According to the 2008 National Ambulatory Medical Care Survey, there were over 960 million visits to office-based physicians. But outpatient care is not limited to primary care services. Once performed only in hospitals, most surgeries are performed on an outpatient basis, or day surgery. Non-hospital based outpatient services are expanding to include home health care, ambulatory clinics and several other specialty services.
A primary care provider (PCP) is a physician who is seen for checkups and general health problems, helping to manage overall patient health. Primary care is seen as the entry point to the health care system, with the use of primary care physicians as “gatekeepers” to the system.
The term “generalist” often refers to medical doctors (MDs) and doctors of osteopathic medicine (DOs) who specialize in internal medicine, family practice, pediatrics or obstetrics and gynecology.
Obstetrician/Gynecologists (OB/GYNs) are doctors who specialize in obstetrics and gynecology, including women’s health care, wellness, and prenatal care. Many women use an OB/GYN as their primary care provider.
Other health professionals involved in the primary care setting include nurse practitioners (NPs) who can serve as a primary care provider in family medicine (FNP), pediatrics (PNP), adult care (ANP), or geriatrics (GNP). Others are trained to address women’s health care (common concerns and routine screenings) and family planning. NPs can prescribe medicines. A physician assistant (PA) can provide a wide range of services in collaboration with a Doctor of Medicine (MD) or a Doctor of Osteopathic Medicine (DO). Licensed practical nurses (LPNs) are state-licensed caregivers who have been trained to care for the sick, registered nurses (RNs) have graduated from a nursing program, have passed a state board examination, and are licensed by the state. Advanced practice nurses have education and experience beyond the basic training and licensing required of all RNs. Advanced practice nurses include nurse practitioners (NPs): clinical nurse specialists (CNSs) have training in a field such as cardiac, psychiatric, or community health; certified nurse midwives (CNMs) are trained in women’s health care needs, including prenatal care, labor and delivery, and the care of a woman who has given birth. Licensed pharmacists have graduate training from a college of pharmacy. Pharmacists prepare and processes drug prescriptions written by primary or specialty care providers.
Facilities where ambulatory or outpatient services are offered include medical procedures or tests that can be done without an overnight stay. The types of procedures and tests, offered usually within a few hours, include wellness and prevention services, such as counseling and weight-loss programs; diagnostic services, such as lab tests and imaging scans; treatment, such as day surgeries or chemotherapy; and, rehabilitation, such as physical therapy or addiction treatment
Because no overnight stay is involved outpatient services usually cost less., Some centers specialize in one kind of treatment or procedure, although many can be provided in one place.
PRIMARY CARE PRACTICES
General Internal Medicine
General Medicine, or Internal Medicine, is the practice of specialized adult patient care of a broad and comprehensive range of illnesses when undefined symptoms present to a primary care physician. Patients are referred to these specialists for diagnosis related to a variety of symptoms, such as shortness of breath, chest pain, abdominal pain and back pain. Collaboration in the treatment of chronic illness and in health promotion and disease prevention. involves a multidisciplinary team of specialized experts. Preventive care includes mammograms, Pap smears, routine colon cancer screening evaluations, cholesterol screening and blood pressure screening. Internists communicate with primary providers so care plans for ongoing care when a patient returns home. Internists also provide comprehensive management for hospitalized patients, including risk assessment for preoperative patients. Internist practice primary care as the follow adult patients over their lifetime.
In the United States, Internal medicine is the largest medical specialty, with nearly 200,000 internists in practice. Internists may function as generalist physicians practicing primary care, hospital medicine, or both. They may also pursue further training to practice a subspecialty. The National Institutes of Health (NIH) is awards over two-thirds of it’s research grants to internists.
Family Medicine provides healthcare for the individual and family, integrating all aspects of care and encompassing all ages, genders and types of diseases. Family physician visits account from 20% of medical office visits, almost half of all medical specialties combined. According to the World Organization of Family Doctors (WONCA), the aim of family medicine is to provide personal, comprehensive, and continuing care for the individual in the context of the family and the community. The types of medical training of family physicians are usually the Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree. Family practice physician visits account for 25% of all doctor visits in the United States, over 200 million office visits per year. Family practice physicians provide preventive care through routine checkups, health risk assessments, immunization and screening, and health behavior and lifestyle counseling. Family practitioners also diagnose and treat acute and chronic illnesses and coordinate with specialists to manage chronic illnesses.
