Tips to prepare for a rotation in outpatient medicine
From the July-August ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason van Steenburgh
When Michael E. Ezzie, ACP Associate, started his first community outpatient rotation last year, he was a bit surprised by his reaction to the most mundane cases. "I was more comfortable with a patient who had '10-out-of-10' chest pain than a 20-year-old with a sprained knee," he recalled.
Educators agree that working in a community-based practice can open up a whole new world of medicine. Outpatient rotations not only give residents the chance to polish and improve the clinical skills that are the bread and butter of private practice, but also to fine-tune their communication skills. Residents can even get a glimpse of how the business of medicine gets conducted from doctors working in the trenches.
Twenty years ago, outpatient rotations in community-based settings for internists were rare. Today, however, educators say that about 90% of training programs offer some type of outpatient rotation.
But as Dr. Ezzie, a second-year resident at Ohio State University College of Medicine and Public Health in Columbus, Ohio, learned, the world of outpatient medicine brings entirely new challenges. It can also require what may seem like an entirely different set of skills.
Educators and housestaff say, however, that some basic preparation can go a long way to help residents make the switch from inpatient to outpatient care. Here are some tips they offered to make the most of community-based rotations.
Getting off to a good start
Before you start working at your new office, ask other residents who have been on the rotation what to expect. Miguel Parilo, ACP Member, a general internist with a group practice in Dayton, Ohio, completed several outpatient rotations during his residency.
Before beginning one rotation with a Dayton allergy and immunology practice, Dr. Parilo asked some colleagues about his new preceptor. He heard that the physician liked to get a quick read on new residents by quizzing them right off the bat.
Once he learned the doctor was interested in pathology, Dr. Parilo quickly read up on asthma pathology and "passed" the quiz. He got off on the right foot with a tough new preceptor and enjoyed the month he spent there.
While you may not have time to bone up on your preceptor's interests, you should at least ask what he or she expects from you. And make sure to tell your preceptor about your goals for the rotation. Explaining your agenda will help him or her teach to your needs.
As soon as you arrive at your new rotation, get a lay of the land. Every orientation should include a tour of the facilities and introductions to all of the staff. If no one offers a tour, ask for one.
Also, ask what resources are available for research. The practice may have outdated textbooks or lack computers, Internet access or electronic patient records. If the practice's resources are so poor that you have trouble finding information, talk to your program director. Michael L. Green, ACP Member, associate program director of Yale University School of Medicine's primary care residency program in New Haven, Conn., said that medical schools occasionally provide resources to practices in exchange for resident training.
'You won't have all the data at your fingertips and you can't instantly get a lab test.'
—Catherine R. Lucey, FACP
If you normally use a computer to view patient records and track lab results, you may be in for a big adjustment. In most outpatient settings, you won't have instant access to lab results and other data until patients are long gone.
"You won't have all the data at your fingertips and you can't instantly get a lab test," said Catherine R. Lucey, FACP, residency training program director at Ohio State. "You'll be forced to rely on your history-taking and clinical skills, and you'll need to develop a tracking system for labs."
This is definitely not the time to leave your laptop or handheld computer at home. After only a few years in a university setting, most residents know more about electronic resources than their older colleagues. Teaching preceptors to use a new program on a palmtop or introducing them to online decision-support tools like ACP's Physicians' Information and Education Resource can build collegiality and reinvigorate the learning process.
And don't forget that you're not in the hospital. Dr. Parilo, who now teaches residents in his office, said that residents' busy schedules sometimes overpower their social graces, and they forget they are entering a professional office.
"Show up on time and dress professionally," he suggested. "Don't come in wearing scrub tops."
After spending most of your time training in a hospital, you'll probably be a bit rusty handling common outpatient complaints such as coughs and colds, twisted knees and ankles, back pain and skin rashes.
"I walked into a dermatology rotation and was totally inept at managing common acne," said Dr. Parilo. "Toxic shock syndrome was no problem, but if soap and warm water didn't work on acne, I was at a loss."
The advice from community-based educators is simple: When you have time, ask a question. Unlike inpatient rotations, where attending physicians often lecture and identify clinical learning points, outpatient rotations require you to see a higher volume of patients with little or no time for discussion in between.
If you never seem to have time to ask questions, talk with your preceptor about meeting once daily or weekly to discuss the questions you've collected. When you find a clinical skill that you need to sharpen, tell your preceptor so he or she can guide those patients your way.
Clinical issues aren't your only concern. Keep an eye on the balance between service and education. If you're grinding away and not learning anything, speak up.
Yale's Dr. Green had to intervene on behalf of one resident when the practice she was working for lost two doctors. The group overwhelmed the resident with grunt work, while providing no education. "We don't allow practices to solve their problems on the backs of our residents," he said.
Unfortunately, the resident didn't complain until two months of a three-month rotation were finished. The lesson: If you feel the practice is taking advantage of you, talk to your preceptor right away. If the situation doesn't change, immediately consult your program director.
Being worked to death on an outpatient rotation is usually not a big worry. In fact, the shorter work hours give you a great opportunity to rest up and catch up on reading.
"It's not like the inpatient grind where you're so fuzzy from lack of sleep that you can't absorb anything," said Stephen J. Oehlers, ACP Associate, a third-year internal medicine resident at the Yale University School of Medicine primary care residency program. "Jot down questions as they come up so you can research them later."
