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Governor's Newsletter, August 2000

James B. Reuler, MD, FACP
Governor, Oregon Chapter

Chapter Meeting

Mark Your Calendar for the 2000 Oregon ACP-ASIM Meeting November 2-4, 2000

  • Programs Are In The Mail
  • Register Early
  • 12 Category 1 CME Credits
  • 16th Annual Infectious Diseases Society of Oregon Meeting, November 2

Daniel Federman, MD, MACP, an endocrinologist and master teacher from Harvard Medical School, will be the Lewis Visiting Professor, and William J. Hall, MD, FACP, Chief of General Medicine and Geriatrics at The University of Rochester School of Medicine, and President-Elect, ACP-ASIM, will be the College Representative. Topics will include updates in General Medicine and Geriatrics, and Women's Health, hemochromatosis and obesity.

Infectious Diseases Society Of Oregon

The Infectious Diseases Society of Oregon invites you to attend the tenth annual conference, which takes place November 2, 2000, at the Eugene Hilton Hotel, preceding the Oregon Chapter Scientific Meeting. The IDSO meeting will highlight flesh-eating bacteria, meningococcas, Lyme disease, staph aureus, pneumonia treatment and more. Afternoon sessions will be on two tracks one for primary care physicians and the other for infectious diseases specialists. For more information about the IDSO meeting, please contact Elizabeth Kerl at (503) 215-6088, or e-mail ekerl@providence.org.

Community Service

This edition's Community Service column is authored by George A. Porter, MD, FACP. Formerly Head of the Division of Nephrology and Hypertension and Chairman of the Department of Medicine, OHSU, Dr. Porter is Chair of the Oregon Board of Medical Examiners www.obme.org.

Community service can include a large number of varied activities, especially if one is at the end of a career. For me they have run the gamut from President of the Mount Sylvania Little League, trustee for Oregon State University, Chairman of Region #2 ESRD Network Coordinating Council, serving on the Governor's Renal Disease Taskforce, being the CME director for the Foundation for Medical Excellence, being elected Vice President for Scientific Affairs for AHA, serving as the founding Editor of the NKF's American Journal of Kidney Disease, presiding as President of the American Kidney Fund and serving on advisory councils for the National Institutes of Health, National Academy of Science and the American College of Physicians. While all these activities have been rewarding, an endeavor from which I derive great pride and personal fulfillment involves working, on behalf of the medical community, on projects and with groups which have direct impact on improving the care of patients that extend beyond those in my own practice.

Following completion of my nephrology fellowship at UCSF's Cardiovascular Research Institute, I returned to Portland and joined the faculty at OHSU. The year was 1964, and Dr Richard Drake and Charlie Willock were beginning production of the home dialysis machine. That same year, I witnessed the stark reality of what is now known as ESRD with several of my patients dying on the wards of Multnomah County Hospital because nothing was available to replace their lost kidney function. The Kidney Association of Oregon was organize to collect money to help support the home patients. While my initial involvement was to provide expert advice as to the acceptability of patients applying for support, it soon became a fundraising role to improve both the number of patients that could be treated and quality of care we could provide. This effort continued for 10 years until the passage of the federal ESRD legislation in 1974, a proposition for which I was able to lobby our congressional delegation with a personal conviction that dialysis patients could lead a productive life. Although the ESRD legislation provided financial support, many of the costs of daily living were not included. Fortunately, I became associated with two organizations which addressed many of the major problems which ESRD patients faced. The AKF is dedicated to providing financial grants to needy ESRD patient for drugs, transportation, heat, etc. I continue to serve on the patient programs committee and chair the committee on secondary insurance which is critical due to the capitation of federal support. The second group is the Life Options for Rehabilitation Advisory Council. The LORAC has pushed a national agenda for renal rehabilitation and over coming the barriers that ESRD patients face by addressing five areas of concern: employment, encouragement, education, exercise and evaluation.

In the 1980's, I became involved in the Eastside Community Clinic, which was dedicated to providing care to the homeless. At the urging of Dr Paul Brown, a group of community leaders, including myself and Dr Peter Kohler, began the process of planning for a downtown infirmary where homeless patients could recuperate as a transition between hospitalization and a return to the street. Despite substantial legal and political impediments, HealthBridge NW was launched at a site off Burnside and provided services to the homeless for over 2 years. However, in the end, the financial burden was too great and the project was closed down. This experience was bittersweet as it reinforced how impor- tant public appeal is to the success of community projects.

