Introduction
This chapter aims to prepare students for clinical rotations in medical subspecialties, such as rheumatology, endocrinology, neurology, pulmonology, nephrology, infectious disease, and gastroenterology.
Patient approach
Typically, a patient is referred to one of these specialists by his or her primary care provider (PCP) for assistance with a condition that is out of the scope of the PCP’s practice or has been suboptimally managed in primary care. In some cases, a patient will seek specialist care independently. The specialty care provider will review the reason for the referral and the patient’s medical history to decide if the referral is appropriate. In some cases, the consultant will decide the patient would be best managed within another specialty or that the case is outside her or his particular expertise.
In the introductory consultation, it is important for the specialty team to take a full history and perform a complete physical examination. The patient and the referring provider will often have formulated their own differential diagnoses, which may be outlined in a referral letter or medical records. In the initial consultation, the patient might find herself or himself repeating a history or undergoing a physical examination that was already done in the primary care setting. In the majority of cases, the patient is happy to be listened to and reexamined. The specialist provider will integrate her or his findings with the past medical records to develop their own differential diagnosis and formulate a plan for further evaluation and management.
Specialists may also refer a patient to a more specialized provider (a subspecialist) within their field or to an academic medical center. Patients may benefit from seeing doctors who have significant experience with rare conditions or difficult procedures. For example, some thyroid tumors would benefit from biopsy but may be located very close to a blood vessel. A less experienced provider will be appropriately reluctant to attempt a fine-needle biopsy. The patient might be referred to a center where anatomically challenging biopsies are routinely done by experienced staff. The training of a gastroenterologist includes hepatology, but in many urban or academic settings, diseases of the liver, such as hepatitis C, are managed by a hepatologist who has undergone additional specialized training and manages a large panel of these patients. In pulmonology, rare opportunistic infections and less common lung disease such as cystic fibrosis are often managed in a clinic dedicated to these patients.
Primary care provider-specialist relationship
A PCP will either refer a patient to be seen one time for a procedure or treatment recommendation or for the specialist to take over ongoing management of a condition. It is essential to maintain clear communication between the PCP and the specialist provider. For the safety of the patient, this communication must continue for as long as the specialist is providing care. Poor or infrequent communication can have potentially life-threatening consequences. For example, a cardiologist may not be aware of recent changes in a patient’s medication. She might notice the patient’s blood pressure is elevated and decide to adjust the blood pressure medication. Without the most up-to-date records, she might prescribe a medication the patient is already taking or a medication that adversely interacts with a new medication. It is up to all parties providing patient care to inform each other of changes in management in a timely manner. Patients who are referred to an endocrinologist for poorly controlled diabetes are often taking a long list of medications and find it challenging to remember all of the drug names and doses. PCPs can help ensure that specialists have the current medication list at the time of the visit to ensure the best care for the patient is delivered.
A typical day in medical subspecialties
Physician assistants (PAs) are often the first point of contact for patients in medical subspecialties and have a great deal of responsibility. It is the job of the PA to do a full and thorough history and examination of the patient being evaluated by his or her team and from this assessment develop differential diagnoses, initiate appropriate investigations, and start management. Having requested testing, a PA will then evaluate the results; communicate them to the patient; and develop a management plan, sometimes in consultation with the supervising physician or another member of their team. The extent to which a supervising physician is involved in this process depends on the complexity of the patient, the experience and expertise of the PA, and the preferences of the physician or medical practice where the PA is working.
Expectations of physician assistant students on medical subspecialty rotations
As a PA student, you will be expected to take a full history from the patients being evaluated by your team and perform appropriate physical examinations. To gain the most from your rotations, you need to develop a good list of differential diagnoses and how you would want to test for these disease processes. After developing this list, you should then present the patient to your preceptor for feedback and guidance with how you will continue the care of the patient. You should also generate a reasonable management plan. Be familiar with the most commonly used medications in your specialty, including dose, route of administration, potential side effects, patient education, and drug interactions ( Fig. 32.1 ).
As you gain experience as a student in a clinical setting, you might have the opportunity to perform or assist in procedures under appropriate supervision. When you become more familiar with the clinical setting in which you are working, start to anticipate the needs of the medical team and offer assistance. Volunteer your assistance to gather laboratory and radiology results. Pull together supplies that you know may be needed for procedures. Anticipating the needs of your supervisors will help you to build experience and credibility and will make you a valued asset to the team. Regularly taking initiative may also garner you a job offer at the end of your rotation.
Typical settings for medical subspecialty rotations
In medical subspecialties, you will be working in a private outpatient office or in a practice within a hospital. You may provide consultation to patients hospitalized on other services and manage some inpatients on your own service. You also might liaise with other hospital departments such as surgery, radiology, or other medical subspecialties to coordinate care for your patient.
Other health care professionals encountered in medical subspecialty rotations
A number of professionals are invaluable to the specialist health care team, and it will benefit you to spend time with them early in your rotation. In endocrinology, seek out certified diabetes educators to learn about management of patients with type 1 diabetes, insulin titration, insulin pump management, or the challenges of adhering to a diabetic diet. In a renal practice, there will be dialysis nurses with expertise in the electrolyte testing your patients routinely undergo, as well as advice on how to advise patients on management of their diet and fluid intake based on these results. A wound care nurse will have a wealth of information on the sometimes overwhelming choices available in dressings, which packing material to choose, and what signs they are looking for when they monitor a wound for healthy tissue growth and infection resolution. Introduce yourself to the respiratory therapists to better understand ventilator settings. Ask the smoking cessation team how best to approach this complicated and common addiction. In many specialties, particularly gastroenterology, infectious diseases, and neurology, the services of a registered dietician (RD) can be very helpful to the patient and the medical team. Consider sitting in with an RD as she counsels a patient on how to make complicated dietary changes or how to appropriately take medications with specific foods.
