For many students, the Primary Care Practicum is a highlight of the Foundations phase. Your experience in your PCP will cement your learning in the Foundations blocks as you see patients with the same conditions. It will also help you maintain the empathy and enthusiasm that brought you to medical school, as you’re reminded by your patients why you chose a career in medicine.

Over the course of the next year, you will complete 15 half days in the same primary care clinic, working with an interprofessional healthcare team in the clinical learning environment. During each half day session, we expect you to perform at least one interview and one physical exam – PCP should be a hands on experience.

After each session, you will complete the PCP tracker to log your session. This must be done within 72 hours so that you still remember what you took away from each session as well as to allow us to make sure students are on track to complete this requirement.

In this Pressbook reading, you will learn about:

• • An Introduction to Primary Care
  • Setting the Agenda 
  • Acute Problem Focused Visits
  • Chronic Disease Management Visits
  • Screening and Prevention Visits
  • Outpatient SOAP notes
  • Outpatient OCPs

Advance through each of these sections using the arrows at the bottom of the page.

If you are ill and cannot attend the in-person workshop, please also review the video in this section: The PCP Experience

An Introduction to Primary Care

The Institute of Medicine defines primary care as “the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnerships with patients, and practicing in the context of family and community.”  This definition highlights several key features of primary care:

Primary care and health outcomes

Better primary care leads to better health outcomes. This has been demonstrated across health care systems and across nations since the 1960s.

 

Life expectancy is higher in US states that have higher primary care physician to population ratios. Each additional primary care physician per 10,000 population is associated with an average increase of about 2 years in life expectancy.  Another study showed that American adults who called their personal physician a primary care doctor rather than a specialist had 33% lower cost of care and a 19 % lower risk of death.

Countries with a higher quality primary care system have significantly lower health care spending even if the United States, which is such a high-cost outlier, is removed from the analysis.

In the United States, a study of Medicare beneficiaries in fair or poor health showed that one of the strongest predictors of a preventable hospitalization was living in a primary care shortage area.  Areas with better primary care have better health outcomes including lower total, cardiovascular and infant mortality as well as earlier detection of colorectal, breast, uterine and cervical cancer.

There are always limitations in the evidence, and we can always ask more questions. Most of the evidence supporting primary care is ecological and observational, and it is hard to sort out the covariates, issues of causation, and determinants of health, all of which are extremely complex. Nevertheless, a large body of evidence supports the substantial impact of primary care on health.

PCP: Outpatient Team

The Primary Care Practicum is your first opportunity to participate in an authentic interprofessional health care team.  At almost every clinic, you will work with at least one other health profession. Many practices are moving to a team-based care model that includes a range of professions to better meet the needs of their patients.  Every team is different and you’ll learn who is on your team when you arrive at your PCP.

Medical Assistants

The job of a medical assistant is diverse and involves direct, in-person patient care along with addressing a multitude of between visit care needs.  Medical assistants are usually the first person to engage with a patient during their clinic visits.  They are responsible for rooming a patient, obtaining vital signs, briefly reviewing patient concerns and updating portions of the medical record. Additional clinical duties may include performing EKGs, administering immunizations, assisting with procedures among many other things.  In many clinical settings, medical assistants also develop long-term continuity relationships with patients and are integral in helping with between visit acute and chronic care management.

Registered nurses

Registered nurses are involved in many aspects of patient care.  A key role is the triage of patient concerns, directing them to the most appropriate site of care.  RNs are integral in health education, care coordination and follow-up of clinical care interventions.  RNs develop continuity relationships with patients and help to manage chronic medical conditions which require frequent follow up such as diabetes, heart failure and hypertension.  In the in-person setting, RNs may be involved in caring for and transferring unstable patients, wound care management, and administering medications among other things.

Clinical pharmacists

Washington state law allows clinical pharmacists to see patients for independent visits for common chronic illnesses, including diabetes, hypertension, and warfarin anticoagulation.  Under collaborative drug therapy protocols, established with the prescribers in the clinic, pharmacists initiate, monitor, and modify drug therapy for specific diagnoses.  Patients achieve therapeutic goals more quickly and with fewer provider visits.  Pharmacists can also provide patient education, medication reconciliation, and identify resources for patient unable to afford their drugs.