Finally, after stepping down as Chairman of the Department of Medicine at OHSU, I was able to accept appointment to the Oregon Board of Medical Examiners. Protecting the public and insuring that quality medical care is provided by Oregon physicians is the principle which guides all board decisions. The Board also is consulted by both the Governor and Legislature regarding medical issue such as bariatric prescribing, scope of practice, alternative medicine practices, pain laws and death with dignity. Because this is a regulatory body with substantial public exposure, political pressure is a significant part of the environment in which the Board operates. Despite these pressures, it has allowed me the opportunity to identify key areas of patient-physician friction which interfere with the sound practice of medicine. Because of my interest, I have served on two committees of the Federation of State Medical Boards, which have developed recommendations which will improve the care that licensed physicians of Oregon and other states will provide. In 1998, our committee's "Model Guidelines for the Use of Controlled Substances for the Treatment of Pain," was adopted by the FSMB. This last year the Committee on Professional Conduct and Ethics presented recommendations regarding Internet prescribing and will continue to develop guidelines that allow the proper medical uses of the Internet without patient exploitation.

The opportunity to translate my patients' experiences into improved medical care has been a lifelong pursuit and provided great rewards to a highly satisfying career in medicine.

Immunization Make Them Automatic

By David Shute, MD, OMPRO Clinical Coordinator

Most of us welcome the opportunity to practice primary prevention. We continue, however, to underutilize one of our most effective preventive therapies adult immunization.

In April, the CDC's Advisory Committee on Immunization Practices (ACIP) issued new recommendations for the use of influenza vaccine. The recommendations for influenza and pneumococcal polysaccharide vaccine (PPV) are summarized below.

Influenza Vaccine

Influenza immunization is effective in preventing influenza illness, secondary complications, influenza-related hospitalizations, and death.(1) The current ACIP recommendations for influenza include annual immunization for:

  • all persons age 50 years and older;
  • residents of nursing homes or other chronic care facilities;
  • persons with chronic pulmonary or cardiovascular disorders;
  • persons with chronic diseases such as diabetes, renal dysfunction, hemoglobinopathies, or immunosuppression;
  • children and teenagers receiving long-term aspirin therapy;
  • women who will be in the second or third trimester of pregnancy during the influenza season;
  • healthcare workers and others in close contact with persons at high risk; and
  • members of the general population who wish to reduce the likelihood of becoming ill with influenza.

Pneumococcal Vaccine

As drug resistance strains of S. pneumoniae have become increasingly common in the United States, prevention becomes increasingly important. Not only is pneumococcal polysaccharide vaccine (PPV) highly effective in preventing invasive pneumococcal disease including bacteremia and meningitis it is also cost effective for people age 65 years and older.(2) The current ACIP recommendations for PPV include initial immunization for:

  • persons age 65 years and older;
  • persons age 2 to 64 years who have chronic illnesses (including diabetes, lung disease, alcoholism, cirrhosis, and heart disease) or asplenia; and
  • persons age 2 to 64 years living in social settings that increase the risk for pneumococcal disease.

ACIP recommends a single revaccination after five years for:

  • persons 65 years and older if first dose was given before age 65;
  • persons with functional or anatomic asplenia; and
  • immunocompromised persons.

When indicated according to the guidelines above, people who are unsure of their PPV status should be immunized.

In spite of clearly demonstrated efficacy, we fail to immunize many of our patients. According to the CDC's Behavioral Risk Factor Surveillance System (BRFSS) 1998 survey, only 69.5 percent of Oregonians age 65 years or older reported receiving influenza vaccine in the prior year.(3) Only 59.5 percent of Oregonians age 65 years or older reported having ever received pneumococcal immunization.(3)

Increasing Immunizations In Your Practice

Clearly, physicians have an opportunity to improve immunization rates, and fall is the ideal time. One of the best ways to accomplish this is to seize every opportunity: immunize all appropriate patients who visit your office.(4)

The key to increasing immunizations is using a system that is effective and improves your office workflow. Physician-approved standing orders accomplish this. They empower your staff to immunize appropriate patients without a specific order.

Many physicians use verbal orders requesting their nurse or medical assistant to offer influenza or PPV immunizations to appropriate patients. While this is a good start, a more effective approach is to develop a written policy that includes standing orders accompanied by protocols. A written policy

  • emphasizes the importance of immunizations;
  • assists staff in identifying appropriate patients;
  • broadens the intervention to all practices in an office; and
  • accomplishes a lasting system change that sustains these benefits year after year.

