Final Thoughts: Family Medicine

My eighth (and FINAL) clerkship of third year (Family Medicine) has come to an end...

• 5 weeks, 21 days, 161 hours of work in areas ranging from Family Practice clinic to Inpatient Family Medicine in the hospital.
• Working at the clinic and hospital, I worked 16 days for 141hours (average of 8.8hours/day; about 35.3 hours/week)
• I was in lecture for 5 days, totaling 19.5hours (average of about 4 hours per lecture day).
• I enjoyed 12 days off in the last 33 (that's ~2.5 days/week).
• I completed 0 nights on call.
• I studied family medicine outside of work a total of 50 hours.
• My total work in Family Medicine over the past 5 weeks is: 211 hours in 5weeks (42.2 hrs/week...about 6 hrs/day).

What I LOVED about Family Medicine:

• The lifestyle is amazing. The days when you work are long (9-12 hours), but the days off are pretty much full days off. 
• You get to see different things with each patient, and each day is different. You never know what's going to happen in the office, so it can be somewhat exciting.
• It's the first line of diagnoses for most diseases. Think about it...who diagnosed your asthma? or broncitis? or sinus infection? or your ankle sprain? And they do most of their diagnosing based upon a thorough history and physical alone, and order labs/tests as necessary based upon their clinical inclinations. That is pretty fun.
• I actually enjoyed seeing kids! I couldn't do it all day, but interspersed between adult visits was actually kind of enjoyable. I know, I'm just as shocked as you are. I like the kids! 
• You have a long-term relationship with your patients.
• Patients trust you, and rely on you for your second opinions for more specialized conditions. And they are always asking for advice from their family doctors. Strangely, although some medical professionals seem to lack large amounts of respect for family doctors, the patients seem to respect their family doctor most.
• If anything gets too complicated --> refer to specialist.
• There are procedures that you can do! ...even if it is just removing a wart, it's still a procedure!! 
• I delivered a few babies, without going through OB-Gyn residency. That's pretty awesome. And both the mom and the new baby will be members of the family doctor's practice for many years to come. I love that.
• I love working in a clinic. We also got to do some rounding on the patients who were in the hospital, which I also enjoy doing. 
• It's just a little bit of everything. And if there's something you don't like to do, you don't have to do it - just refer to a colleague. The freedom is unbelievable.
• I really love preventative medicine. I enjoy having conversations with patients regarding their nutrition, exercise, lifestyle, habits. I also like to talk to them about what they can expect in regards to their health. I also like the idea of stopping a disease before a patient even notices its presence (like with hypertension or hyperlipidemia or diabetes).

What I DIDN'T love about Family Medicine:

• Some days get super long.
• Some patients come in with the strangest complaints...like weird complaints. Like "my belly button itches, what's my diagnosis?" kind of complaints. I know it's probably just anxiety, but it still feels strange to hear such bizarre reasons for coming in to the doctor.
• Each visit is so short. 10-15minute visits just aren't enough for some of the more complicated patients or diagnoses. 
• I would like to know more about the specific diseases. I think deep down inside, I'm meant to specialize. I just want to know everything about something rather than something about everything.
• Often times, other doctors don't give family physicians the respect they deserve. 
• Patients will do as they wish...all of our best interventions are useless if the patient decides not to comply with our recommendations. This is such a huge source of frustration for me, but can sometimes be avoided with proper patient education - which requires more time spent with the patient in each visit, which is simply not very feasible.
• The compensation is nothing to write home about...not that money matters, but it is certainly a factor in the decision making process.

Since I didn't actually get the chance to work in the Ambulatory Clinic with an Internist, I'm not sure if this is kind of how their days are arranged (minus the kids). If so, even life as a General Internist wouldn't be a bad choice for me...but at this point in time I really would love to specialize (likely in Medical Oncology).

Family Medicine Shelf

Family Medicine (and THIRD YEAR) is finished - - - such a good feeling!


The shelf exam was alright. The questions are really broad and varied; I'm glad to have scheduled family medicine as my last clerkship of third year. Classically, it is the most failed shelf due to how broad the information is - the shelf would be pretty difficult if it was your very first clerkship of third year. But as it was my final clerkship, I felt quite prepared and confident in how I did. I ended up with an above-average score (and let's just leave it at that).

