, shortness of breath, or light-headedness? 2. Heart failure. Any weight gain, PND, orthopnea, leg edema, exertional dyspnea, palpitations, or excessive fatigue? 3. COPD. Any wheezing or productive cough? Are you short of breath at rest? How far can you walk before becoming short of breath? Are you using the inhalers as prescribed? 4. BPH. Any slowing of the urinary stream, incomplete emptying, dribbling, dysuria, urgency, or nocturia? 5. Gout. Any recent episodes of joint pain, swelling, and redness, especially in the big toe joints, ankles, hands, or wrists? Note that even a focused review of systems for a patient with several chronic medical conditions will cover a lot of territory. This patient’s focused review includes the neurologic, cardiovascular, pulmonary, endocrine, urologic, and musculoskeletal systems. A full review of systems is generally done at the time of the annual physical, and for all new patients. A full review can be done at any routine follow-up visit as well, but the first priority for these visits should be the management of chronic conditions,

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which if complex can easily consume all of the allotted time. Visits for acute complaints should be narrowly focused, but exploration of the complaint will often open up lines of inquiry into other symptoms and systems. For example, a patient presenting with a complaint of right shoulder pain might end up having a cervical radiculopathy, or pleurisy, or shingles, or even biliary colic. Knowing the questions to ask to sort out these possibilities is a key skill for medical students. The review of systems is more than a list of yes-or-no questions to be checked off in the EMR and then forgotten. Significant, even critically important symptoms are often discovered in the review of systems. For example, I’ve diagnosed TIAs ­(transient ischemic attacks) in a number of patients simply by asking routinely about transient numbness or weakness, difficulty speaking, loss of vision, or double vision. Patient with TIAs have a substantially higher risk of stroke over time (29.5% over a median of 8.8 years of follow-up in a recent population-based cohort study [7]), and they don’t always recognize the significance of their TIA symptoms. Timely diagnosis of TIAs allows for effective preventive measures that can reduce long-term stroke risk. The review of systems helps us with surveillance, disease management, and differential diagnosis in the primary care clinic. Think of it as a diagnostic spider web woven together with pertinent positives and negatives, waiting to catch symptoms instead of flies.

7.8

 sing Motivational Interviewing U for Behavioral Change

Motivational interviewing can be summed up in a single sentence: “Let the patient set the goals.” Instead of simply telling the patient to quit smoking, lose weight, exercise, or cut back on alcohol, the physician might ask, “If you had one habit that you wanted to change in order to improve your health, what would that be?” The patient might say that he drives the four blocks to the grocery store every day; he’d like to walk, but he doesn’t want to carry his groceries all the way home—they’re too heavy:

7.8 Using Motivational Interviewing for Behavioral Change

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Doctor: I can see that would be difficult, especially with your shoulder arthritis. Patient: Exactly. But I do like to walk. Doctor: Is there some other way you could get the groceries home without carrying them? Patient: Actually, there might be a way. I think I have an old grocery cart in the basement that still works. Maybe I could take the cart to the store on nice days, when it’s not raining. Doctor: That sounds like a good plan. Another patient might say that she’s been thinking about cutting back on her drinking. She goes out with her co-workers every Wednesday night and has five or six mixed drinks, and then drinks a full bottle of wine on Saturdays and Sundays: Patient: I’d like to cut back, but I enjoy my evening out, and wine relaxes me on the weekends. I have a lot of stress in my life. Doctor: Have you thought of any ways you might be able to cut back a little? Patient: Well, I don’t really have to finish a whole bottle of wine in one sitting. I could have a glass or two and save the rest for the next day. Doctor: That sounds like a reasonable goal for you. Patient: And I have been the designated driver a couple of times on Wednesday nights and actually had a pretty good time without drinking. Maybe I could volunteer to do that more often. Note that the goals are modest and attainable, and are set by the patient. Instead of giving directives and warnings (“You need to stop drinking—it could cause liver damage”), the physician helps the patient resolve her ambivalence about cutting back on alcohol, and offers support and affirmation for her plan. The key to this patient-centered approach is that the motivation for change must emanate from the patient, not the physician. There is evidence that very brief (5-minute) sessions can have positive results, even in

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patients who are resistant to change [8]. This supports the regular use of motivational interviewing in the clinic. Stewart and Fox [9] provide us with a useful list of seven principles that capture the spirit of motivational interviewing: 1. Motivation to change is elicited from the patient, not imposed from outside. 2. It is the patient’s task, not the physician’s, to resolve his or her ambivalence. 3. Direct persuasion is not an effective method for resolving ambivalence. 4. The counseling style is a quiet one, with a focus on eliciting the patient’s thoughts. 5. The physician is directive in helping the patient examine and resolve ambivalence. 6. Readiness to change is not a patient trait but a fluctuating product of interpersonal interaction. 7. The therapeutic relationship is more like a partnership or companionship; expert/recipient roles can impede the process [9].

