Clerkship: Family Medicine

The goal of clerkship rotations is for students to acquire a defined body of knowledge, skills and attitudes necessary for the recognition, understanding and management of the common and unique health care problems. During each core clerkship and elective rotation, the PA student will participate, in a supervised capacity, in the care of patients presenting to the specific health care setting (Emergency department, Clinic, in-patient ward, etc).

Family Medicine Rotation

  • Location: A Family Health Team located in Brampton, ON
  • Length: 12 weeks

Read more as I write about:

  • What a Family Heath Team is
  • A day in the clinic
  • Who I worked with
  • Common encounters I had, procedures I was able to do/assist
  • Some of my most memorable cases

Family Health Team

I did my rotation in a Family Health Team (FHT). The definition of a FHT as per the Ministry of Health:

Family Health Teams are primary health care organizations that include a team of family physicians, nurse practitioners, registered nurses, social workers, dietitians, and other professionals who work together to provide primary health care for their community. They ensure that people receive the care they need in their communities, as each team is set-up based on local health and community needs. (source)

Patients rostered on a FHT have access to a variety of health care services: dieticians, massage therapist, chiropodist, physiotherapist, etc. There is also a continuity of care. For example, all HCP in the clinic has access to the patient’s e-chart.

  • If the patient is unable to see his/her primary care physician, s/he can see other HCP on the team, like a Physician Assistant or Nurse Practitioner. Their visit will be documented on in their e-chart and their primary care provider will be able to review the charts as well.
  • If this patient went to an outside walk-in clinic, the primary care physician will never know what the visit was for, what investigations were done, what medications were prescribed. The patient won’t necessarily remember what they were given as well.

My clinic offers after-hour clinic times on a first come first serve basis, every day for 3 hours to allows patients the opportunity to see us first before going to an outside walk-in clinic. That said, a FHT will also get penalized by the government every time a FHT-rostered patient visits an outside walk-in clinic. Their rationale is if patients are seeing a walk-in clinic, that means the FHT clinic was unable to provide timely care to their rostered patients

A Day in the Clinic

  • I came in mostly 5 days a well, the schedule is different everyday depending on who I’m working with that day. I do walk-ins if my supervising physician is scheduled to do them (usually 5-8PM or weekends 10AM-1PM).
  • Dress code – casual/professional (not hoodies and leggings casual)
  • I work off of the physician’s or PA’s schedule as I need to review with them after each case
  • I would take a history, do an appropriate physical exam, then review with the physician/PA. I like it when I can review in a different room so that we can talk about what I was missing and be asked about what my differentials/investigations are. Sometimes that doesn’t happen though, so I just review infront of the patient and observe what the physician does, taking notes of pertinent questions I missed. Charting is electronic, I usually save a rough draft and finish them at the end of the day in the clinic if I can (if not enough time, I finish them at home).
  • I get feedback at the end of each day.
  • Sometimes there will be guest speakers/pharma reps who come in to talk about updated guidelines or promote their medication. This usually happens over lunch. If the clinic is running late, I usually missed the first half the of presentation 😦

Who I Worked With

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  • Physicians
    • I was supervised by two physicians during my rotation (they’re founders of this FHT clinic and also husband and wife!). They are very involved in the community and also have extended training, with privileges to work in Brampton Civic Hospital. One of my supervising physicians works in general obstetrics, so I had a lot of opportunities to do prenatal visits in the clinic.
  • Physician Assistants 
    • When my supervising physicians are not in the clinic, I work with the PAs! Both are McMaster PA alumnae. They’ve been through what I am now going through so they know me best. They gave me really useful tips for future rotations. They’re also readily give me opportunities to do hands on procedures.
  • Nurse Practitioner 
    • I didn’t get a chance to work with the NP in the clinic but she runs a Travel Clinic in the clinic and also does research. In the travel clinic, she advises patients or families who are thinking of travelling to an endemic area what vaccinations they need and other health precautions during their visit there.
  • Lab techs
    • They do venipunctures, vaccinations, procedure cart preps, urine dips/betas, etc.  They are so essential to the team – efficient in time and also amazing at what they do! There was one day where we didn’t have a lab tech at all. The PA and I had to draw up our own vaccines when usually this would be done for us while the patient is being seen.
    • The lesson here: know how to draw up vaccines, what needle gauge and length to use, and how to get rid of air bubbles in the event you have to do all this on your own.
  • Other Learners – Medical Resident, Nurse Practitioner Student
    • There was a medical resident there the same time I was doing my rotation. She has her own appointment list though – patients are directly booked under her, whereas I work off the physician’s list. An NP student came on during the last month of my rotation. She comes in two days per week, and also working off of the physician’s list. Things were more hectic then in terms of wait time (because the physician has to review BOTH our cases) and the number of patients I get to see (since we’re both sharing the physician’s list). Both the resident and NP student are super nice and taught me many things as well. I often review with them first if the physician is bust, just to see if I missed anything.