Family Medicine is incredibly broad and it is difficult to predict which questions will be asked on the shelf. I was at an advantage, taking this clerkship last, but I don't think it would have been horrible to have taken it earlier. I personally felt like IM was more a bit more difficult. To prepare for the exam, I:

• Followed, managed, and learned from a variety of patients - including those with diseases such as Diabetes, Hypertension, Stroke Syndrome, Pregnancy, Well-Visits, Cellulitis, Musculoskeletal Injuries, Back Pain, Psych Disorders, Dementia, CHF, COPD, Surgical Clearance, etc etc etc etc etc
• Used Uptodate to learn more about each of my patient's diseases and treatment plans.
• We had lecture for a few hours during the course of the clerkship, which were somewhat (but not really) useful.
• Read Family Medicine Case Files. It's a quick and easy read, honestly. And helpful to prepare for all of those "what is the next appropriate step" questions that are asked.
• Read over the Ambulatory Medicine section in my Step Up to Medicine textbook.
• Read bits and pieces of Step Up to Step 2 to review previous clerkship info (like surgery, ob-gyn, peds, psych, neuro).
• Completed about 500 of UWorld's Step2 IM questions - which were really helpful to broaden my base of studies.
• Completed all but 125 questions from USMLE Easy's Step2 Family Medicine's Question Bank.

My final takeaway on how to best prepare for the shelf exams during third year:

• Have a quick review book (like Case Files) stuffed in your white coat pocket, and read over it whenever you have some down time.
• No matter how busy you are (and you will be busy), always make time to read at least an hour each day.
• Do questions every day. This is the part of studying which I dislike most, and I'm not nearly as faithful at completing the questions as I would like to be, but I did notice that once I started to use the QBanks more frequently, my shelf scores (and confidence) improved significantly.
• Take on a variety of patients, even if it makes you uncomfortable. The single best way to learn is through experience.
• Keep your Iphone or Ipad on you at all times, with a QBank open, UpToDate logged in, and the Epocrates app ready.

Family Medicine: Day 16, 17, 18

I feel like I need to get this post in while I'm still officially a Third Year Medical Student - even though I really should just be studying for my shelf!

The past week has been crazy! On Monday, the clinic had over 50 patients. It was crazy. And every patient seemed to need a little extra time, with things like Depression, Pap Smears, Newly Diagnosed Diabetes, Nutrition Advice, etc etc etc. Things were insane. I finally got out of the office by 6:30 after all of my notes were complete (I had no time during the day to finish any notes, so it took me an extra 90 minutes just to finish notes). Also, we had a few patients that we saw in the hospital for a knee replacement and cellulitis. Then on Tuesday, the afternoon slowed down after we left clinic early to deliver a baby. That's always fun!!! I can't believe that I may never get to do that again... The attending even asked if I wanted to repair the episiotomy; I am going to miss procedures so so so much. Finally on Wednesday, I saw a variety of patients in the morning and the attending even let me finish early so I could go home to study. Today, of course, is a big time study day, because tomorrow I take the "most failed" shelf of third year!

I have had a great experience on Family Medicine. I was lucky to work with and learn from such a great family doctor; I know the score I will get on my shelf will be due, in large part, to her education and guidance. I really loved this rotation, and I'm definitely going to miss the freedom I was given while away from my medical school's hospital!

Family Medicine: Day 11, 12, 13, 14, 15

Time to recap on all of the things that I've been doing on Family Medicine!

• Yesterday, I delivered my first baby. The doctor I am working with allowed me a lot of freedom in the delivery, so I did most of it on my own (under her very close supervision). She did the episiotomy and repair, and I delivered the baby and placenta. It was amazing. Witnessing the miracle of life never ceases to amaze me. What beautiful moments!
• I attempted to pull an object out of a child's ear (sadly felt like I had foreshadowed this occurrence by telling a previous patient that day about The Things We Find in Our Patients' Ears!).
• I spoke with a patient - at lengths - about the basic principles of good nutrition. For example, I advised that instead of eating a double-bacon-half-pound-cheeseburger with large fries and a giant-sized Coke twice a week, try to make it more of a once-every-other-week treat. 
• I made *almost* every kid I saw in the past week smile and laugh. (Yes, this is coming from the girl who has openly admitted her significant disinterest in pediatrics)
• I am getting to be quite proficient in pap smears, and could probably now diagnose BV based on the whiff test alone...!
• I continue to be surprised by how people will openly tell me the most personal details of their life without hesitation. Some questions which I routinely rattle off and patients honestly respond to:
• Any new sexual contacts?
• Any possibility of a new STD?
• Number of sexual partners you have had?
• What type of sexual protection do you routinely use?
• Have you had any recent constipation or diarrhea?
• Has urination been painful recently?
• How many times do you get up in the middle of the night to urinate?
• Are you breast-feeding your child?
• Are your nipples sore or cracked?

