Outpatient clinics are an essential component of contemporary practice. Some interventional radiologists have held outpatient clinics for many years but for others, this will be a new experience. The functions of the clinic should simply be extensions of various aspects of daily practice. The challenge of the clinic is to deliver this in time-limited encounters. Broadly speaking, the roles of the clinic can be understood as shown below.
The roles of the clinic
Establish what the patient expects
You should ask the patient what they understand about why they have been referred to you and perform a quick reality check that this corresponds with why you think you are seeing them. If there is a mismatch, then the first priority should be to try to rectify this.
Confirm the diagnosis
This requires you to have reviewed all of the information provided, including the referral document, patient records and also the imaging. Try to look at the imaging yourself rather than just relying on the reports.
In many instances, the diagnosis will be certain and it will be evident how this relates to the patient’s symptoms. However, this is not always true, sometimes information from the referring team will be unclear or perhaps even incorrect. If there is doubt then obtain further history and perform clinical or perhaps even ultrasound examination as part of the clinic assessment. When there is uncertainty you will need to communicate this to the patient.
Tip A useful strategy is to spend a few minutes reviewing the clinical request, the patient record and relevant imaging before bringing the patient into the clinic. This way, there will be fewer surprises during the consultation.
Confirm symptomatology
Remember that symptoms may have changed in the interval between referral and the patient seeing you, e.g. claudication may have resolved following successful exercise therapy. Always make sure you verify the current symptomatology and any impact on the patient’s life and work.
Discuss with the patient their concerns, wishes and expectations
Doctors have a tendency to assume that they understand a patient’s concerns and that they will be similar to their own. This is often incorrect, so ask the patient what they are worried about. Many patients with peripheral vascular disease are very concerned that it will lead to amputation and relatively untroubled by their claudication or their walking distance. In this case, they should be reassured and placed on best medical therapy rather than reaching for angioplasty balloons and stents.
Find out what the patient wishes to know about their condition and what they hope to achieve from treatment. Do not be surprised to find that some patients are incredibly well-informed and you may even learn from them. Expect to be asked to explain the prognosis of the condition in the context of a variety of treatments.
Patient expectations vary widely from the very modest to highly demanding. It is essential to deal with any ‘expectation gap’ by providing clear and realistic explanations regarding what can be achieved and the limitations of treatment.
Provide realistic information
Interventional procedures
This will often be the principal focus of the clinic and builds on the discussions above. As a minimum you should be able to discuss the following questions:
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Whether the treatment is feasible for this patient?
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Whether it will be inpatient or outpatient?
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Will it be painful during or afterwards? (e.g. uterine artery embolization)
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The likelihood of technical success?
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The likelihood of symptom relief?
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Whether the treatment is curative or palliative?
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Whether the treatment is a ‘one off’ or whether a series of treatments may be necessary?
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How quickly symptoms will resolve and the likelihood of recurrence of symptoms/the disease?
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Whether the treatment can be repeated?
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The ‘material risks’ of the procedure (see consent), i.e. anything that any prudent patient would want to know and anything that this particular patient would be expected to want to know.
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How long it takes to recover after the treatment?
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The place of this treatment compared with alternative treatments?
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Whether this treatment will impact on other therapies?
Alternative therapeutic strategies
In many cases, there will be a number of therapeutic options, ranging from doing nothing at all through to major surgery. There will be pros and cons to each approach. Remember that you are there to help the patient work out which is best for them and not to promote interventional radiological treatments above other strategies. In fact, once you start considering the individual patient, you may find that interventional radiology is not the answer.
The consultation presents a lot of information and it is impossible for the patient to remember everything. Your clinic may come with a supply of printed information sheets; if not, you can either arrange to send them out later with a summary of the discussion or direct them towards websites with the relevant information.
Obtain consent
It is best practice to obtain consent in advance of the procedure. This is especially important for complex procedures where there is a lot of information for the patient to consider. Consent can be obtained in the outpatient clinic or alternatively in a dedicated ‘consent clinic’. Just remember that the person obtaining consent must be trained to do this.
Book appointments for treatment
The commonest question after a long discussion of the pros and cons of treatment is often ‘How long will I have to wait?’ Some clinics may allow direct booking of appointments. Alternatively, give the patient an indication of the likely waiting time. Enquire whether the patient is able to attend at short notice if there is a cancellation. Find out if there are any times the patient will not be available, e.g. booked holidays.
Patient follow-up after intervention
One of the joys of being a doctor is seeing patients after successful treatments and reviewing their progress. The news is not always good, so be prepared to hear that the symptoms did not improve or recurred rapidly, this is particularly common following angioplasty for claudication. It is also good to review patients in whom there were complications to see how these are resolving.
Clinic records
Make accurate records and make sure that you send letters to the patient’s referring team and general practitioner (GP). Consider either copying the correspondence to the patient or sending them a separate summary of the key points discussed and additional information. This is particularly useful if the patient was going to consider whether they wished to proceed with a particular treatment.
Further review
Sometimes you will find that it is impossible to cover everything in the allotted clinic time. Quite often the patient will indicate that they would like a family member, friend or carer to attend, to consider the information. In either case, consider offering the patient a longer appointment at a later date. Patients will usually appreciate this option and it beats running impossibly late.
Clinics running behind schedule
Everyone is familiar with this; either the administrators book patients ludicrously short appointments or you will find several patients arrive at once. If you are running late, you risk being left with a waiting room full of increasingly irritated patients. You know exactly how this feels from personal experience in a clinic or when your flight is delayed. If you are running behind, it pays to let any patients who are waiting know what is happening and when they can expect to be seen. Sometimes a patient will not be able to stay, in which case apologize and offer an early repeat appointment at the start of the list. On occasion a patient will be implacable and in this case you should continue apologizing and explain how they can make a complaint.
Discharge from the clinic
There comes a time when there is little value in repeat appointments. Usually it is fairly obvious that you have fulfilled all of the above roles. When a patient is discharged you should always indicate that you will be happy to review them again if the circumstances change, e.g. if symptoms recur or if they decide that they desire treatment in the future. Do not forget to inform the referring team and GP what is happening.
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