The clinic panel, part 2:
what nobody refers out

1. Depression. The most consequential diagnosis in this hour and one primary care manages more of than psychiatry does. Screening in adults is recommended where systems exist to support diagnosis and follow-up; the same statement reviewed screening for suicide risk separately and found the evidence insufficient to recommend for or against it — which changes nothing about the duty to assess risk once depression is on the table.¹ The approach: a validated screening instrument, a diagnostic conversation that separates depression from grief, thyroid disease, sleep disorder, and substance use, then treatment — psychotherapy, pharmacotherapy, or both — with follow-up close enough to matter, because the weeks after starting treatment are the ones that need contact. The value question is the follow-up, not the workup: a broad laboratory search for a medical cause in a patient with a clear depressive syndrome rarely changes anything, while a scheduled two-to-four-week revisit changes outcomes. The intern owns: asking about suicide directly and without euphemism — asking does not plant the idea — the safety assessment when the answer is yes, the treatment started rather than deferred to a referral that may never happen, and the follow-up put on the schedule before the patient leaves.

2. Anxiety disorders. Enormously common, frequently presenting somatically — chest pain, palpitations, dyspnea, abdominal pain, dizziness — and therefore frequently worked up rather than diagnosed. Screening in non-elderly adults is now recommended by the current statement, which found the evidence insufficient in older adults.² The approach: screen, distinguish the anxiety disorders from each other and from medical mimics, and treat with psychotherapy, pharmacotherapy, or both — cognitive behavioral therapy having strong evidence and being chronically under-referred. The value question is the cardiac workup that replaces the diagnosis: the young patient with panic symptoms who receives serial troponins and a stress test instead of a diagnosis is both expensive and, in a real sense, untreated — and the workup itself often reinforces the illness belief. Benzodiazepines deserve their own honest paragraph: real short-term relief, poor long-term evidence, meaningful harms, and a strong caution in older adults (the cross-cover session’s Beers teaching applies in clinic too). The intern owns: making the diagnosis out loud rather than by exclusion alone, explaining it in a way that validates the symptoms as real, and starting treatment with a follow-up date.

3. Substance use: alcohol, tobacco, and opioids. Screened for universally, discussed without judgment, and — the part most often missed — treated, because effective medications exist for all three and are under-prescribed in primary care. The approach: a validated screen, a brief intervention, and treatment offered in the clinic where possible; tobacco cessation combining behavioral support and pharmacotherapy at every visit; alcohol-use disorder medications considered rather than reserved for specialists; and opioid-use disorder treated as the chronic, treatable condition it is — primary-care prescribing of buprenorphine no longer requires the separate federal waiver that once limited it, a standard DEA registration now being sufficient, though a one-time federal training attestation tied to DEA registration, and state and institutional rules, still apply. The value question is treatment versus referral-and-forget: the intervention with the best evidence is one you can start today. The intern owns: asking every patient, asking without shame, naming the treatments as treatments, and knowing your local routes — and for opioids, the overdose-prevention conversation and naloxone.

4. Acute respiratory infections — and the antibiotic conversation. The commonest acute visit and the commonest source of unnecessary prescribing: most are viral, most resolve, and the clinical skill is the conversation rather than the prescription. The approach: distinguish the presentations that warrant antibiotics from those that do not, use symptomatic treatment honestly, and offer clear return precautions. The value question is the most-studied one in ambulatory medicine: antibiotics for viral upper respiratory infections and uncomplicated bronchitis are a leading low-value practice⁴ — and the evidence is equally clear about what works instead: naming the diagnosis, explaining the natural course with a timeline, giving a specific symptom plan, and stating when to come back. Delayed-prescription strategies and shared decisions preserve the relationship without the prescription. The intern owns: the two-minute explanation that satisfies the patient who came for antibiotics, documenting the decision, and resisting the pressure of a full waiting room — the prescription is faster in the moment and costlier in every other way.

5. Urinary tract infection and dysuria. Very common, mostly straightforward, and the source of two persistent errors: treating asymptomatic bacteriuria — pregnancy and screening before urologic procedures with mucosal trauma being the guideline exceptions — and treating dysuria without considering the alternatives — sexually transmitted infection, vaginitis, atrophy, interstitial cystitis, prostatitis. The approach: symptom-based diagnosis, the narrowest effective agent for the shortest supported duration, and a low threshold for testing for sexually transmitted infections in the appropriate patient. The value question is the urine culture sent by reflex: screening urine in patients without urinary symptoms, then treating the result, is a top low-value practice with real harms.⁴ The intern owns: the sexual history taken routinely and without awkwardness, the alternative diagnoses considered, recurrent infection worked up rather than re-treated indefinitely, and pyelonephritis recognized as the one that changes the setting of care.