Although the number of primary care providers in slowly increasing, many studies indicate the demand for family physicians will exceed their supply by 2020. Salaries for family practice physicians are lower than specialty providers and the increasing frustrations in billing, financing and record keeping has contributed to the shortage. Most family physicians have solo or small group practice, or practice as an employee of a hospital.
Pediatrics is the branch of medicine that deals with the care of infants, children and adolescents. Pediatric health services include diagnosis and treatment of diseases. The specialty recognizes the anatomical, physiological and immunological differences between children and adults. The differences in body size are paired with developmental issues of greater concern than when treating an adult. Pediatricians are proficient in the differing diagnostics and prescription needs of the infant and child. Another consideration is that the patient is not responsible for their own care, so the pediatrician must consider issues of guardianship, privacy, legal responsibility and informed consent . Pediatricians often must take in to account the patient as part of a family in procedure.
Obstetrics and Gynecology
Gynecology is the care of the female reproductive system. The specialities of gynecology and obstetrics are most often combined. In the United States, law and many health insurance plans allow gynecologists to provide primary care in addition to aspects of their own specialty.
Obstetrics is the care of women during pregnancy and immediately after childbirth. Prenatal care is important in screening for various complications of pregnancy. This includes routine office visits with physical exams and routine lab tests: ultrasound, complete blood count (CBC), blood type, general antibody screen,, amniocentesis, hematocrit and screens for gestational diabetes. During labor, the obstetrician monitors the progress of labor, delivery and the postpartum phase.
A primary care physician (PCP), or primary care provider, is a health care professional who practices general medicine. PCPs are our first stop for medical care. Most PCPs are doctors, but nurse practitioners and even physician assistants can sometimes also be PCPs.
A PCP is the person your child should see for a routine checkup or non-emergency medical care. If your child has a mild fever, cough, or rash, or is short of breath or nauseated, a PCP usually can find the cause and decide what to do about it.
Usually, PCPs can treat conditions in their own offices. If they can’t, they can refer you and your child to a trusted specialist. If your child needs ongoing treatment or is admitted to a hospital, the PCP may oversee the care, help you make decisions related to treatment, or refer you to other specialists if needed.
One of a PCP’s most important jobs is to help keep kids from getting sick in the first place. This is called preventive care.
The best preventive care means forming a relationship with a PCP you like and trust, taking your child for scheduled checkups and vaccines, and following the PCP’s advice for establishing a healthy lifestyle, managing weight, and getting the right amount of exercise.
Types of PCPs
Different types of PCPs treat kids and teens. Which is right for you depends on your family’s needs:
- Family practitioners, or family medicine doctors, care for patients of all ages, from infants, kids and teens, to adults and the elderly.
- Pediatricians care for babies, kids, and teens.
- Internists, or internal medicine doctors, care for adults, but some see patients who are in their late teens.
- Adolescent medicine specialists are pediatricians or internists who have additional training in caring for teens.
- Combined internal medicine and pediatric specialists have training in both pediatrics and internal medicine, allowing them to bridge the gap between treating young patients and adults.
- Obstetricians and gynecologists specialize in women’s health issues and are sometimes PCPs for girls who have started menstruating.
- A nurse practitioner or physician assistant sometimes is the main provider a child sees at a doctor’s office.
Focus of Medical Specialties
There are four general areas of focus in medical specialities. Surgical or internal medicine involves diagnosis and treatment achieved through major surgical techniques, such as cardiothoracic surgeons, neurosurgery, oral and maxillofacial surgery. Age range of patients focuses on care and treatment of specific groups, such as neonatologists, pediatric surgeons or geriatrics. Diagnostic or therapeutic specialists focus mainly on examinations, such as pathology or radiology. Organ-based or technique-based specialties focus on symptoms and diseases of a particular organ, such as allergists, cardiologists, or dermatologists.