The task of developing a standing order policy and procedure can be time consuming. Fortunately, most of the work has already been done. OMPRO has reviewed a number of standing order policies already in use and has developed examples that can be used as is or modified to meet the needs of specific office practices or institutions. These are available in hard copy or as electronic files to ease customization and duplication.

In addition OMPRO can provide consultation services to assist with the implementation of standing orders or other office-based system changes. All of OMPRO's services are available at no charge.

Start Now

Immunizations are too important to trust to our busy memories. Make them automatic. Decide now to establish standing orders for influenza and pnuemococcal immunizations. Begin the process soon to be ready for the fall immunization season. Contact us at OMPRO we are here and ready to help. Phone (503) 279-0100, or visit our Web site at www.ompro.org.

OMPRO is a nonprofit organization. Our mission is to improve healthcare quality and cost effectiveness through education and collaboration with the healthcare community and the public.

  1. Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR;49:RR-3.
  2. Advisory Committee on Immunization Practices (ACIP). Prevention of pneumococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR;46:RR-8.
  3. 1998 Behavioral Risk Factor Surveillance System (BRFSS). Self-reported survey data from the Centers for Disease Control and Prevention.
  4. 1997 Medicare Pneumococcal and Influenza Vaccination. Presented at the National Adult Immunization Conference, June 21-22, 1999, Dallas, Texas

Kudos

  • Sima Desai, MD, ACP-ASIM Member, of OHSU, elected to be the Faculty Coordinator for the Chapter's Associates' Council. Sima will be replacing Elizabeth Eckstrom, MD, MPH, and will also join the Chapter Council. Thanks, Elizabeth and Sima!
  • Geoffrey Sewell, MD, FACP, of Legacy Portland Programs, recipient of the Oliver M. Nisbet Teaching Award for an outstanding volunteer faculty member given by the graduating class of 2000 of the School of Medicine, OHSU.
  • Kavita Patel, MD, Associate Member, of OHSU, has been appointed to the National College Council of Associates.
  • Elizabeth S. Allen, MD, ACP-ASIM Member, of OHSU/VAMC, recipient of the David W.E. Baird Award for excellence in a junior faculty member given by the class of 2000 of the School of Medicine, OHSU.
  • Gregory J. Magarian, MD, FACP, of OHSU, recip- ient of the Allan J. Hill, Jr., Award for excellence in teaching in the clinical sciences, given by the class of 2000 of the School of Medicine, OHSU.

Please keep us informed of your activities and accomplishments. We want to recognize your good work!

Internists and the Media

This edition's Internists and the Media column is authored by Lynn Goldberg, MD, FACSM, Professor and Head of the Division of Health Promotion and Sports Medicine at OHSU. A graduate of George Washington University School of Medicine and OHSU's internal medicine residency, Linn's early interest in exercise has catapulted him and his group into the national spotlight. Through his research projects with adolescent athletes, the US Olympics Committee, OMSI and the Safe, Disciplined and Drug Free Schools project, Linn has appeared on Capitol Hill, at the National Press Club and before Oregon legislature and media groups.

Starting as a section of General Internal Medicine in 1995 and achieving Division status in 1997, the Division of Health Promotion and Sports Medicine is staffed with three internal medicine and two physical medicine physicians, an exercise physiologist, medical assistant and health promotion researchers. The Division currently has 17 members, and soon to expand to 24 within the next three months. The Division of Health Promotion and Sports Medicine coordinates clinical teaching, education and research to promote healthy lifestyles practices and target potentially at-risk populations for intervention programs.

This year has been particularly busy for the Division. After years of research and clinical work in exercise science in the Human Performance Laboratory, Linn Goldberg and Diane Elliot published a book for patients entitled, The Healing Power of Exercise (John Wiley & Sons, 2000), complementing their medical textbook, Exercise for Prevention & Treatment of Illness (F.A. Davis, 1994). The book describes patients who have prevented and treated various medical problems with physical activity, the scientific principles behind those benefits and how patients can use exercise to treat and prevent disease. Chapters include motivations to exercise, as well as prevention and treatment of hypertension, dys- lipidemia, diabetes, osteoporosis, obesity, coronary heart disease, affective disorders, as well as healthy aging and rehabilitation of common injuries. It can serve as a tool for patients who want to begin or continue an exercise program.

