Resident Readiness General Surgery (71 page)

Ambulatory Care and the Surgery Intern

John Maa, MD, FACS

OVERVIEW AND EXPECTATIONS

As a surgeon, running an outpatient clinic effectively is critical to patient flow, patient safety, and patient satisfaction. In the United States, typically 15 to 20 minutes are allocated for an outpatient visit. Patients are often double booked. Recognize that in some Asian countries, outpatient clinic visits are only 3 minutes long. Clearly, much of the key work in clinic visits can be completed in a very short amount of time, but it requires a very focused discussion.

Recognize the possible destinations for patients after being seen by you in clinic. The majority will return home. Some will need urgent admission, possibly through the emergency room, or as direct admissions. A few will require urgent surgery. Others will be sent to a different specialty or primary care clinic as a result of your evaluation, to have an elusive diagnosis made by being seen in a different specialty clinic. For these patients, what you can do to be most helpful is to expedite that evaluation by a different consultant, perhaps by calling him or her directly. You will realize that a few patients have been sent to the wrong clinic; they may be quite frustrated and refunding their insurance copayments for the visit might be indicated. Some patients will have traveled long distances to be seen, and may be tired or anxious. Some patients are most appropriately seen by the chief resident because of the complexity of their chief complaints, whereas others are suitable for junior residents or interns. In some clinics, interns are assigned primarily to perform history and physical examinations within 30 days of surgery for patients who have already received a diagnosis and treatment plan. Performing examinations and reviewing final lab and x-rays are critical roles you can play. You can demonstrate your value if you identify key elements that may have been overlooked by the attending in the preoperative assessment (carotid bruit, abnormal EKG, incomplete preoperative consults).

PREOPERATIVE AND POSTOPERATIVE CLINIC VISITS

Clinic patients will fall into 1 of the following 2 phases: (1) preoperative and (2) postoperative.

Postoperative
visits are relatively straightforward. A clinic schedule should be configured to allow a mix of preoperative and postoperative patients, with the easier postoperative visits an opportunity for the clinician to catch up on the schedule.

The key things to do in a postoperative visit are
:

A. To review the surgical incisions for possible infections, hematomas, seromas, lymphoceles, or incisional hernias.

B. To check the pathology report and ensure that further treatment plans (particularly for cancer diagnoses) and referrals (ie, oncology) are in place.

C. To ensure adequate pain medication refills, work notes, and disability paperwork are complete.

D. To answer the final questions from the patient, with further instructions about activity level (no heavy lifting after hernia repair, bathing and the care of steri-strips, symptoms about which to be vigilant).

E. To transfer the patient back to the care of the primary care physician. Recall that the global period in surgery often allows patients to be seen for up to 90 days after surgery at no cost to the patient. New appointments to see the patient back should be made liberally available if there is uncertainty about wound healing and recovery.

Preoperative
patients can be most complex. As you begin speaking to the patient, recall that you are essentially being asked to answer this focused question: does the patient require surgery for the surgical condition that is proposed? You are being asked for an expert opinion, as a consultant, and must thus answer at the level of an attending, not as a trainee. Most likely, restating the chief complaint in the patient’s own words is most helpful to frame the discussion and presentation to the attending. At times, you will encounter patients who don’t even know why they were referred by their other doctor to the surgery clinic. In such cases, you should carefully review all primary sources of data, which may include the medical record, paperwork in the patient’s possession, recent radiology reports, or verbal communications with other family members.

As clinicians gain greater expertise, they often learn to focus on abnormalities as the subtle clues to find the true diagnosis. Ultimately, to complete your assessment expeditiously, think of yourself as a detective. Focus on the question at hand, and direct all of your questions, review of the vital signs, and physical examination toward this main point. There is no need to address chronic medical conditions that are under the care of other treating physicians and unrelated to the surgical question at hand.

Once the decision to operate is made, the next important question becomes how to perform the procedure safely. Deciding what incision to use will depend on the past surgical history and evaluation of the previous surgical scars, so your evaluation and presentation to the attending should focus on these findings. If available, all of the previous operative notes should be requested and reviewed. Read all sources of primary information, and beware of chart lore. Don’t make assumptions about information, particularly anything that is critical to the decision to operate. Review of the complete medication list is necessary to determine
which medications should be discontinued preoperatively (pay special attention to antiplatelet medications such as Plavix and aspirin and anticoagulants such as warfarin). The general health of the patient is assessed through the past medical history. Advising smoking cessation is also wise, especially for some orthopedic and plastic surgery procedures where active smoking may be a contraindication to elective surgery. Some patients will require joint procedures with other services (plastics, vascular) and coordinating surgery across specialists is a task you can delegate to the clinic staff.

