Benjamin A. Voss
Ambulatory care is medical care provided to an outpatient. Disease prevention, health promotion, medical decision-making, and acute illness management are all performed in the ambulatory setting. The goals of an office visit will vary from visit to visit, and not every issue can or should be addressed at each visit.
PREVENTION OF FUTURE HEALTH PROBLEMS
· Primary prevention limits disease from occurring by removing the cause (e.g., immunizations). Primary prevention often takes place at the community level with efforts such as fluorination of water.
· Secondary prevention entails screening for asymptomatic disease while in an early, treatable phase. This includes screening for common cancers using modalities such as Papanicolaou (Pap) smears, colonoscopies, or mammograms.
· Tertiary prevention refers to those activities and interventions that prevent worsening of a disease or further complications, for example, using statins in patients with known coronary disease.
· The periodic health exam, also known as the “annual physical exam,” is often used to address these preventive issues, and more time is typically allotted for these visits.
THE PERIODIC HEALTH EXAMINATION
· Covering all the issues that need to be covered as part of a periodic health exam in one visit is challenging. Many insurance companies may not cover a “routine visit.” Therefore, addressing health maintenance and chronic disease management in an ongoing manner is necessary.
· Preventive medicine requires an individualized assessment tailored to each patient’s age, gender, risk factors, and chronic illnesses.
· Counseling about a healthy lifestyle is a critical component of health care at any age.
Adolescents and Young Adults
· Adolescents and young adults are at risk for serious morbidity and even mortality related to the risky behaviors that are common in this age group.
· The clinician should maintain an open and nonjudgmental attitude to encourage the adolescent to speak frankly.
· Confidentiality is critical and should be assured.
· Topics to discuss include the avoidance of smoking, alcohol abuse, and illicit drug use; the use of bike helmets and car seatbelts; firearm safety; depression and suicide; the potential consequences of sexual activity and how to avoid them; and healthy dietary habits, eating disorders, and appropriate exercise. Unintentional injury is the leading cause of death among adolescents.
· Family history is an important part of the history in this age group.
· The physical examination should include height, weight, blood pressure (BP), cardiac, musculoskeletal, and testicular examinations. Routine internal pelvic examinations are not recommended in this age group but may be performed when indicated.
· Laboratory tests should include Pap smear (if the patient is over 21), screening for Chlamydia trachomatis and Neisseria gonorrhoeae in sexually active women, and targeted screening for HIV and other sexually transmitted diseases (STDs) in high-risk patients.
· Preventive measures include updating immunizations, especially rubella in women, hepatitis A virus (HAV), hepatitis B virus (HBV), human papillomavirus (HPV), tetanus, pertussis, and annual influenza vaccination.
· Women of childbearing age should take a daily vitamin with 0.4-mg folic acid to reduce the risk of neural tube defects in their offspring.
Midlife Adults
· Important topics to discuss include continued reinforcement of the importance of healthy habits, especially diet, exercise, avoidance of tobacco, alcohol abuse, and drugs.
· Physical and laboratory examinations should include height, weight, BP, cardiac exam, and screening for dyslipidemia and common treatable cancers.
· In most women, annual mammography should begin at age 40 (see Chapter 5).
· Men can be offered screening for prostate cancer beginning at age 50 (see Chapter 4).
· All patients should be screened for colorectal cancer beginning at age 50. Patients with high-risk factors, including a family history of disease, need more aggressive screening (see Chapter 5).
· Perimenopausal women should be counseled and should be offered screening for osteoporosis (see Chapter 3).
Older Adults
· Important topics to discuss include continued reinforcement of the importance of healthy habits, especially diet, exercise, and avoidance of tobacco, alcohol abuse, and drugs.
· Reviewing medication lists is critical for avoidance of polypharmacy and surveillance for side effects, drug interactions, and the need for dose adjustments (see Chapter 38).
· Physical and laboratory examinations generally continue as for younger adults with additional screening for deficits in vision, hearing, and mobility. Fall risk assessment and dementia screening are important (see Chapter 38).
· Patients should be monitored to ensure their ability to perform activities of daily living, including driving and taking medications accurately.