Over the past several years, the Division's focus has been on behavioral change techniques and drug prevention. The ATLAS (Adolescents Training & Learning to Avoid Steroids) program was initiated in 1994 as a National Institute on Drug Abuse (NIDA) sponsored investigation. It was designed to reduce anabolic steroids and other drugs and alcohol use, and enhance healthy behaviors of adolescent athletes. Because the sports team has recognizable goals and are directed by influential coaches, it seemed important to deliver the curriculum in this natural setting. By use of a scripted and structured curriculum that focused on enhancing athletic achievement through sport nutrition and strength training, along with enhancement of decision-making and resistance skills, ATLAS was a success. Published in JAMA and most recently, the Archives of Pediatrics and Adolescent Medicine (April, 2000), a press conference was convened at the National Press Club by NIDA, and became the cover story of USA-Today. The 31 school study showed that new use of steroids were cut by 50%, while alcohol, marijuana, amphetamine and narcotic use were reduced, along with drinking and driving and use of "athletic enhancing" supplements. In addition, nutrition behaviors (less fat, higher protein) diets were achieved among the ATLAS trained student athletes. More specifics about the program and the risks of anabolic steroid use can be found on the Internet at www.atlasprogram.com, or the NIDA site, www.steroidabuse.org. The ATLAS program was honored during a Capitol Hill ceremony in May 2000, by being selected as a Model program by the Center for Substance Abuse Prevention, Department of Health and Human Services. ATLAS is now available to schools through Sunburst Communication and the Center for Substance Abuse Prevention.

Because of the success of ATLAS, two new research programs are underway. ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternatives), is a team-centered intervention designed to reduce disordered eating practices and drug use among adolescent female athletes. Our prior research along with other investigators have shown that disordered eating and substance abuse are closely linked. Like ATLAS, ATHENA is a NIDA sponsored investigation that targets middle and high school athletes.

Another behavioral study will determine whether the "team-centered" approach will work with adults in the workplace, as compared to individual counseling. The Portland and Salem Fire Departments have been recruited, along with fire stations in Washington, and the hope is to find a cost-effective approach to reducing cardiovascular and cancer risk by promoting healthy nutrition and exercise.

Our Division's latest investigation is SATURN (Student Athlete Testing Using Random Notification). This is the first study to evaluate the efficacy of mandatory, random drug testing as a deterrent to sub- stance abuse among high school athletes, and has both national and international implications for drug prevention. Since the Vernonia (Oregon) v Acton Supreme Court Decision in 1995, schools across the United States have implemented drug testing programs,without knowledge of it's deterrent effect. Although billions of dollars have been spent in the military, business, sport and the federal government, no study has addressed the question whether drug surveillance reduces drug use. This study will help inform schools whether or not to spend critical funds to support this type of intervention.

In addition to the above-mentioned research studies, the Division's Human Performance Laboratory, directed by Kerry Kuehl, MS, MD, is very active in evaluation of exercise intolerance (exercise) induced asthma, cardiomyopathies, metabolic myopathies, and exercise prescription), while our physical medicine physicians, Hans and Nels Carlson have clinical practices in diagnosis and rehabilitation of sports injuries and neuromuscular evaluation. This summer, the Division is sponsoring the "Sports Medicine Summer Spectacular" conference in Sunriver, Oregon, for primary care providers. It will provide lectures and an interactive learning format which will include office orthopedics, exercise prescription, information on dietary supplements, substance abuse among adolescent athletes, sports psychology, and "hands-on" training in health promotion techniques and neuromuscular exams. Ernie Kent, the University of Oregon's head basketball coach, will be the featured after-dinner speaker. To learn more about the Division and the upcoming conference, you can log onto the OHSU website.

Preceptorship Opportunities

Precepting young professionals is one of the most rewarding aspects of physicianhood and a critical building block in the foundation for the future of our profession. ACP-ASIM has emphasized this role through its Community Based Teaching (CBT) Program. If you are interested in learning about the resources of the CBT Center, receiving the CBT newsletter, or applying for a CBT Certificate of Recognition (requires at least one year of office based teaching), please contact Patrick Alguire, MD, FACP, at the CBT office within the Department of Education and Career Development at ACP-ASIM national office, (215) 351-2400, ext 2845, or see the CBT section at www.acponline.org/cme/cbt,or the ACP-ASIM web page.

