In our current Internal Medicine training environment, we rarely get exposure to ambulatory models of care. For many valid reasons, our residency training relies heavily on inpatient “teaching units” and consultant teams.  However, when it comes time to practice, few will end up working exclusively in this environment (notable exceptions include those pursuing critical care and pure hospitalist practices). 

Learning how to manage patients and time in the ambulatory setting is therefore a crucial part of medicine. I want to pass on some tips that I have learned over the years in a new series.

Tip #1 Ambulatory medicine thrives on longitudinal relationships:

Start your visits and consults with the social history. When I am on the inpatient service, I often start by asking patients “What is the reason you came into the hospital?” However, in the ambulatory setting this opener doesn’t work – they came to this appointment because they were scheduled for it!  Also, in the inpatient setting we are focused on functional status, because this is such an important limitation to discharge. However, in ambulatory medicine generally our patients meet a minimum functional status in that they are able to independently keep track of appointments and come for visits. This means we have to dig a bit more when we gather our social history.

If someone is new to clinic I find the following approaches are helpful:

• Before we jump into your medical history, I’d like to spend some time getting to know a bit more about you. Can you tell me about yourself and what’s going on in your life right now?
• If someone isn’t working, be aware that this may be a source of stress for them. Instead of asking them about why they aren’t working, ask instead “What do you spend time on during the day?”.

Some opening lines I find helpful for follow up visits include:

• What is new for you since the last time you were seen in our clinic?
• Is there anything in particular you were hoping we could cover with our visit today?
• I see that you work as a _____, could you tell me more about that?

Overall, you are trying to understand what makes your patient “tick”. What makes them excited? What does their day look like when they aren’t going to appointments? What are they looking forward to?

If you seen them again, you can ask them about these things. It will make both them and you happy to keep track of important life events outside of their illness.

Stay tuned for the next installment, how to increase efficiency and balance a full clinic schedule.