Family Medicine is so much fun. I can really see the appeal of the lifestyle, the short residency, the close relationships with patients... I actually find it interesting to see a few kids interspersed between adult visits for hypertension, COPD, Diabetes, etc... if only there could be an Oncology Fellowship at the end of its residency, then it would look quite tempting!!!

Family Medicine: Day 9, 10

The doctor with whom I am working asked me to see a patient who came in to talk about diabetes management. This patient, she had told me, was considerably non-compliant with our interventions and the importance of monitoring her blood glucose regularly. The patient was young, but had significant morbidity associated with poorly controlled Diabetes; she had some peripheral neuropathy, poor vision, and recurrent yeast infections. After looking through some items I planned to speak with her about,  I went into the patient’s room, and I introduced myself. The patient quickly asked me, “you have to follow them HIPPA rules, right?”, to which I hesitently responded,  “Yes, whatever you tell me will be held in complete confidentiality, aside from 2 exceptions: if you are planning to harm yourself or someone else, I must contact proper authorities to maintain the safety of yourself and others”. She then quickly began to tell me about her anxiety and depression, which has been causing her significant distress over the past several months. This patient has a child with developmental disabilities, who can be exceedingly challenging to care for at times. She also was suffering from many other stressors, including loss of employment, feelings of failure, mental abuse from her husband, and the lack of a good emotional support or friend. I listened to her empathetically, and I managed to slide in questions about the diagnostic criteria for depression (SIGECAPS), and I found that she met criteria for clinical diagnosis of depression, without thoughts of suicide or homicide. I felt really overwhelmed by the difficult situation this patient was in; I have completed my psychiatric clerkship, but the interaction felt a lot different in a family medicine office visit than in the psychiatrist's office, especially since this interaction was completely unexpected. The main concern that this patient had was the fact that she utilized an illegal substance in order to deal with the stress of caring for her developmentally disabled child, and she wanted to quit with help from us. We were able to prescribe to her an antidepressant and an anxiolytic for acute attacks, as well as referring her to our psychologist for further assistance, and we will follow up with her again in a week.

The whole interaction was so quick. The scheduled office visit was for 10 minutes, but we spent much longer than that with her. As it happened, I wish I would have spent more time with her, and directed the conversation a little bit more (I had allowed her to talk freely with empathetic statements to encourage her to speak freely - its what we do on psych, but not very time efficient for family medicine!). It’s never easy to ask about suicidal or homicidal ideation, and I hope I didn’t make her feel uncomfortable with my questions. I look forward to seeing her in the clinic for a follow up visit, knowing that I will have had some time to prepare for the encounter.  I do feel like I handled this situation fairly well, but it emphasizes the fact that you never know what to expect when you walk into a patient’s room, and it is best to remain open minded. I’m glad that I didn’t have this experience when I first started third year rotations, because I would have felt completely off-guard; it’s reassuring to know that I was able to handle this interaction without too much of my own anxiety!

Family Medicine: Day 5, 6, 7, 8

Last week, I had a few interesting patients:

1. A multiparous woman at 41 weeks gestation required emergency Cesarean section due to non-reassuring fetal heart tones/fetal distress...we quickly went from calm and collected to running down the hallway to the OR. Baby came out with APGARs of 8 and 9 (healthy), so it was a happy ending to a stressful situation.

2. I watched about 20 pap smears in one day. That is one long day.

3. I saw a kid with a complaint of hurting her ankle and I was able to diagnose cellulitis (somewhat rare to find in kids, so when I suggested cellulitis as my diagnosis to the attending before she went in to talk with the patient, my attending thought I was crazy - but I was correct!).