Chapter members who served as preceptors for first or second-year medical students at OHSU in the Principles of Clinical Medicine course during 1999-2000 include:

John Bauer
Steven Beeson
Brian Cox
Theo deBruin
Thomas DeLoughery
George Demetrion
Leigh Dolin
Elizabeth Eckstrom
Diane Elliott
Arthur Hayward
Donald Girard
Andrea Kielich
Kelly Krohn
David Labby
James Leggett
Roger Leverette
Nancy MacNeal
Scott Mader
Daniel Mangum
Mary Meyer
Robert Mullen
Craig Nichols
Rebecca Orwoll
Steven Redmond
James Reuler
Frank Rosenbaum
Ellen Singer
Carol Sprague
Brian Trifficante
Richard Wise

If you wish to learn more about PCM Preceptor opportunities, please contact Ms. Pam Tise at OHSU, (503) 494-6617.

Through the Area Health Education Centers (AHEC) Program and the Primary Care Clerkship at OHSU, primary care practitioners from around the state serve as preceptors for third-year medical students. Chapter members who served as AHEC preceptors during 1999-2000 include:

Andrew Gilchrist–Newport
Jeffrey McDonald–Coos Bay
George Potter–Coos Bay
Charles E. Hoffman–Baker City
William Moriarity–Coos Bay
Jerry Robbins–Newport
Albert Tsien–Coos Bay

If you are interested in learning about preceptorship opportunities in the AHEC Program, please contact Ms. Becki Anderson at OHSU, (503) 494-1165.

Student Mentorship Program

By Amy Schmitt, 4th year medical student OHSU; Sarah Cassell 4th year medical student OHSU; and Richard Wise, MD, Student Mentorship Program Chairman

The Oregon ACP-ASIM Student Chapter has been in the process of establishing a mentorship program between OHSU medical students and Internal Medicine physicians, which will be designed to give students the opportunity to build lasting relationships with faculty throughout their four years of medical school. The program will be open to medical students at various stages in their training who express an interest in an Internal Medicine residency program and career. Each student/faculty pair will plan their own meetings and interactions in order that their relationship may meet their individual needs and interests.

After initially announcing this program in the last newsletter, we have had response from nearly eighty physicians in Oregon who are interested in being a part of the program. There are currently about twenty medical students who have voiced an interest in the program, not including the incoming first year students, and we will be contacting students again now that the program will shortly be up an running to see if others are interested in participating. Rick Wise MD and Jim Reuler MD faculty advisors, and students Sarah Cassell and Amy Schmitt are coordinating the program and anticipate that the program will be underway by September 2000. Unfortunately, not all of the physicians who volunteered to participate will initially be matched with students, however they may later be called upon to participate as more students begin to voice an interest. Students may primarily be matched with physicians within the Portland area to make interactions easier, however they are free to request a mentor anywhere within the state so we encourage interested physicians anywhere within Oregon to get involved. Participants will be contacted in the near future in order that we may attain additional information to be used in the student-mentor matching process.

Membership

The Oregon Chapter has grown over recent years. Here is a breakdown:

Category 9-1-97 6-1-98 6-1-99 6-1-00
Students 36 104 127 139
Associates 183 217 238 205
Members 533 524 642 634
Fellows 179 182 191 199
Masters 2 2 2 2
TOTAL 933 1,029 1,200 1,179

Tell your friends about ACP-ASIM. For more information, contact ACP-ASIM Customer Service at (800) 523-1546, ext 2600, or Mary Olhausen at (503) 494-8676.

Career Column

This edition's Career Column is authored by Jocelyn White, MD, FACP, FAAPP. Jocelyn received her medical degree from New York University. Since completing her residency at Legacy Portland Hospitals and a Fellowship in General Medicine at OHSU, Dr. White has received her Certificate in Medical Ethics, is the President of the Gay and Lesbian Medical Association, and Co-Editor-in-Chief of the Journal of the Gay and Lesbian Medical Association.

Career Building is All About People

When Jim Reuler asked me to write an article for this newsletter on how I built my career, I suddenly felt well, there was no other way to say it old. Either that, or I have over the years done something noteworthy. I hope it is at least a bit of the latter. He asked me to tell the story of how I came to build an academic medicine career in the field of lesbian health. I think it goes without saying that most of you will not be planning on building a career in lesbian health anytime soon. I hope, however, that Jim was right about my being able to share with you some basic tenants of career building that I have learned along the way.