· Preventive measures include offering pneumococcal, zoster, and annual influenza vaccinations (see Chapter 5).
· Many elderly patients benefit from a daily multivitamin to prevent nutritional deficiencies.
· Few guidelines exist regarding the decision as to what age to cease routine cancer screening. Therefore, the decision must be individualized and based on patient preferences, age, comorbidities, functional status, and estimated life expectancy.
· Family and community resources can provide support to enable the aging patient to remain as independent and active as possible.
· End-of-life care and establishing a living will should be discussed on an ongoing basis with patients and their families.
SCREENING FOR DISEASE
· The benefit of screening depends on the prevalence of the disease, the sensitivity and specificity of the screening test, the ability to change the natural course of disease with treatment, and the acceptability of the test to the patient. See also Chapter 5.
· Various professional organizations have made recommendations regarding screening for disease; these guidelines apply only to asymptomatic patients at average risk, and they must be individualized.
o The U.S. Preventive Services Task Force (USPSTF) usually takes a conservative standpoint and does not recommend screening without relatively clear evidence for a meaningful change in outcome (http://www.uspreventiveservicestaskforce.org/, last accessed July 18, 2013). Table 1-1 lists screening activities currently recommended by the USPSTF specifically for asymptomatic patients at average risk.
o Disease-specific and subspecialty groups often advocate for more aggressive screening, such as prostate and lung cancer screening.
o Other groups, such as the American College of Physicians (ACP), generally take the middle ground.
· Many areas of controversy exist, including ages to start and stop screening, frequency of screening, which tests to use, and potential harms in screening.
· There is a lack of definitive research regarding the effect of screening on morbidity and mortality for many diseases.
Table 1-1 Screening and Preventive Measures Recommended by the USPSTF for Asymptomatic Average Risk Individuals
USPSTF, United States Preventive Services Task Force.
Cancer Screening
· Cancer screening recommendations have been issued by many organizations, including the American Cancer Society (ACS; http://www.cancer.org, last accessed July 18, 2013), the National Cancer Institute (http://www.nci.nih.gov, last accessed July 18, 2013), the American College of Physicians (ACP; http://www.acponline.org, last accessed July 18, 2013), the United States Preventive Services Task Force (USPSTF; http://www.uspreventiveservicestaskforce.org/, last accessed July 18, 2013), and many specialty societies.
· As with screening for other conditions, the approach much be individualized.
CURRENT DISEASE MANAGEMENT
· The clinician should evaluate the status of chronic diseases and any potential new problems.
· Not every problem can be analyzed exhaustively at each visit.
· The average office visit is scheduled for approximately 15 minutes, so prioritization must occur and is usually based on the patient’s chief complaint and what the clinician feels is the most serious problem.
· Explanation of disease and relief of symptoms are keys to the patient’s satisfaction. Symptom relief does not always require prescription drug therapy but may include lifestyle changes, physical therapy, or over-the-counter medications.
· Reassurance that a symptom is not indicative of a more serious illness is important.
· Screening for risk factors and treating chronic conditions known to produce cardiovascular disease are critical components of ambulatory care.
Hypertension
High BP is the most common primary diagnosis in the United States and is often referred to as “the silent killer” because it is generally asymptomatic. See also Chapter 6.
· The relationship between BP and cardiovascular events is continuous, consistent, and independent of other risk factors.
· All adults should have their BP measured at least every 2 years, and more frequently if elevated, but the optimum screening interval is unknown.
· Persons should be seated quietly for at least 5 minutes in a chair, with feet on the floor and arm supported at heart level. At least two measurements should be made with an appropriate-sized cuff.
· Ambulatory BP monitoring provides more detailed information and can evaluate for “white coat” hypertension.
· Normal BP is <120/80.
· Prehypertension is defined by a systolic BP of 120 to 139 or a diastolic BP of 80 to 89 mm Hg. Prehypertensives are at high risk of developing hypertension, and early intervention can decrease the rate of progression to hypertension.