4. I walked into a patient's room, anticipating a conversation regarding diabetes management, when I was bombarded with someone who was suffering from massive anxiety and depression (more on that story later!). 

I see some crazy thing each day. I'm constantly surprised by the number of "oh, by the way" symptoms that patients bring up just as we are leaving the room. And you honestly never know what to expect behind each patient's door!

Family Medicine: Day 3, 4

This is fun. A day on Family Medicine is like a day spent taking practice exams - each patient is so very different, and you have no idea what to expect when you walk into a patient's room. It's like a big quiz - and, since it's the end of third year, I am having a lot of fun remembering all the things I've learned in the past 3 years. I'll admit I'm astonished by the amount of stuff I have remembered; when you continuously work with specialists, you feel like you know nothing because they know so much about their particular field.

I had a young girl with abdominal pain today, and I figured out she was suffering from acute cholecystitis (not a difficult diagnosis, but I was definitely expecting her to have viral gastroenteritis before I walked in the room). So I put together the appropriate work up and treatment. When the family doctor went into the room, she didn't even have to ask the patient any questions, she went straight into explaining diagnosis and the tests we were ordering. It felt pretty great to know that I did this one on my own, from start to finish. I know I've done this before, and I've helped in the care for my patients in the past year, but today I actually felt confident enough to have done it on my own - which is a big deal. I actually feel like I am directly responsible for the patients I see, so I'm really integrating everything I know so I can treat them in the best way that I can. I feel like I'm one step closer to becoming a doctor...

I have also been caring for a man with Stage IV Lung Cancer who is in the hospital with low white cell counts and an infection. I sat in his room talking with him about his story for over an hour yesterday; I learned so much and we had some laughs. I can't help but love the oncology patients...


On a side note:
Lucky me - I have a FOUR DAY WEEKEND!!!!!!!! :) :) :)

Family Medicine: Day 1, 2

For my Family Medicine rotation, I am working at a rural hospital about an hour away from my apartment (and about a half hour away from my mom & dad's house).

 I love working in the rural hospitals for a few selfish reasons:

1. I'm encouraged to do stuff. I'll be doing proper doctor stuff for the next five weeks, including providing a differential diagnosis, selecting the most likely diagnosis, offering a treatment plan, and determining appropriate follow-up testing and appointments. I will also be doing loads of pap smears, wart removals, and other procedures that family doctors routinely do.
2. Free food. All the time. And it's decent food.
3. Patients mistake me for a real doctor because I wear a white coat. They don't even realize it's a short one! They just see white and immediately warm up to me.
4. Pharmacy reps are allowed on the hospital grounds. Which means more free food, and sometimes I also get fun little demonstration kits! I have one in my apartment which demonstrates how to properly insert a copper IUD - it sure makes for a good conversation piece!
5. The hours are pretty great. I work like an attending, not like a dog resident.
6. There are literally no pretentious doctors around. They don't get paid just for being smart, they get paid for being an effective (and likable) doctor. So they tend to be a lot of fun to be around.
7. Free food. Like, breakfast/lunch/dinner. I cannot stress this enough!

The physician I'm with for the next 5 weeks also has 6 women who are due to deliver sometime in the next 2 weeks. That means this girl will get to catch some babies! Beyond excited!!!!

The Things We Find in Our Patient's Ears

Going through 10 hours of orientation to the five-week Family Medicine Clerkship today reminded me of a patient I saw while I was on Peds...

She was about 12, and she had come in for her annual physical. Being the med student, I was the first of three people on the medical team to see her. After a clear H&P, I started on her physical exam. I began by looking into her ears...but when I peered down her left auditory canal, all I could see was fuzz. "Weird," I thought, "I don't really know what an ear drum is supposed to look like, but something tells me its not supposed to be fuzzy..." So I fetched the resident, who noticed something strange as well. After looking in her ear, she left the room, grabbed a long pair of tweezers and a flashlight, and returned. After fishing in her ear to retrieve the fuzzy mass, I pulled out a massive, waxy Q-tip head.

The girl didn't even know anything was in there.

I wonder what treasures I will discover in the next 5 weeks on Family Medicine! ;)