Social workers.

Social workers assess patients’ and families’ strengths & needs and identify resources to meet those needs, within the clinic or healthcare system or in the community.  These needs are diverse and may include issues around insurance, housing, mental health, substance use disorders, caregiver support systems and grief among many others.  In some clinics social workers may provide short term counseling services.

Mental health specialists.

Many clinics have integrated mental health or behavioral health specialists into the clinic, given the prevalence of mental illness in both primary and specialty care.  These specialists may be psychiatrists, psychologists or licensed social workers.  Many of the behavioral health programs in the primary care setting aim to provide guidance around medication management, mindfulness and cognitive behavioral therapy tools to help with mood disorders, and provide more immediate support while patients are transitioned to a mental health provider who can provide a longer-term therapeutic relationship.

Dietitians

Dietitians work with patients to assess nutritional status, counsel on eating habits, diet modifications, and healthy lifestyle and provide education on nutrition for disease management.

Setting the Agenda

Agenda setting is important in all clinic visits. When all concerns are put on the table up front, worrisome issues don’t ‘pop up’ at the end of the visit and the physician and patient can decide together how to spend their time.  This strategy has been shown to shorten primary care visits without decreasing patient satisfaction. People remember that their concerns were addressed, not the actual time they got to spend with the physician.

The video below, created at the Mayo Clinic, shows a dermatologist and a patient setting an agenda in a specialty visit.  All videos like this are a little corny, but it gives you the idea.

Here is a step-by-step approach to practice in class and in your PCP.

Acute Problem Focused Visit

At an acute visit, you’ll evaluate a new issue, like cough or rash, in the context of the patient’s overall health. Since time is limited, you will not collect the entire database.  Rather, you’ll focus your data gathering on the questions and exam maneuvers that will help you diagnose the chief concern. You will have the ability to review the patient’s electronic health record (EHR) to be aware of other chronic medical conditions and medications that may impact their current concerns and obtain additional details if relevant to the acute condition.

History

You’ll collect an HPI in the usual way – starting with the patient’s story then filling in gaps with focused questions, perhaps using OPQRSTAAA as a guide.

For the other history sections, you’d only ask the pertinent questions.  Pertinent means that it’s somehow related to the differential diagnosis for this acute problem. Since the differential diagnosis for cough includes postnasal drip, bronchitis, pneumonia or GERD, you’d gather data that would help to differentiate between these illnesses.

Rather than eliciting a complete past medical history, you would ask about conditions important to know about when assessing a patient with cough: allergies or asthma, other lung disease or GERD. Pertinent social history could include tobacco exposure or other environmental irritants. The pertinent review of systems questions might include fever, nasal congestion or runny nose, shortness of breath, chest pain, or acid reflux.  You would not ask other review of system questions.

Physical Exam

For an acute condition your exam should be hypothesis driven. This means that you decide which physical exam maneuvers will support or argue against the conditions on your differential diagnosis.  For cough, that might include an exam of the nose, oropharynx, and chest.

Chronic Disease Management Visits

A chronic disease is a health problem that requires ongoing management over years or even decades.  Many clinic visits focus on chronic disease management occur in both primary and specialty care settings.  Your approach to these visits is not about a differential diagnosis. It is about how well the disease is managed, how it is impacting your patient’s life, and how you can work together to optimize control while minimizing the side effects of treatment. The purpose of a chronic disease management visit is to assess and update the status of the illness, identify any complications, and adjust treatment if needed.

Impact of Chronic Illness

60% of American adults have at least one chronic illness and 12% have 5 or more. Seniors carry the heaviest burden with 8 of 10 living with one of these chronic illnesses and most have more. The prevalence of chronic illness is lower in children under 18. Untreated dental caries affects the most kids and is the most frequent cause of law school days.

No matter what the illness, our goal at the end of the visit is a patient armed with the knowledge, skills, resources and support to take care of themselves at home. Research shows that this ability and willingness to manage one’s own health, often called patient activation, is associated with getting better control of the disease they already have and getting fewer new ones. Working collaboratively with our patients can increase their activation, giving us a chance to make a real impact during a chronic disease visit. Strategies like collaborative agenda setting,  tailoring education, using ask-tell-ask, motivational interviewing and negotiating rather than dictating a plan have been shown to increase a patient’s willingness to really take on their chronic illness.