· A systolic BP >140 or diastolic BP of >90 mm Hg (measured on more than one reading) is considered hypertension. in patients younger than 65-years-old. For patients over age 65, the definition of hypertension is BP >150/90 mm Hg.
· Antihypertensive therapy has been associated with a 40% reduction in stroke, 25% reduction in myocardial infarction, and 50% reduction in heart failure.
· Initial therapy includes counseling on weight loss, aerobic exercise, limiting alcohol intake, and reduction of sodium intake. The decision as to whether to start drug therapy should depend on the severity of hypertension, the presence of other disease, and evidence of end organ damage.1
Dyslipidemia
Research from many different sources indicates that elevated LDL cholesterol is a major cause of coronary artery disease (CAD). See also Chapter 11.
· Cholesterol screening is recommended at least every 5 years for all adults older than 20 years of age.
· Screening is best performed with a lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) obtained after a 12-hour fast.
· Individual patient risk assessment and classification is critical for determining treatment goals and therapeutic options.
· Initial therapy for patients with elevated cholesterol includes counseling to decrease consumption of fats and to promote weight loss in overweight patients.
· Clinical trials demonstrate that LDL-lowering therapy reduces risk for CAD.2,3
Diabetes Mellitus
· Diabetes mellitus (DM) requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications. See also Chapter 20.
· The American Diabetes Association standards of care are as follows:
o For decades, the diagnosis of DM was based on either fasting plasma glucose (FPG) or the 2-hour oral glucose tolerance test (OGTT).
o In 2009, an international expert committee recommended the use of the A1C test to diagnose DM, with a threshold of ≥6.5%.
o The established glucose criteria for the diagnosis of DM remain valid. FPG ≥126 mg/dL, 2-hour plasma glucose ≥200 mg/dL during an OGTT, and a random plasma glucose ≥200 mg/dL with classic symptoms of hyperglycemia or hyperglycemic crisis are all diagnostic.
· Asymptomatic adults with sustained BP (treated or untreated) >135/80 mm Hg should be screened for diabetes.
· Screen overweight (body mass index [BMI] ≥25 kg/m2) adults who have additional risk factors (presented in Table 1-2).
· Patients with prediabetes should be referred to an effective ongoing support program targeting weight loss and increasing physical activity.4
Table 1-2 Criteria for Testing for DM in Asymptomatic Adults
Modified from American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35:S11–S63.
Obesity
· Periodic height and weight measurements are recommended for all patients. See also Chapter 22.
· The BMI is calculated as weight in kilograms divided by the height in meters squared.
o BMI ≥25 kg/m2 is considered overweight.
o BMI ≥30 kg/m2 is considered obese.
o BMI ≥40 kg/m2 is considered severely obese.
· More than one-third of US adults are obese.
· Obesity increases the risk of many health conditions including heart disease, stroke, diabetes, and certain cancers.
· Diet and exercise are the cornerstones of weight loss, though medications and bariatric surgery can be considered when lifestyle changes fail.5
Tobacco Abuse
· An estimated 45.3 million (19.3%) US adults smoke cigarettes. See also Chapter 45.6
· Cigarette smoking is the leading cause of preventable death in the United States, accounting for one of every five deaths each year.
· Although only approximately 7% of patients are able to quit long term on their own, it is estimated that counseling and appropriate pharmacotherapy can increase the quit rate to 15% to 30%.
· A widely accepted approach to brief office-based counseling and pharmacotherapy was published by the U.S. Public Health Service in 2008.7
· Brief counseling should be provided to all smokers at every visit. Even short interventions can increase quit rates significantly.
LIFESTYLE COUNSELING
· The most important interventions for promoting good health center on changing personal health behaviors and habits rather than specific clinical interventions or medications.
· Regular physical activity is important at all ages. Patients should be encouraged to be physically active with a goal of accumulating 30 minutes of moderate to vigorous activity on most days of the week. There is strong evidence that exercise protects against CAD. Cardiac risks of physical activity can be diminished by appropriate screening, counseling, and adopting a staged approach to exercise. Frequent follow-up and physician support are vital components of a successful exercise program. Physicians should attempt to present themselves as positive role models to patients by maintaining their own physical fitness.8
· All patients should be counseled regarding a prudent low-fat diet with abundant fruits, vegetables, and whole grains. Some patients may benefit from decreased sodium intake. Women at risk for osteoporosis should be counseled to consume daily calcium and vitamin D. Women of childbearing age should consume at least 0.4-mg folic acid daily by diet or supplements.
