Ambulatory Care: The “Healthy Sick” Patient

Today I saw my first ambulatory clinic patient in over a year. Coming into the experience, I felt surprisingly nervous. I realized I had forgotten how to approach a patient who was not acutely sick and lying in a hospital bed. I suppose it might have something to do with the fact that all my electives over the last few months were done on inpatient units where patients upon initial consultation were rarely able to walk comfortably down the hall or offer a complete and accurate history.  In that kind of setting, we often relied on the physical exam and the lab numbers (though primarily the latter) to make the diagnosis and monitor clinical improvement. Here in the ambulatory setting, newly referred patients may come without bloodwork results, positive physical exam findings or even previous clinical notes. They have legitimate health concerns but appear well externally –or as some individuals call it, the “healthy sick” patient.

The focus in ambulatory medicine returns to the history-taking, the “art” that complements the science. We were first introduced to this in our preclerkship ASCM curriculum. The practice relies on producing a broad yet specifically-targeted set of questions that, ideally, is able to identify the diagnosis. Back then, we took pride in our ability to take an extremely comprehensive history, complete with our patients’ social details. However, as we began our clinical duties in the hospital, the comprehensiveness of our histories suffered in favour of shifting to the more “reliable” lab tests and imaging. We didn’t need to take a history to know a patient was sick; his/her appearance and numbers told us so. It’s so easy to forget that patients exist outside of the hospital setting when you’ve worked there for such a long time, that when we finally switched to the few ambulatory half-days we have, it suddenly becomes difficult to imagine the patient in front of us having a complex medical concern unless they look acutely unwell. Perhaps that switch was what I unexpectedly experienced today –a transition from the analytical and reactive mindset of the ward to the narrative and investigative approach in an office.

It’s important to not get fooled by the “healthy sick” patient. What our clinical experience has taught us over and over again is to never underestimate the utility of history-taking. This is often emphasized more in certain specialties, for example, family medicine where care is predominantly clinic-centred and the accessibility to immediate investigatory techniques is certainly lacking compared to a hospital ward. So for those of us entering specialties that are predominantly hospital-based, the chance to work in an ambulatory clinic is a unique opportunity to practice and develop our own art to medicine. This is particularly relevant in internal medicine where the diagnosis of so many rare and complex illnesses lie within the subtleties of which questions are asked by the physician.

- JJ