TIME MANAGEMENT

1.
Keep the clinic flowing smoothly.
Most often, the number of examination rooms is the rate-limiting step in clinic throughput. Sometimes, this means sending a patient to the laboratory or radiology to free up clinic space temporarily while you collect more information that may assist in making the diagnosis or a decision about the need for admission to the hospital. If a patient needs to be admitted, the best strategy is for the patient to be moved out of the examination area and back to the waiting area or hospital admitting to await the availability of an inpatient bed. If a patient is particularly complex, move on to another patient, and sometimes a solution for the challenging patient will enter your mind as you are speaking to the second patient.

2.
Focus the conversation with the patient.
After a brief open-ended question such as “How are you feeling?” or “What may I do for you?,” redirect the patient if the response is tangential. For example, the question “What brought you here today?” may yield the reply “an ambulance,” or lead to a lengthy discussion of the difficulty in finding a parking space in the garage. Politely and professionally constrain extraneous conversations, and try to focus on the medical condition and the relevant history for which the patient has been referred. Before a lengthy discussion of the risks of surgery or plans for future care, it is most often helpful to bring interested family members who might be in the waiting room into the examination room, so that you don’t find yourself repeating a 10-minute explanation again to another family member.

3.
Delegate appropriately.
You are a limited resource, so don’t spend excessive time doing things you don’t need to do. Defer prescription refills to the primary care provider, and involve the clinic staff to assist you with administrative matters such as obtaining insurance authorizations, HIPAA clearances, and completing disability paperwork or work requests. Some preoperative questions, such as the precise timing for discontinuation of anticoagulants, use of oral antihypertensives the morning of surgery, and fasting for breakfast, will be addressed by the anesthesiologist and preoperative staff. In some clinics, clinical decision aids and educational materials (handouts or videos) can be given to patients in the waiting room or as they wait in the examination room to be seen, to better
prepare and focus the ensuing discussion once the doctor arrives. At times, a formal review of radiologic imaging from a different hospital will be needed, and speaking to a radiologist by telephone will be insufficient to make a clinical decision. One solution is to ask a member of the clinic staff to hand carry the films or CD to the radiology department for interpretation. Ultimately it may require having the patient return to clinic, or speaking to him or her later by telephone once the x-rays have been formally read, to make the final decision whether surgery is necessary.

PROFESSIONALISM

1.
Arrive in clinic on time and try to stay on schedule. Delays only compound as the clinic progresses, as more time is spent hearing the subsequent complaints of frustrated patients who have been waiting prolonged periods. This can be minimized by starting clinic promptly.

2.
Wear professional attire. In general, wearing surgical scrubs to clinic is discouraged. One’s attire, grooming, and overall appearance can leave a lasting impression on the patient and family (both positive and negative).

3.
Refrain from being excessively critical of other clinicians or referring providers. Try not to criticize the care delivered by other physicians based on allegations or hearsay, without confirming the facts. Be objective and truthful in your assessment.

COUNSELING THE PATIENT

1.
You may be in the uncomfortable situation of caring for an unhappy patient. Don’t speculate, and be willing to say “I don’t know.” Be certain to notify the attending promptly if this situation arises. At times you will be contacted by patient relations or risk management, and in those situations be completely honest, objective, and accurate in your description of the events and reports of the medical record.

2.
Don’t make pronouncements about prognosis or treatment too early, as the condition may be more complex than you realize. Use caution when making statements that may impact family perceptions and travel plans.

3.
Don’t try to oversimplify a complex situation, and don’t try to place certainty on an uncertain situation. This is a first chance to meet with the patient, and it may take future repeat visits to make an accurate diagnosis and come to a final decision. Don’t make guarantees or promises to patients that you can’t fulfill. Sometimes you will encounter unrealistic patient expectations about the outcome or plan, which may sometimes be the result of information that has been inaccurately conveyed by the primary care provider, who may also have unrealistic expectations. You will have to handle these difficult situations delicately.
At times, referring doctors may have intentionally misstated the reason for referral to gain access to your clinic, so you sometimes have to question the diagnosis that is written on the referral sheet.

OTHER FINAL WORDS OF ADVICE FOR THE EFFICIENT INTERN

1.
Dictate or write notes as you go. You may forget key information later on if you leave dictations until the end of clinic.

2.
An effective intern uses time to call consults and to check labs if the opportunity to present a patient to the attending is delayed. Similarly, the time waiting to present to an attending can be well spent in self-directed reading about the clinical questions relevant to the patients you are seeing in clinic.

3.
For effective time management, defer questions about insurance authorizations and hospital bills to the appropriate institutional offices.

4.
Don’t assume anything about what you are told or jump to conclusions. Some of the worst outcomes in patient care are a result of communication breakdowns, particularly in caring for complex patients.

5.
Avoid performing procedures in clinic, which can consume significant amounts of time and clinic rooms.

6.
To promote safety and quality in delivering care, beware of truncation and communication failures, errors propagated in sign-out, or chart lore.

A 55-year-old Man Who Was Struck by a Beer Truck and Needs a CT Scan