· Patients should be advised to use seat belts for themselves and their passengers, to use safety helmets when riding motorcycles or bicycles, and to avoid alcohol or sedating medications when driving.
· Other areas for counseling and screening include alcohol use, dental health, domestic violence, unintended pregnancy, and STDs.
· Alternative health care practices, including herbal medicines, chiropractic care, acupuncture, or hypnosis, should be inquired about in a nonjudgmental manner.
PATIENT SAFETY
· Patient safety and medical errors are pertinent topics in the ambulatory setting. Adverse drug events can account for hospital admissions and significantly contribute to increased morbidity and mortality. Steps must be routinely taken to reduce the number of errors.
· Make patients active participants in their care.
o This helps avoid misinterpretation of diagnostic or therapeutic plans and problems with compliance or follow-up. Involving other members of the health care team, including family, nurses, dietitians, and therapists, is vital.
o Ensure that the patient leaves with a clear comprehensible written plan and contact information if he or she has any questions.
· Medication reconciliation is mandatory.
o Request patients bring all of the medicines and supplements they are currently taking to each visit to ensure an accurate ongoing list of all medications.
o Make sure they know what the medication is prescribed for, the dosing schedule, how long they should take it, interactions with other medications and alcohol, any monitoring or screening that may be necessary, and the importance of compliance with the medication.
o Inquire about any new allergies or adverse reactions.
· Electronic medical records (EMRs) are helpful.
o EMRs serve to limit errors due to illegible handwriting.
o Automatic allergy alerts to prescription medications are beneficial.
o Reminder and alert systems help minimize systemic errors in practice.
o Lack of product functionality can be frustrating for physicians.
ADHERENCE
· Assessment of adherence requires a nonjudgmental attitude and acknowledgment of the many challenges to compliance.
o Open-ended questions actively involve the patient.
o Pill counts are rarely useful and may be insulting to the patient. However, encouraging patients to bring medications to their visits can help both patients and physicians maintain accurate medication lists.
o The patient’s pharmacy can provide information on refill patterns.
o Low serum drug levels may represent failure to take the medication, poor absorption, rapid metabolism, and/or large volume of distribution.
o Cost of medications is a common barrier to compliance. Generic alternatives should be considered when possible.
· Noncompliance must be distinguished from ineffectiveness of treatment. Presumed nonadherence should be approached as any other clinical symptom by forming a differential diagnosis of possible etiologies.
Strategies to Enhance Adherence
· Educate the patient about the medical condition, the risks and benefits of therapy, and alternatives using understandable language.
· Consider the patient’s perspective and keep a nonjudgmental attitude. The patient’s health belief model includes acceptance of diagnosis, perceived seriousness of condition, supposed benefits of treatment, apparent barriers, readiness for change, and the level of confidence in the physician and treatment plan.
· Maintain contact through follow-up visits and telephone calls.
· Keep care as simple and inexpensive as possible by using generic medications, once-daily or combination formulations, and drugs that are not affected by meals.
· Give written instructions. Have the patient repeat the instructions to assess understanding.
· Encourage self-monitoring so that the patient feels a sense of control over his/her own health (e.g., home BP, blood sugar, food diary, exercise log).
· Identify and address barriers, which can include limitations of time, money, transportation, functional illiteracy, social isolation or conflict, depression, mental illness, substance abuse, or cognitive dysfunction.
· Focus on the positive benefits of treatment and reinforce the patient’s efforts. Set small specific goals that are achievable. Take a problem-solving approach to analyze causes and work out alternative strategies if failure occurs.
· Discuss adherence strategies such as the use of medication log sheets, alarms, calendars, or daily pillboxes.