6. Skin: infections, rashes, and the lesion. Dermatologic complaints fill a remarkable share of primary-care visits, and dermatology access is among the hardest to obtain — which makes basic competence essential rather than optional. The approach: recognize the common inflammatory rashes and treat them; manage skin and soft-tissue infections with attention to purulence and the mimics of cellulitis; and triage the pigmented or growing lesion — describing it properly, photographing per policy, and referring on defined features rather than on unease. The value question is the biopsy or referral that is actually indicated: topical steroids used correctly resolve most of what walks in, while the referral queue fills with rashes that could have been treated and the melanoma waits behind them. The intern owns: a described lesion rather than “rash,” the treatment tried and reassessed, the biopsy learned as a clinic skill (the procedure lab puts shave and punch technique on the map), and the referral that names the concerning feature so it gets triaged correctly.

7. Women’s health in the general clinic. Contraception, abnormal uterine bleeding, vaginitis, menopausal symptoms, and cervical-cancer screening arrive in general internal medicine constantly, and patients frequently do not have — or do not want — a separate gynecologist. The approach: contraception counseling that starts from the patient’s preferences and covers the full range including long-acting methods, with the recognition that most methods can be initiated in primary care; abnormal bleeding evaluated systematically with attention to the features that require prompt evaluation for malignancy; vaginitis diagnosed rather than treated empirically over the phone; and menopausal symptoms taken seriously, with hormone therapy discussed on the current evidence rather than on the distorted memory of a single trial’s headline. The value question is the pelvic and the ultrasound: screening pelvic examinations in asymptomatic non-pregnant adults and routine ultrasound without an indication are recurring low-value practices, while the cheap, high-value moves are an accurate history, a correct screening interval, and a specimen taken properly. The intern owns: asking about periods, contraception, and menopausal symptoms rather than waiting to be told; a chaperone offered per policy for every sensitive examination; and knowing your precise referral thresholds — postmenopausal bleeding, for one, is not a wait-and-see problem.

8. Breast concerns. The palpable lump, breast pain, nipple discharge, and the abnormal screening result — all arriving first in primary care, and all carrying the same risk: false reassurance. The approach: a systematic evaluation of the discrete mass regardless of a recent normal mammogram, because imaging does not exclude a clinically suspicious lesion; targeted imaging appropriate to age; and prompt referral of the findings that require tissue. The value question is speed over volume: the value here is not in restraint but in not delaying — the expensive outcome is the mass followed for six months. The intern owns: examining rather than deferring, documenting the finding precisely enough for the next clinician to compare, ordering imaging that matches the question, closing the loop on the result, and explicitly telling the patient what to do if the lump persists despite reassuring tests — that sentence has saved lives.

9. Men’s genitourinary complaints. Lower urinary tract symptoms and benign prostatic hyperplasia, erectile dysfunction, hematuria, and scrotal complaints — brought to internists constantly, and frequently under-addressed because nobody asks. The approach: symptom assessment with a validated instrument for lower urinary tract symptoms, medical management started in primary care, and referral for the specific indications; erectile dysfunction recognized as a cardiovascular and psychosocial marker and evaluated as one rather than treated as a lifestyle request; hematuria taken seriously — visible hematuria in particular warrants evaluation, not a repeat dipstick; and the acute scrotum treated as the emergency it can be. The value question is the prostate-specific antigen conversation: screening belongs in the shared-decision zone, and testing without that conversation — or in men who will not benefit — generates a cascade of biopsies and treatment for disease that would never have harmed them. The intern owns: asking, the medication review for the drugs that cause both problems, the cardiovascular workup that erectile dysfunction should trigger, and the referral thresholds known cold.

10. Fatigue, sleep, and the symptom without a diagnosis. The most common presenting complaint with the least satisfying algorithm, and the one that most tests an intern’s discipline. The approach: a thorough history that includes sleep, mood, substances, and medications before any laboratory panel; a limited, indication-driven initial evaluation; screening for the treatable causes that hide here — depression, anxiety, sleep apnea, thyroid disease, anemia, medication effects; and a plan with follow-up rather than a plan with more tests. The value question is the panel versus the conversation: broad undirected testing in fatigue is expensive, low-yield, and productive mainly of incidental findings that generate their own cascades — while the sleep history and the depression screen are free and frequently diagnostic. The intern owns: resisting both traps — the dismissal (“everything’s normal”) and the shotgun workup — naming what has been excluded and why, validating that the symptom is real, and scheduling the return visit, which is itself the intervention for the symptom that has not yet declared itself.