Essential clinical information in medical subspecialties
“The primary role of the examination becomes the testing of the hypothesis derived from the history.”
An excellent workup of the patient starts with a thorough and appropriate clinical history because this guides everything from there. Certain areas of the clinical history need to be more detailed, depending on the specialty in which you are working. This section provides a good place to start with an emphasis on specialty-specific information to remember when interviewing patients on your rotations. It is important to remember that these are specifics that should enhance but not replace the general medical history. WILLIAM LANDAU
Neurology
When interviewing a patient in neurology, always consider the questions: “Where is the lesion?” (e.g., brain, spinal cord, peripheral nervous system) and “What is the lesion?” (e.g., Does it have a vascular, infectious, malignant, compressive, or degenerative cause?). A detailed history enables the potential location of pathology to be identified and the development of your differential diagnoses, which in turn informs your physical examination and choice of investigations.
Every neurologic history should start with the age, sex, and handedness of the patient. If a patient has experienced seizures or blackouts or is presenting with possible dementia, then obtaining a history from a family member or close friend can be invaluable. Take care to clarify patient descriptions that can be ambiguous. In particular, words such as dizziness, numbness, and weakness can mean very different things to different patients. Your supervising physician or PA will want to see evidence that you have thoroughly explored exactly what the patient means by these words. Table 32.1 details some of the questions you may wish to ask when exploring these presenting complaints further.
| To be defined as distinct from | Potential Diagnoses | Red Flags | |
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Box 32.1 lists some common neurologic presentations with which you should be familiar. Think about how you would thoroughly explore the history of these presentations and go on to investigate them. Patients may not use medical terms correctly; therefore you need to be careful in taking the patient’s claim of a “stroke” or “migraine” as a confirmed diagnosis. Be sure to ask specifically about birth history and childhood development; this may require confirmation from family members. Ask if the patient had any neurologic conditions in the past that he or she no longer experiences (e.g., epilepsy; Fig. 32.2 ).
Headache
Dizziness or vertigo
Change in gait
Seizures
Tremor
Dysarthria
Dysphasia
Confusion
Memory impairment
Limb weakness
Involuntary movement or tremor
Change in taste or smell
Altered hearing
Change in personality
Sensory disturbance
Medications and drugs can cause many neurologic symptoms. A detailed history of all drugs ever taken, including recreational, complementary, herbal, and alternative therapies, is essential. Drugs commonly used in family practice, internal medicine, and surgery can have neurologic side effects. For example, a patient may have myopathy as a result of taking a statin or ataxia as a side effect of lithium. When taking a family history, use a genogram and annotate it with illnesses and cause of death. Depending on the background of the patient, consider inquiring about consanguinity.
The social history of a patient undergoing a neurology assessment should include details of his or her diet. Is the patient a vegan or vegetarian? Does the patient take supplements or have a known deficiency? A detailed travel and sexual history is also important because of the neurologic effects of human immunodeficiency virus (HIV) and syphilis. Alcohol can cause widespread neurologic damage. Ask about the patient’s living environment and any support structures required. This not only helps gauge how well the patient is coping but also helps the team prepare for discharge planning. Always ask whether the patient drives and try to ascertain how essential it is to his or her everyday living and job. Each state has slightly different requirements regarding a provider’s responsibility to report a change in health status to the department of motor vehicles. In general, a provider should report a change in health that will impact a person’s alertness, judgment, coordination, or skill necessary to operate a motor vehicle.
Neurologic symptoms can cause untold anxiety. Always assess what the patient’s ideas, concerns, and expectations about her or his illness and treatment are at the initial interview. This enables a clear and open discussion around what to expect and how things will move forward. It also provides an opportunity to address concerns. If a patient has significant concerns that are not discussed early on in care, he or she might have difficulty accepting the diagnosis and retaining the information or advice you and the rest of the team provide.
Rheumatology
Rheumatology is a specialty that focuses on musculoskeletal conditions as well as systemic autoimmune conditions. As a result, it incorporates the vast majority of the body’s systems, and detailed clinical histories are paramount. Box 32.2 details some of the key points that should be considered when taking a musculoskeletal history. There is a substantial genetic component to all rheumatic diseases. It is always important to consider the interaction between genetics and the environment. It is therefore essential to obtain both a strong family and social history. Because of the extensive systemic involvement of rheumatologic diseases, careful consideration should also be given to any current or previous pregnancies and any lung, liver, endocrine, hematologic, or dermatologic diseases.
Pain: OLD CARTS (or another pain mnemonic such as SOCRATES)
Affected joint(s): Acute or chronic onset, pattern of fluctuation
Stiffness: Time of day
PMHx, previous trauma, FHx
Swelling or deformity
Impairment to ADLs
Systemic symptoms
As with taking a history from a patient in any specialty, be sure to elicit any “red flag” symptoms. Those that need particular attention in rheumatology include pain preventing sleep, loss of appetite, unintentional weight loss, visual loss, blurred vision and temporal headache, loss of bladder or bowel control, and rapidly progressing symptoms. Equally, all of the following signs are red flags: inability to weight bear; red, hot joints; upper motor neuron signs; bilateral changes in limb strength or reflexes; saddle anesthesia; a temperature greater than 100°F (38°C); and painful swelling.
The rheumatologist’s perspective on routine blood tests are detailed in Table 32.2 . A rheumatology text will be useful to review blood tests that are more specific to this discipline, such as antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibodies.