The cases you see in an outpatient rotation will also serve as a springboard for future learning. The intricacies of shingles will come to mind much more readily if you can recall Mr. Tanner, the German language teacher who presented with the disease, rather than a faceless case from a textbook.
What about urgent questions that simply can't wait? Although asking open-ended questions can bog down a busy physician, you can get answers from your preceptor without slowing the patient flow.
Dawn E. DeWitt, FACP, a community-based teaching veteran who is now head of the school of rural health and dean of the rural clinical school at Australia's University of Melbourne, noted the time pressures in the outpatient setting. She said that many educators recommend deciding what information you want before you present the patient to your preceptor.
"Ask your question up front, then follow up with your presentation," she said. "This strategy focuses the preceptor on your problem, shortens your presentation and reduces stress in time-critical situations."
(This and other techniques are explained in the ACP book, "Teaching in Your Office: A Guide to Instructing Medical Students and Residents." More information is available online.)
Changing your clinical approach
Outpatient care differs from inpatient care in more than just the severity of patient complaints. Often your focus will be prevention rather than treatment.
"The worry of missing a bad diagnosis isn't even relevant for many patients," said Yale's Dr. Oehlers. "You know what's happening and you follow up to prevent a bad outcome."
You'll also learn the "other side" of admitting patients to the hospital. "Learning when we can deal with problems through phone calls and when we need to put a patient in the hospital can be tricky," Dr. Oehlers said, recalling one patient with severe cellulitis and septic bursitis of the right elbow. After taking antibiotics at home for a few days, the patient called his physician complaining of fever and chills. The physician changed his antibiotics and had him admitted for an infection.
Working in the hospital, Dr. Oehlers said he might have questioned whether the patient had to be there. In the outpatient setting, however, he learned that patients need hospital care when they aren't getting better.
Some residents also said that facing a crush of mundane problems can make staying focused a challenge. Fadi S. Braiteh, ACP Associate and a third-year internal medicine resident at Yale University School of Medicine, recalled one instance from his rotation in a community clinic to illustrate that point.
After he treated 20 patients with minimal complaints, a patient came in complaining of headaches, a sore throat and exhaustion for three days. After taking his history, Dr. Braiteh suspected the patient might have bacterial meningitis, but he worried that his inpatient training was making him see exotic diseases instead of a simple case of the flu.
After further examination—and despite the doubts of a fellow clinician—Dr. Braiteh sent the patient to the ER. The patient turned out to have bacterial meningitis with a Klebsiella pneumoniae liver abscess, a unique finding in the United States.
Building communication skills
The high volume of patients in the outpatient environment forces you to hone your communication skills, particularly when it comes to patients who are leery of young physicians. Dayton's Dr. Parilo recalled a cantankerous elderly patient who yelled "Get the hell out of here!" before he'd even gotten through the door.
The best way to gain patients' trust from the start is to ask their regular physician to introduce you. If you are the first doctor through the door, however, try telling them you are the "warm-up crew," then assure them that their doctor will be in later.
Sometimes residents can work a little magic with a reluctant patient. Dr. Parilo recalled an endocrinology rotation in which he saw a diabetic with Charcot foot. The busy attending physician hadn't been able to find out why the man's foot ulcer hadn't healed.
Although the patient initially didn't want to talk to Dr. Parilo, the two chatted for a while and eventually connected. During their talk, Dr. Parilo discovered the patient spent a lot of time walking barefoot, and he was able to successfully address the patient's foot condition.
Learning the business
While you clearly need to know the clinical side of medicine once you enter practice, you'll spend much of your time dealing with billing, coding, hiring and firing staff, picking record systems and choosing scheduling software. Although medical schools now concentrate more on business management, most internists still have to learn business skills on the fly when training is over.
"The business aspects are very important, especially given the economic climate of medicine today," said Yale's Dr. Oehlers. He suggested asking the office manager to explain how the staff codes your visits. "Some know the criteria down cold," he said, "while others always undercode because they don't want to be audited."
An outpatient office rotation drops you into the trenches of the medical business-but many residents fail to take advantage of their front-row seat. Keep in mind that you are not there just to practice, but to learn the profession.
Aruna K. Prattipati, ACP Associate, a third-year general internal medicine resident at Wright State University School of Medicine in Dayton, Ohio, advised residents to concentrate on business as much as possible. "You can learn most of the medicine on other rotations," she said, "but you have to find out how to deal with insurance, code, and manage patients and your time from people who are doing it."
Many practices use outpatient rotations as a way to recruit new physicians. Dr. Parilo joined his practice in Dayton after rotating through as a resident. When he walked in as a resident, they gave him his own schedule, medical assistant and exam room. When he joined the practice later, he already had a group of patients who knew him.
Community rotations are also a great scouting opportunity. If you take notes on what you like and dislike about practices, you'll have a better idea of what to look for when you start job hunting.
Even if you decide to become an inpatient physician, an outpatient rotation will help you better understand what community physicians need when patients pass into their care. Several residents said their ability to write more complete discharge summaries greatly improved after they served in the community.
"I found that rather than sending community doctors a letter at some point down the road, I'd call them and tell them what is going on with their patients," said Ohio State's Dr. Ezzie. "It makes a big difference."
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