Clinical Year: Family Medicine

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I started my clinical year in Family Medicine, and personally it was a great place to start for me.  I was at a private practice with one physician who has been practicing for years in the area.  He's getting close to retirement, so he only sees patients in the mornings each day from about 8-12.  I was a little worried at first that I wouldn't see enough patients to feel like I was getting good experience, but that was not the case at all. We would usually see 12-15 patients each day and I think I had plenty of exposure to family medicine during my 4 weeks there.

My first day there I was a bundle of nerves for multiple reasons.  I was going into a new place where I didn't know a soul and it was my very first rotation.  I walked in and the sweet nurses told me where to put my stuff and then I went to meet the doctor in his office.  He was very nice, but had a somewhat flat affect and not much to say starting out.  I still didn't have any idea what to expect or what he would actually want me to do.  When patients started showing up, I was thrown to the wolves, which ended up being a good thing.  I would go to see the patient first and then come back and present to him.  He would ask me questions, which made me think about things I should be asking and considering.

Throughout my 4 weeks, I saw a large variety of conditions and types of patients.  Here are some of the main things I saw during my time there:

  • Yearly well-checks/physicals - There is a lot of counseling done at these appointments and reviewing diet, social habits, medications, vital signs, and just basically a good check-up.  This is a great time to practice the physical exam.  Some preceptors may do a modified PE, but if you have the time, practice your skills.
  • Hypertension (high blood pressure) - If the nurse checks the BP and it's high, you should recheck it manually in the room and possibly in both arms before reporting to the physician because they will most likely ask you to do this.
  • Hyperlipidemia (high cholesterol) - If a patient ate a fatty meal the day before they had labs drawn that is not the reason their cholesterol is high....maybe triglycerides, but still.
  • Diabetes - This is tough, and can be very difficult to control.  There's a lot of counseling involved in diabetes treatment, and if you have the chance to do a rotation in endocrinology, I would definitely recommend it.  Uncontrolled diabetes can lead to some scary stuff.
  • Shingles/Herpes Zoster - This one is so easy to miss when it presents early, and I know that from experience.  And it still tricks me sometimes!  The biggest clue is if it only appears on one side of the body.  So if a patient is having symptoms (tingling, itching, pain) or even a slight rash and you feel like it follows a single unilateral dermatome, then you should at least consider shingles.

I had my first encounter with a drug seeker/addict on my first rotation as well, and I felt like the most naïve person alive when I reported by my preceptor.  He had known the girl for years, so he had expectations that were different than mine.  She gave me a really intense story about how her life had been crazy lately and she really could use some help with anxiety, and she has a lot of trouble paying attention at work, and she has to stand a lot so she has a lot of back pain.  I told the physician about all of her ailments, and his response was, "Ah, the trifecta."  I came to learn that people will frequently want not only pain medication, but also medications for anxiety and ADHD as well.  These substances are so commonly abused by patients and by providers prescribing them incorrectly that you have to be a little skeptical of patient's intentions, which is sad but also the real world.

I had one very scary experience while I was on this rotation with a diabetic patient.  I knew he was somewhat uncontrolled going into the room, but at first glance this patient was flushed and just didn't look good.  I started questioning him, and he had been having diarrhea for about 2 weeks.  A change in fluids or intake/outtake in a diabetic patient is a dangerous thing.  He was on insulin, and his blood sugar was reading in the 300 range consistently.  He was basically going into a diabetic coma (hyperosmolar hyperglycemic syndrome) and needed to be at the ER, but was at our office.  I left the room to grab the doctor and we heard a loud noise, which was the patient basically passing out and falling back on the table.  That could have been really bad, and led to one of the lessons I share below.  We called an ambulance to help him get some fluids, but that was a learning experience for sure.

Things I learned:

  • Be skeptical.  It stinks, but there are some patients that may try to take advantage of you, so just be careful.
  • If you get to present, go for it.  Go ahead and say your differential and what you would like to treat with.  The physician is likely going to ask you about this anyways, so no harm in just presenting it from the start.
  • Never leave a patient's room if you think they may not be stable, like I learned from my diabetic patient.
  • Don't laugh at what patients say no matter how hard it is at times.  People will say some of the craziest stuff and pronounce things a little funny sometimes, so try to stay neutral if possible.  Like "asmur" (asthma) and "diabeetus" (diabetes).
  • Work on your shocked face.  I'm really bad about showing all of my reactions on my face.  This is still something I struggle with at times, but I've gotten a lot better.  Whether it's a baby moving in a mom's belly (that can be strange) or a 4 cm skin cancer that is bleeding like crazy and has been there for 5 years, it's best just to smile.
Step-Up to Medicine (Step-Up Series)3rd EDITION
By Steven S. Agabegi MD, Elizabeth Agabegi MD

As far as resources, since this was my first rotation, I was just trying to figure out what the best book might be.  I ended up using my PANCE review book (which every PA student must own) a good bit, but sometimes it just didn't have as much specific information as I was looking for.  I ended up also using Step Up to Medicine as well, and I really like this book for both family medicine and Internal medicine.  

Overall, I really liked family medicine.  I love that you get to know your patients so well and follow them closely over time.  The one thing I didn't like was seeing "sick" patients like ones who have the flu or colds.  I didn't see as much of this here because it was August though.  I would love to hear your thought or questions about family medicine!

Here is a blog post of an interview with a rural medicine PA.  And another one with a family medicine PA