Common Health Care Visits I Encountered

  • Periodic Health Exams
  • Prenatal visits
  • Well baby visits + immunizations
  • Respiratory tract infections – viral upper resp infections, sinusitis
  • Urinary tract infections
  • MSK – Low back pain, Knee pain, Feet pain
  • Diabetic follow-ups
  • Eczema

Procedures I Was Able to Do

  • Urine dip
  • Immunization administrations
  • Measuring fetal heart rate with a doppler
  • Pelvic exams – including pap smears
  • IUD insertion (assist in cleaning the insertion site, sounding)
  • IUD removal
  • Skin tag removal (assist) + cautery with silver nitrate

Some of my most memorable cases (in no particular order)

Seeing a patient with gout

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  • This was memorable for me because it was during one my first week in the clinic. The patient presented with classic symptoms of gout – acute red, warm, tender joint at the base of the great toe. He said that even when his blanket brushed the spot, he would be in intense pain.
  • The mistake I made was not considering other differential diagnoses (eg. osteomyelitis, septic arthritis, etc)

Holding a 10 day old baby for the first time

  • This is the youngest, most fragile human being I held in my life so far – with maternal permission of course! The mom actually taught ME how to hold a baby!

Infantile esotropia

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  • This was towards the end of my rotation. At this point, I’ve seen at least 20 babies. I do my head-to-toe exam for the baby and usually, when I check the eyes, there’s the red reflex and normal cover-uncover test. This was the first time the cover-uncover test was abnormal for me.
  • I learned that a complete exam needs to be done, no skipping thinking that it probably would be normal. Also, knowing what normal is comes with experience! The more normal you see, you’ll know what abnormal would be.

flu-mist

First time giving someone the intranasal flu mist vaccine

  • With the introduction of the intranasal flu mist, I had the opportunity to administer it to a patient.

Fecal impaction (aka FOS)

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  • In family medicine, most of the cases I see are relatively non-acute, so when this lady came in crying, expressing pain in her L left quadrant, I didn’t know what to do. She went to ER but decided she didn’t want to wait, so she walked into our clinic around noon. We sent her for a STAT abdo x-ray downstairs and instructed her to come back up after. She never came back up…so we went downstairs to get the x-ray – it was fecal impaction. Which made sense, since she’s on Percocet for chronic pain. Apparently, she went home because she felt a bit better -__-

Acute otitis media in 18 mo child

aom-tm-pictures

  • Kids with fever are one of my biggest challenges. This child was memorable for me because he was having a fever (above 39.0C), transmitted airway sounds vs abnormal lung sounds were difficult to differentiate to a naive learner like myself, cries whenever I try to touch him (I was afraid to stick the tongue depressor in further thinking I’ll hurt him, so I didn’t get a good view of his throat), and his ears were both impacted with cerumen – I couldn’t see his tympanic membrane. I reviewed with the PA – she did everything I was scared to do and decided to treat based on suspicion of AOM due to his fever not going down with regular dosing of Advil.
  • What I learned here is that you gotta do what you gotta do to make a diagnosis (and that it’s not going to hurt the kid if you stick the tongue depressor further).

Overall

Family medicine is more than meets the eye. Before clerkship, I definitely underestimated the role of a family health care worker (physicians, PAs, NPs). It’s a jack of all trades and knowledge about a bit of everything in medicine is necessary. There’s an emphasis on chronic care as well.

This was my first and longest rotation. I’m lucky to have done my rotation at this FHT – I had great supervisors who gave me feedback. I came out knowing what I need to work on.

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