Upon referral of a primary care provider various specialties are consulted when necessary. The following are examples among many of the long list of specialty areas of medical care. Try to identify the focus area as mentioned above.
- Allergists – allergy and asthma
- Anesthesiology — general anesthesia or spinal block for surgeries and some forms of pain control
- Cardiology — heart disorders
- Dermatology — skin disorders
- Endocrinology — hormonal and metabolic disorders, including diabetes
- Gastroenterology — digestive system disorders
- General surgery — common surgeries involving any part of the body
- Hematology — blood disorders
- Immunology — disorders of the immune system
- Infectious disease — infections affecting the tissues of any part of the body
- Nephrology — kidney disorders
- Neurology — nervous system disorders
- Obstetrics/gynecology — pregnancy and women’s reproductive disorders (can be primary provider)
- Oncology — cancer treatment
- Ophthalmology — eye disorders and surgery
- Orthopedics — bone and connective tissue disorders
- Otorhinolaryngology — ear, nose, and throat (ENT) disorders
- Physical therapy and rehabilitative medicine — for disorders such as low back injury, spinal cord injuries, and stroke
- Psychiatry — emotional or mental disorders
- Pulmonary (lung) — respiratory tract disorders
- Radiology — x-rays and related procedures (such as ultrasound, CT, and MRI)
- Rheumatology — pain and other symptoms related to joints and other parts of the musculoskeletal system
- Urology — disorders of the male reproductive system and urinary tract and the female urinary tract
OUTPATIENT CARE SETTINGS
OUTPATIENT CARE SETTINGS
Outpatient care facilities offer a wide range of services beyond primary care services. Outpatient services range from diagnostics to treatment, with most surgeries now performed in outpatient settings. Outpatient care is also called ambulatory care. Outpatient means the patient is not hospitalized. Ambulatory care includes patient visits to physician offices, outpatient departments of hospitals and a variety of health centers such as freestanding clinics, community health centers and free clinics and alternative medicine clinics. Outpatient care can include routine services such as check-ups, visits to clinics, home care, hospice care, outpatient long-term care services, and public health services. New types of outpatient services have emerged including telephone triage and mobile facilities for medical, diagnostic, and screening services .
Patient visits at an “outpatient facility” for care include physician’s offices that may include primary care or specialty care services. These may be single specialty or multispecialty offices.
Other outpatient or ambulatory services, such as retail clinics and urgent care centers have seen enormous growth in urban areas. Other services based on outpatient treatment include surgical services, rehabilitation treatments and mental health services.
MEDICAL AND DIAGNOSTIC LABORATORIES
Hospital laboratories perform tests on specimens from admitted patients. Outpatient laboratories receive samples of specimens order by physicians for analysis, although when more specialized analysis is required samples may go to a research laboratory. The multiple specialties of laboratory medicine are divided into anatomical and clinical pathology.
histopathology – processes solid tissue removed from the body (biopsies) for evaluation at the microscopic level.
cytopathology – examines smears of cells from all over the body (such as from the cervix) for evidence of inflammation, cancer, and other conditions.
electron microscopy – prepares specimens and takes micrographs of very fine details
anatomy – studies the organ systems of the body
physiology – studies the body functions
histology – studies the microscopic structure of tissues.
pathology – examination of samples of body tissue for diagnostic or forensic purposes
pathophysiology – functional changes of a particular disease
- Clinical Microbiology: including bacteriology, virology identification of viruses in specimens such as blood, urine, and cerebrospinal fluid., parasitology examining parasites, feces samples may be examined for evidence of intestinal parasites such as tapeworms or hookworms and others, immunology, and mycology. Microbiology receives almost any clinical specimen, including swabs, feces, urine, blood, sputum, cerebrospinal fluid, synovial fluid, as well as possible infected tissue. The work here is mainly concerned with cultures, to look for suspected pathogens which, if found, are further identified based on biochemical tests
- Clinical Chemistry: includes instrumental analysis of blood components, enzymology, toxicology and endocrinology.
