GAMe Levers — a structured way to prepare for outpatient visits

I have started my first month of outpatient clinic. Heretofore I have only done weeks worth of clinic at a time. As I have jumped from the intense yet methodical environment of the inpatient world to the slower, yet more hectic world of outpatient care I have struggled to adapt for the first few days. In the inpatient world I have a relatively long time to interview the patient and gather pertinent data for their treatment plan, and I will be revisiting it daily on rounds. But on the outpatient side things are a little more hectic — I have anywhere from 6–10 patients per day that I have to quickly read up on, understand where they are in the management of all of their medical problems, listen to new problems they have, and then formulate a plan going forward. Needless to say it has been stressful. Lets say you have a patient coming in who has diabetes, HTN, COPD, end stage renal disease, and mild dementia. Oh, and they just got out of the hospital. It’s easy to get overwhelmed!

It’s amazing what a little structure can do. I’ve talked about the wonders of what applying the OHIO principle has done for me. Now it’s time for another one, and this one I’ve come up with. It’s a method I came up with that combines UCSD Medical School’s excellent guide to successful participation in outpatient clinics along with Dr. Reid’s five levers. I call it:

GAMe Levers

G — goal: What is the goal of the visit? This can often be found in the documentation: through a telephone note (what did the patient call in for? Why are they coming in?); in the prior clinic note (did they just start a new med last visit? are they following up after seeing a consult service?). Sometimes there won’t be a clearly stated goal you can find, and that’s okay too.

A — active issues: These are problems that require regular follow up that need to be addressed every visit. Diabetes — check blood sugars, Hypertension — check BP, Depression — check depressive symptoms.

Me — Medications: It’s amazing what you can learn for a medication list. Quickly glance over it, because problems that may not be stated in past notes may be reflected by medications in the list. Plus, medication reconciliation may be one of the most important things we do in primary care

L — Levers*: Look over what levers have been pulled recently — labs, imaging, tests, etc from physicians in prior visit, consult physicians, prior care taking facilities, recent discharges, etc.

So there it is. Getting your GAMe Levers on should take about 5–10 minutes per patient, and should help you efficiently sift through the vast amounts of information in the EMR to help you be the best prepared for your visit.