Looking back on how it all happened, it is clear to me that career building is all about the people. Everything has happened because of someone I met or a conversation I had with a new friend or a networking connection. Over the years I have built relationships with people of common interest, and because of those shared interests we entered into projects together. Fortunately for me, the projects were all meaningful and enjoyable. Finding the meaning in what I do has helped sustain my career trajectory.

Back in college, I knew that I wanted to go into medical school to be able to provide health care to other lesbians who had been unable to find a caring, compassionate physician. The introduction to the anthol- ogy that I edited, The Lesbian Health Book, describes sitting around in the dorm common room, sipping mugs of tea, hearing stories from my friends about bad experiences they had had with doctors. From those discussions, I developed a career goal which has been a sustainable focus for my work.

During my general medicine fellowship, that goal began to be translated into academic projects. First, a review paper for the Journal of General Internal Medicine, with help from my faculty, then, through an SGIM connection, I developed a workshop in lesbian health care that I presented at three national meetings. At the first of those workshop presentations, I met another academic internist who belonged to a national lesbian physicians organization. She invited me to present a keynote address at their upcoming national meeting. She and I have remained friends, and in fact, she invited me to author a book chapter with a co-author of my choosing for the textbook she was editing for the ACP-ASIM called Gynecology for the Internist.

That is basically how it started. When people got to know me at the first national presentation, they invited me to present a plenary session at the national meeting of the Gay and Lesbian Medical Association when it was held in Portland. I met some of the Board of Directors at the evening recep- tion, and invited the president of the Board to Papa Haydn's for dessert that night. I enjoy playing host like that. I believe it was over the sacher torte that she invited me to join the Board of Directors. I spent a total of six years on the Board meeting people and helping with projects. These new contacts and previous accomplishments developed into book chapters, articles, research grants and projects, atten- dance at national advisory committee meetings for various branches of the government, a book contract, and finally invited presentations at the Institute of Medicine meetings on lesbian health research priorities and the chance to be a reviewer for their final report.

So, if I had to give advice to somebody on how to do this sort of thing, I would say it is important first to have a goal, a clear focus. Then it is important to be an expert on something and have good communication skills so that you can convey that expertise to others. The next thing to do is to be sure to be active in an organization that is aligned with your goal. The people that you meet in ACP-ASIM and the projects that you can do through the organization, are a great example of something that can help you build a career. It is important to get to know people. Don't just meet them, actually get to know them and find out what their interests are. One of the great rewards of our work is knowing truly wonderful people. Spend some time keeping up with connections at the same time as you invest time staying an expert in your field. The time you spend developing your communication and leadership skills will serve you well as you work on projects that move you through your career. But, most of all, career building is all about the relationships with people, working together in teams, networking and having friends who will make the next project fun.

In Memoriam

George B. Long, MD, FACP, Governor of Oregon ACP-ASIM Chapter 1978-81, died May 7 at the age of 87. A graduate of Northwestern University School of Medicine, Dr. Long practiced gastroenterology in Portland until 1983. Formerly, Head of the Division of Gastroenterology at OHSU for over a decade, Dr. Long was past-president of the North Pacific Society of Internal Medicine and volunteered his time to teach and represent CARE MEDTCO in Kabul, Afghanistan. One of the great leaders in the Chapter and Oregon Internal Medicine, Dr. Long's contributions will be long remembered.

Tips For Preceptors: How to Organize the Ambulatory Visit

By Patrick C. Alguire, MD, FACP, Director, Education and Career Development

Learners, and students in particular, often have trouble deciding how to organize the process of collecting and then presenting patient data. As compared to the hospital environment where time is not a factor, the ambulatory setting presents unique challenges of addressing patient concerns and collecting information in a limited amount of time and solving problems with limited use of technology. Linda Pinsky, MD, has created a useful organizational scheme that is used at the University of Washington. The learner is asked to organize the outpatient visit using the following framework:

  • What?
    Elicit the patient's agenda: "What should we talk about today?"
  • Why?
    Elicit the patient's attribution or understanding of the problem: "What do you think is causing this? What do you think should be done?"
  • Why?
    Identify the most likely hypothesis and supporting data. Be able to answer the probing question, "What is the supporting evidence?"
  • What else?
    Create a prioritized and weighted differential diagnosis. Be able to answer the probing question, "What is the supporting evidence?" for each of the diagnoses.
  • What now?
    Determine the immediate next steps: "What history, parts of the focused examination, and tests need to be done? What are the treatment options?"