7.9

 ealing with Talkative, Angry, D and Distracted Patients

Talkative Patients  This is a common problem in the clinic, especially for medical students, who are often hesitant about interrupting and redirecting their patients. A qualitative study of Dutch GPs’ communication strategies [10] gives interesting insights into the doctor’s dilemma with talkative patients: a patient-centered approach with open-ended questions might lead to an unmanageable torrent of information, but an overly directive approach could harm the doctor-patient relationship. The Dutch GPs’ strategies for dealing with talkative patients center on first understanding the cause for the patient’s talkativeness (loneliness, nervousness, or simply the patient’s usual communication style) and then using an appropriate strategy—emotional support for the lonely patient, safety and comfort for the nervous one, and struc-

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ture for the inveterate talker. Damage control can include a structured approach without being too directive, sharing responsibility for time management with the patient (setting a shared agenda), and ensuring that the patient doesn’t lose face by using empathic interrupting and humor. Redirection can be subtle, with reformulating and clarifying the patient’s symptoms (so you’re saying your hand has been hurting for about a week, in the joint at the base of the thumb?), or straightforward with strict instructions (“I need you to tell me how long your hand has been hurting, exactly where it hurts, and what the pain is like”). Many patients will respond to gentle redirecting; others need a firmer approach. In my experience, very few take offense at being redirected as long it is done politely and tactfully rather than impatiently. One of the Dutch GPs commented: Very subtly, I try to be really kind and to join in with something, so that I can interrupt. What I do is, I take a detail and then I interrupt him with a question about that detail, which allows me to get the floor. Once I have the floor I start to direct more, like ‘yes, I understand what you’re saying, but I would like to know more about…’ and then I try to focus on something that is relevant. [10]

Yet even with the most talkative patients, it is helpful to listen without interrupting for a few minutes at the beginning of the visit: In my experience, [the story’s essence] is often conveyed during the first minutes of the consultation. When you give people the chance to talk for a while...when you lean back for a moment, you often find the crux in the first few minutes already. So it will save you time which you can use for exploring the specifics. [10]

I think it’s particularly important to remember that talkative patients are often lonely, and fairly bursting with things to say when they get the rare chance to see somebody who is ready to listen to them. Be sensitive to this. Listening patiently to a lonely person is an act of kindness. Never underestimate the therapeutic benefit of simple acts of kindness in the clinic.

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Angry Patients  On the one hand, you have enough on your plate as a third-year medical student without having to deal with angry patients. On the other hand, you will need to learn how to care for all patients in the future, including angry ones. In my experience as an attending, medical students do surprisingly well with angry and difficult patients. One advantage that students have is the luxury of time to probe the causes of the patient’s anger and work on de-escalating the situation. Students also tend to be good, respectful listeners, which is one of the keys to success in defusing difficult encounters. Let’s say that you’re seeing a 48-year-old man with a history of depression, PTSD, and chronic and increasingly severe low back pain. He has had physical therapy, acupuncture, and epidural steroid injections, and is currently taking ibuprofen, gabapentin, and diclofenac gel with little relief. While you are taking his history, he suddenly becomes angry and agitated. “Nobody is treating my fucking back pain! I need something stronger! Are you going to give me what I need for this pain or not?” He goes on with this loud tirade for several minutes, never rising from his chair or making threats, but causing a major disruption in the clinic. How do you handle this? First, you should maintain your equanimity. Responding with anger and getting into a shouting match with the patient is the worst thing you can do. Consider the medical, substance-related, and psychosocial causes of anger [11]: does he have a history of traumatic brain injury, chronic insomnia, or temporal lobe epilepsy? Is he on steroids for his back pain, or intoxicated with alcohol? Does he use methamphetamine or phencyclidine? Psychosocial causes of anger can include depression, mania, pain, PTSD, personality disorder, and grief—we know that he has several of these conditions. Better treatment for his PTSD and depression might be the key to controlling his pain. Next, is he making verbal threats or showing signs of an impending physical assault, such as making a fist or assuming a fighting posture? If so, you should leave the room as quickly as possible and seek assistance. If not, you can stay and use de-escalation tactics, including acknowledging the patient’s grievance and frustration (“I feel like you are angry,” or “I feel like our communication has broken