- Hematology (analysis of blood cells) includes coagulation and blood bank.
- Genetics – mainly performs DNA analysis. Cytogenetics uses blood and other cells to get a karyotype
- Reproductive biology: Semen analysis, Sperm bank and assisted reproductive technology.
There may be a single laboratory for microbiology in some facilities, while separate labs may exist for each unit. Clinical laboratories may include any number of trained scientists including pathologists, biochemists, clinical laboratory scientists (CLS), medical technologists (MT) medical laboratory scientists (MLS), medical laboratory technicians (MLT), medical laboratory assistants (MLA) and phlebotomists (PBT).
URGENT CARE CENTERS
Urgent care centers provided extended hour, walk-in services of acute care. Some urgent care facilities have on-site laboratories and diagnostic equipment. Urgent medical conditions that require care within 24 hours include accidents, falls, sprains and strains, breathing difficulties, back pain, bleeding, eye irritation, vomiting, diarrhea and fever or flu. In some clinics, minor broken bones and fractures can be treated. Other conditions my include urinary tract infections, skin rashes, infections, sore throat and cough,
MENTAL HEALTH CLINICS
Mental health clinics treat mental conditions such as depression, anxiety and post-traumatic stress disorder (PTSD). These clinics provide care to individuals on low income medical assistance or whether covered on a health care plan or not,
ALCOHOL & SUBSTANCE ABUSE TREATMENT CENTERS
Alcohol and substance abuse treatment centers provide several types of therapies aimed at treatment of addiction. Cognitive-behavioral therapy helps the addictive personality recognize, avoid and cope with trigger situations that might make them likely to use drugs. Multidimensional family therapy works with families and drug abusing adolescents. It looks at patterns of abuse and targets improving family interactions. Motivational interviewing seeks to change behavior when an addict enters into treatment, along with motivational incentives or contingency management, using positive reinforcement to encourage abstinence from drugs.
OUTPATIENT SURGICAL CENTERS
Ambulatory surgery is any operation that does not require an overnight stay in the hospital. It has also been called day surgery. More than half of elective surgery procedures in the United States are performed as outpatient surgeries.
PHYSICAL AND OCCUPATIONAL THERAPY CENTERS
Physical therapy centers offer rehabilitation to help strength, mobility and fitness, They also offer occupational therapy to help with daily activities and speech-language therapy to help with speaking, understanding, reading, writing and swallowing. Rehabilitation centers also offer treatment of pain.
HOME HEALTH CARE
Home health care helps older adults live independently for as long as possible. Home health care may include occupational and physical therapy, speech therapy, and skilled nursing care. Home health care involves helping older adults with activities of daily living (ADL), such as bathing, dressing, and eating and often assistance with cooking, cleaning, housekeeping and monitoring medication regimens.
Hospice care helps the terminally ill live their remaining days with dignity. Hospice workers assist the family or other caregivers, usually in the patient’s home. There are also hospice residences and sections within the hospital setting. Hospice care combines symptom and pain management with emotional and spiritual support. Hospice teams develop a care plan to address the individual needs of the patient.
PRIMARY CARE IN CRISIS: THE LOCAL OUTLOOK
The United States Health Care System, without a universal right to care, has created a crisis in primary care. The increasing number of older Americans living longer with complicated medical concerns and the decrease in number of physicians practicing primary care, several factors work to compound are the two major contributors to the problem. The cost of health care delivery continues to rise due to the large number of financing systems (public and private insurance) and inconsistent and complicated billing and reimbursement systems. As technology expands there is a much greater reliance on expensive diagnostic and treatment services, often unnecessary. Access to preventive care services continues to be challenge for millions with a sicker population requiring more testing and treatment services. Outpatient clinics must provide more after-hours care to avoid use of the emergency department (ED) for non-emergencies. There is an increasing demand for health information specialists to manage the increasing demand for documentation, coding and billing. When participating in the great American health care debate, solutions to all of these challenges must be considered. It’s just not as simple as a market justice vs. social justice argument. Looking at your local health care industry, become familiar with primary care and outpatient services in your area.