This organizational framework, formatted as a set of instructions and a series of tables for student use, is available in the CBT Clearninghouse or can be obtained by calling 800-523-1546 ext 2614. Theese materials can help a student or first year resident organize an efficient and effective visit with the patient and construct a concise follow up presentation to the preceptor. We recommend that they be copied and given to the student during the office orientation on the first day of the rotation.

Tips for Office-Based Preceptors

What do students and residents want from a community-based teaching experience?

To students, preceptor characteristics are the most important factors defining a successful office-based experience. One of the most highly related teaching characteristics is the preceptor's ability to promote student independence.(1) Most often this was accomplished by giving the student increasing patient care responsibility. Other highly favored characteristics is the willingness to allow students to practice technical and problem-solving skills, enthusiasm and interest in students, and the ability to actively involve the student in learning. The willingness of a preceptor to act as a mentor and advise the student is also highly valued.(1-3)

Characteristics of the office are of secondary importance to the learner when compared to preceptor characteristics. Valued office characteristics include having a wide mix of different available preceptors, a wide variety of presenting patient problems, and a range of patient ages.(1)

The areas providing the most difficulty for students are learning to work within the time constraints of the office setting, performing a focused examination, and learning to rely upon data gathering skills and problem-solving abilities rather than imaging and laboratory tests.(4) Other highly valued educational experiences include discussion of general management issues, diagnosis, and demonstration of physical examination skills.(5) Residents value the opportunity to discuss differential diagnosis and management issues, and appreciate the close supervision, feedback, and to practice and improve clinical and procedural skills.(5)

The message from the learners is consistent and clear; they want the opportunity to practice basic data collection and management skills on a wide variety of patients typically seen in the office setting. They desire feedback on their performance and a role model to emulate.

  1. Biddle WB, Riesenberg LA, Dacy PA. Medical student's perceptions of desirable characteristics of primary care teaching sites. Fam Med 1996;28:629-33.
  2. Prislin MD, Feighny KM, Stearns JA, et al. What students say about learning and teaching in longitudinal ambulatory primary care clerkships: a multi-institutional study. Acad Med 1998;73:680-87.
  3. Epstein RM, Cole DR, Gawinski BA, Piotrowski-Lee S, Ruddy NB. How students learn from community-based preceptors. Arch Fam Med 1998;7:149-54.
  4. Feltovich J, Mast TA, Soler NG. Teaching medical students in ambulatory settings in departments of internal medicine. Acad Med 1989;64:36- 41.
  5. O'Mallery PG, Kroenke K, Ritter J, Dy N, Pangaro L. What learners and teachers value most in ambulatory educational encounters: A prospec- tive, qualitative study. Acad Med 1999;74:186-91.

Upcoming Dates

August 22-23, 2000 ABIM Certification Examination in Internal Medicine

October 14, 2000 NW Regional Symposium "Physician Well-Being" sponsored by Northwest Center for Physician Well-Being, Skamania Lodge (Stevenson, WA)

November 2, 2000 10th Annual IDSO Meeting (Eugene, OR)

November 2-4, 2000 Oregon Chapter ACP-ASIM Annual Meeting (Eugene, OR)

December 1, 2000 Fellowship Applications due at ACP-ASIM

March 29-April 1, 2001 ACP-ASIM Annual Session (Atlanta, GA)

June 1, 2001 Fellowship applications due at ACP-ASIM

How to Reach Us

James B. Reuler, MD, FACP
Section of General Medicine
Veterans Affairs Medical Center (P-3-MED)
PO Box 1034
Portland, OR 97207
Phone: (503) 220-8262, ext. 55582
Fax: (503) 721-7807
reulerj@ohsu.edu
reuler.james@portland.va.gov
Mary A. Olhausen
Department of Medicine
Oregon Health Sciences University
3181 SW Sam Jackson Park Road, OP-30
Portland, OR 97201-3098
Phone: (503) 494-8676
Fax: (503) 494-5636
omary@teleport.com
olhausen@ohsu.edu

Contact Information

Thomas G Cooney, MD, MACP
Oregon Chapter Governor

Mary Olhausen
Phone: 360-892-1814
Fax: 360-326-1844