DIFFICULT DOCTOR-PATIENT INTERACTIONS
· The “difficult patient” refers to those patients with whom a physician has trouble forming a normal therapeutic relationship.9
· A more comprehensive definition is “a person who does not assume the patient role expected by the healthcare professional, who may have beliefs and values or other personal characteristics that differ from those of the caregiver, and who causes the caregiver to experience self-doubt.”10
· Nearly one in six outpatient visits is considered difficult. These visits lead to physician burnout and lower work satisfaction.11
· One great advantage of an ongoing physician-patient relationship is that it allows an opportunity to become familiar with all of a patient’s problems and understand them in the context of the patient’s personality and life circumstances. Hopefully, for most patients, mutual understanding and trust will grow as a therapeutic relationship develops.
· Improved communication between the physician and patient can result in better patient outcomes, improved satisfaction of both parties, decreased litigation, and less physician burnout.
· Do not lose sight of the contributions the clinician makes to the doctor-patient relationship, even when it is difficult.
· Consider the interaction itself “difficult” rather than the actual patient.
· Patients who interrupt a caregiver’s established routines and make extra work are often considered difficult patients.
· Patient-related characteristics that appear to be associated with difficult doctor-patient interactions include12
o Mental disorder
o Multisomatoform disorder
o Panic disorder
o Dysthymia
o Generalized anxiety
o Major depression
o Alcohol abuse or dependence
o High health care utilization
o More acute and chronic problems
o Tendency to bring up new symptoms at the last moment
o Demanding/controlling
· Potentially contributory physician factors include13
o Less experienced
o Younger
o Poorer psychosocial attitudes
o Work more hours
o Higher stress
· Given the fiduciary nature of the doctor-patient relationship, it is generally accepted that the physician has a greater responsibility to resolve relationship issues and to ensure that the interactions are as productive as possible.
· Potentially helpful recommendations include14:
o Recognize when an interaction is not going well and acknowledge this to yourself and to the patient.
o Remember that you are not required to solve every problem in a single visit.
o Carefully consider how your own responses to certain patient characteristics are contributing to the interaction.
o Try to understand the patient’s perspective, consider any cross-cultural issues, and be willing to work with different personality types.
o Be empathetic regarding displays of sadness and fear.
o Always keep in mind your fundamental responsibilities to the patient. Be sure to take a history, perform an exam, make an assessment, and offer your best medical advice in clear, nonjudgmental terms.
o Set clear expectations/limits and maintain boundaries. “Agreeing to disagree” can be a respectful way to summarize a challenging interaction.
o Do not prescribe a medication or order a study that you do not think the patient needs just to satisfy the patient’s wishes.
o Self-reflection is critical after a difficult interaction. Analyze what barriers led to the difficult visit and try to learn from them.
REFERENCES
1.Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program Coordinating Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA2003;289:2560–2572.
2.Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486–2497.
3.Grundy SM, Cleeman C, Merz NB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004;110:227–239.
4.American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35:S11–S63.
5.Ogden CL, Carroll MD, Kit BK, et al. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief 2012;(82):1–8.
6.Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥18 years—United States, 2005–2010. Morb Mortal Wkly Rep 2011;60(33):1207–1212.
7.Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Washington, DC: Public Health Service, U.S. Department of Health and Human Services; 2008.
8.Metkus T, Baughman K, Thompson P. Exercise prescription and primary prevention of cardiovascular disease. Circulation 2010;121:2601–2604.
9.Simon JR, Dwyer J, Goldfrank LR. The difficult patient. Emerg Med Clin North Am 1999;17:353–370.
10.Macdonald M. Seeing the cage: stigma and its potential to inform the concept of the difficult patient. Clin Nurse Spec 2003;17:305.
11.An PG, Rabatin JS, Manwell LB, et al. Burden of difficult encounters in primary care: data from the minimizing error, maximizing outcomes study. Arch Intern Med 2009;169:410.
12.Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med 2001;134:897.
13.Krebs EE, Garrett JM, Konrad TR. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data BMC Health Serv Res 2006;6:128.
14.Coulehan JL, Block MR. The Medical Interview: Mastering Skills for Clinical Practice, 5th ed. Philadelphia, PA: F. A. Davis Company; 2006.