Problem Focused History

The problem focused history for chronic illness should explore how well our patient is able to manage their illness at home and how the health care team can support them in their self-care. Following elements are key to all chronic disease management visits.  Each section will be explored further below.

You want to start with a little bit of background; the onset of the illness, current prescribed treatments, and any complications. You may be able to review this in the patient’s medical record or you may need to elicit this history.

Baseline health status

Get a really good picture of how things have been going at home since the last visit.  Try to understand the impact of the illness on their lives. How well of any symptoms have been controlled.  What has self monitoring shown?  Things like home blood pressure measurements in patients with hypertension,  daily weights in patients with heart failure,  blood sugars for patients with diabetes, or peak flows in patients with asthma. Have there been any visits with other providers, testing, hospitalization, and what’s their understanding of their illness?

Treatment adherence

It’s critical to explore how your patient is doing with treatment, both medicines, other interventions, and healthy behavior. Non adherence to medication is incredibly common, estimated at 50% across the board and is even higher for medications for asymptomatic problems like hypertension or hyperlipidemia. There are so many potential barriers to adherence from the individual level up to the systems level. Understanding your patient’s adherence and identifying their barriers can help you and your patient come up with strategies to improve it.

Functional Status

People with a chronic illness spend an average of 6 hours a year in their doctor’s office and another 8,756 hours at home monitoring their health, taking medications, and engaging in healthy behavior or not.

Ask about functional status, especially with patients who have multiple chronic illnesses.  Regardless of their age, patients with multimorbidity are at risk for physical, cognitive and social limitations that can really affect their quality of life and their ability to manage their illness. Check in about social supports, plus any psychosocial problems or concerns. Relationships and social roles can really help or get in the way of patient self-management. If something has changed at home that may well be the reason for worsening control. Revisiting and expanding the social history, exploring the patient’s strengths, their responsibilities, stressors, finances, and insurance is especially important when things aren’t going the way you had hoped.

Depression is more common in patients with many chronic illnesses than in the general population so regular screening should be incorporated into chronic disease visits either with a clinic administered questionnaire like the PHQ-2 or PHQ-9 or a few questions in your history. Finally, don’t forget to ask about your patient’s life goals like upcoming travel, or supporting a spouse, or for their chronic illness specifically. Knowing these goals and priorities can help you and your patient develop a treatment plan that will work for them.

Physical Exam for Chronic Illness

The exam can help us answer two questions.  How well is the disorder controlled and is the patient developing complications.

The exam maneuvers you do will be disease specific. For example:

• COPD:  pulmonary exam
• Congestive heart failure:  weight, complete heart and lung exam, JVP
• Rheumatoid arthritis:  musculoskeletal exam

The examination may focus on whether the patient is developing complications from the chronic illness. For example:

• Diabetes: screening for neuropathy or retinopathy
• Alcohol use disorder: abdominal exam to evaluate the liver, look for ascites, check for leg edema

Assessment

Your assessment will focus on how well the illness is controlled and where it seems to be heading. Include the goals that you and your patient are working toward and comment on any barriers to optimal control that you’ve picked up on.

Plan

The plan for a chronic disease management has the same 4 elements as other visits, emphasizing education to optimize your patient self-care at home.

• Diagnostic tests
• Treatment
• Education 
• Follow up

Diagnostics includes any test planned for today or before the next visit.

Therapy includes both medication and behavior change that address the illness.

Education is the key you may be able to do some during a visit but most patients with a chronic illness would benefit from more than we can do in a 15 minute follow up. Getting to know the other health professionals in your clinic and their role in caring for patients will help you come up with the best plan possible.

In many clinics, a registered nurse takes the lead on chronic disease education either with individual patients or with groups. Pharmacists are of course the medication experts.  They have a lot of strategies that can improve adherence from motivational interviewing,  simplifying drug regimens, to developing reminder systems.  Dietitians are experts in nutrition education and motivation.  Social workers can help address addiction, finances,  stressors, and other barriers to care.