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down”) and then shifting the focus to a discussion of how to solve the problem [11]. You might offer to increase the gabapentin dose, or consider adding a topical analgesic or a low dose of tramadol. If the patient remains angry and there is no progress toward resolving the problem, it’s best to disengage. Don’t insist on having the last word. Call the patient the next day or see them again soon, after they’ve had time to decompress. Patients will often apologize and thank you for your efforts to help them after a short period of reflection. Distracted Patients  In the clinic, distracted doctors are generally a far bigger problem than distracted patients. We’ve all seen doctors who are answering pages, rushing out of the room to see other patients, or staring at the computer screen while patients are trying to describe their symptoms. Over the past few years, however, I’ve noticed that more and more of my patients are coming in with cell phones in their hands, which almost inevitably ring at some point during the visit with bizarre sounds such as barking dogs, breaking glass, and loud, obnoxious snippets of rock or rap music. They look at the phone, tell me who it was that just called them (“Oh, that’s my wife”) and then either hang up or blithely answer the call and begin a conversation, which usually goes something like this: “Look, I’m with the doctor now…I can’t talk…what happened to your sister’s car?...well, tell her to get a tow truck…no, a tow truck, she can’t drive it in that condition… look, I’ve got to go now…yes, I’ll tell him about the rash…bye-­ bye.” Even if they don’t take the call, the phone almost always rings (or barks) again within about 30 seconds. These cell phone episodes can take up substantial amounts of time. Another common distraction since the onset of the COVID-19 pandemic is the telemedicine appointment where the patient takes the call in the car, on the bus, in line at the grocery store, or at work. This can lead to all manner of hurried, abbreviated, interrupted, and unproductive encounters. I had one patient who had a telephone support job who excused himself immediately when I called and then spent the first 10 minutes of our visit telling a client on another line that his gizmo was probably, no, definitely no

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longer under warranty, after which he told me that we had only 7 minutes to talk because he would be docked for the time if he didn’t get right back to his support calls. Other patients have cable news or cowboy movies or jazz on very loud in the background, or carry on contemporaneous conversations with unknown persons, or simply disappear without explanation for a few minutes at a time. As a student, you need to know that it’s okay to ask patients to turn off their phones, turn down the background noise, and try to eliminate other distractions so they can focus for a while on their medical issues. Sometimes, when there are too many distractions that the patient can’t control, it’s reasonable to suggest that the telemedicine visit be cut short or rescheduled for a more convenient time.

7.10 Cyberchondriasis A little learning is a dangerous thing; Drink deep, or taste not the Pierian spring: There shallow draughts intoxicate the brain, And drinking largely sobers us again. —Alexander Pope

For most people, the Internet is the first stop when they need to find out more about their symptoms, or have questions about health and disease in general. Physicians have been aware of this for many years, and are used to fielding questions from patients about their online searches, from sources ranging from reliable to questionable to downright dangerous. Many people feel empowered by their easy access to health information, but others become anxious, distressed, and sometimes even obsessive about what they find as they wander in the dark alleys and rabbit holes of the Internet. Vladan Starcevic has defined “cyberchondria” as “repeated online searches for health-related information that are associated with increasing levels of health anxiety” [12]. Cyberchondriasis can be thought of as a subtype of illness anxiety disorder (IAD), which was formerly known as hypochondriasis. IAD patients are concerned with having a serious illness for more

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than 6 months, have a high level of anxiety about their health, and display excessive health-related behaviors. Consider the following case [13]: Mr. S, a 50-year-old white man, presented with 2 weeks of nausea, constipation, abdominal pain, and anorexia. He was on a keto diet for a few months and then developed an “aversion to fat” so he switched to complex carbohydrates for 3 weeks and noted burning upper abdominal pain. No emesis, diarrhea, blood in stool, black stool, hematuria, fever, or chills. He had numerous food allergies. Starvation improved his symptoms. Past Medical History Chronic kidney disease (baseline creatinine 1.6 mg/dl) Family history of Huntington’s disease (mother, MGM died in their 60s) Untreated anxiety disorder (declined mental health referral) Allergies Lentils, rice, beans, squash, apples, coconuts, seeds, tomatoes, gluten, dairy, and eggplants Medications Calcium, vitamin B12, folic acid, iron, copper, zinc, egg shells, magnesium, potassium, B complex, vitamin K, motherwort, periwinkle, passionflower, St. John’s wort, cassava root, and vitamin D Physical Exam Vitals: Afebrile 64 16 130/80 weight 140 lbs General: thin male, anxious Abdomen: soft, mild mid-abdominal tenderness Back: no flank pain Labs and Imaging Creatinine 3.1 mg/dl (0.5–1.2) Calcium 12.5 mg/dl (8.5–10.1) Vitamin D 258 ng/ml (30–45) PTH