Follow up includes referrals to other providers and when they’ll come back to see you.  It may also include community resources like the YMCA diabetes prevention program or support groups for patients with the same illness.

The management of chronic illness is the cornerstone of primary care medicine.  Learning the approaches above will help you more successfully navigate these visit types in your Primary Care Practicum.

Screening and Prevention Visits

The purpose of prevention and wellness visits is to identify and implement the preventive and screening interventions appropriate for an individual patient.  These interventions may include certain physical exams, tests, immunizations or lifestyle changes.  Recommendations are often based on demographic information – age and sex assigned at birth – but may be influenced by health behaviors and other health conditions.

The USPSTF Prevention Task Force tool is a source of up to date information. ase familiarize yourself with this link. Please visit this page prior to class and consider downloading the app version to your phone for use during PCP.

In this video, Dr. Jeanne Cawse-Lucas discusses tools that will help you individualize your approach to each patient.

Outpatient: SOAP Notes

Outpatient OCPs

For acute problems and chronic disease management, the OCP will be presented in the same format as the SOAP note, aiming for 3-5 minutes long.  Review the previous chapter on how to document acute, chronic and preventive health (wellness visits). Utilize these same approaches for your oral case presentation.

• Subjective: ID/CC, what the patient tells you, organized by problem if more than one problem is addressed
• Objective:  vital signs, physical exam, labs and imaging
• Assessment & plan: you should always include an attempt at formulating an assessment and plan, even if you’ve only had a minute or two to pull your thoughts together

It is a good practice to share your clinical reasoning verbally even if you have not come up with a final assessment or plan.  This helps your preceptor know what you are thinking and provides them the opportunity to give specific guidance and education.

Consider ending your oral case presentation with a ‘learning question’ to guide your preceptor’s teaching:

“My learning question is…

Will you confirm the lung exam with me?

How would I differentiate bronchitis from a URI?”

Under what circumstances would we send someone with a head injury to the ER?”

The following video by Dr. Natalia Filipek (3rd year Internal Medicine resident) is an example of an outpatient oral case presentation that address an acute problem, a chronic medical condition and some preventive health.

Introduction to Telemedicine

Telemedicine is defined as the use of technology to deliver healthcare at a distance.  In your PCP, most of you will see synchronously delivered telemedicine visits. Your clinic may also use telemedicine asynchronously, allowing patients to share data like blood glucose logs or heart rhythm monitoring for review by their healthcare team, who then advise them on next steps with a secure message or phone call.

Specific patient consent is required for telemedicine.  Patients must agree to receive care on the virtual platform and to have their insurance billed. Clinic staff often complete this consent process before the provider begins their visit.

Key elements of this consent include:

• You cannot provide the same evaluation as in a face-to-face visit, and an in-person visit may be requested by either the provider or the patient.
• Technology is encrypted and secure, but no technology is 100% hack-proof.

Communications skills for telemedicine

As with in person visits, start by introducing yourself by name and role, ensuring comfort and privacy for your patient, and asking if they are comfortable conducting the visit where they are.  You can specifically ask if anyone else is in the room, and if the patient would like them to join the visit.

Ensure that you’ve optimized both your own technology and the patient’s before starting the history.  Each of you should be in a quiet and well-lit room, sitting away from windows and bright light sources to avoid shadows. Adjust your camera and ask the patient to adjust theirs so that you each see the other’s face. Hiding “self view” will allow you to focus on your patient.  Look directly at the webcam to convey “eye contact”. You can also let your patient know that at times, your eyes will move around as you may look at their chart as they talk.

From there, proceed with setting the agenda and building rapport.

In this video, Dr. Calvin Chou of the Academy of Communication in Healthcare demonstrates patient-centered communication in a video visit.

Physical exam in telemedicine

The physical exam will (obviously) be more limited in a telemedicine visit, but there are creative ways to maximize the utility of the exam.  In this video, a Stanford physician demonstrates problem focused-exams for upper respiratory infection, low back pain, and shoulder pain.

Resources and references:

The Telehealth 10: A Guide for a Patient-Assisted Virtual Physical Exam.

The PCP Experience

Of note, the tracker deadline for submission of your PCP experiences has changed from 48 hrs (mentioned in the video) to 72 hrs.