Turns out the order of my rotations leading up to Family was helpful. By the time this came around, I had gone through Obstetrics & Gynecology, Paediatrics, and Psychiatry and so I felt comfortable with things like antenatal care, well-baby visits, and common mood and anxiety disorders.
Clinic Days
· preventive health screen · antenatal care · well-baby visits · common clinical presentations; headaches, urinary tract infections, abdominal pain, back pain, rashes, depression, anxiety, fatigue, dizziness · hypertension · dyslipidemia · diabetes · pap smears · bell’s Palsy · morton’s neuroma · prostatitis · pityriasis rosea · pelvic inflammatory disease ·
This was where I spent most of the rotation. I worked with three family physicians in one office. My days usually started at 9 am but patients weren’t booked in till 9:30 am, so, the first 30 minutes were usually spent running through the day's list and my preceptor would assign appropriate patients for me to see. Due to the pandemic, at least 80% of appointments were virtual (mixed feelings about this). Most in-person visits were for pap smears (I eventually become more comfortable doing these), patients who needed a proper physical exam after an initial phone interview, or well-baby vaccinations.
I saw patients alone, reviewed and formulated a plan with staff, and went back to see/speak with patients with them. As the rotation went on, I tried to take some time to come up with my own differential and management plan before reviewing with my staff.
I got familiar with a lot of preventative health issues:
annual periodic health visits; screen for financial insecurity, mood disorders, lifestyle habits (exercise, substance use), etc.
screening guidelines for hypertension, diabetes, high cholesterol, cancer (breast, colon, cervical); appropriate age to begin screening, risk factors to consider, screening modalities, and frequency of screening.
vaccination schedules, especially for children and the elderly.
While common things are common, sometimes patients came in with issues totally out of left field (i.e., Morton’s Neuroma), which happened at least 2-3x/week. Also, sometimes, the written complaint we had on file didn't necessarily line up with what the patient wanted to address (which happened quite often). So, it was always important for me to clarify the reason for their visit at the start, or if I forget, ask if there’s anything else they wanted to address before closing out the appointment.
Diabetes Education
· lifestyle modification · medication Review · hypoglycaemic awareness · optimal glucose control ·
I spent a virtual half-day with a pharmacist and dietician on the diabetes education team. They saw patients with a new diagnosis of diabetes, those in need of tighter glucose control, or patients with microvascular/macrovascular diabetic complications. The appointment started with a brief check-in regarding their diet (a very thorough breakdown of meals & snacks), average glucose readings, and physical activity levels. They also reviewed results of latest bloodwork (i.e., Hemoglobin A1C levels). The pharmacist usually reviewed their medication list (including assessing for compliance) and whether they were experiencing any side effects. Modifications to their diet, physical activity level, or medications, were then suggested based on the information gathered.
Palliative Care
· end-of-life care · home visits ·
I went on a home visit with a registered nurse who provided palliative care in an outpatient setting. This was my first patient home visit. The patient was quite elderly, her illness was not sudden, and she looked quite comfortable. Still, I couldn’t help but feel quite sad and uneasy. I realized that up until this point, my view of medicine had largely revolved around saving and/or prolonging life. However, ultimately, death is inevitable, and providing good end-of-life care is very much an essential part of medicine as well.
Breast Diagnostic Clinic
· routine mammogram screening · fine needle aspirate · ductal carcinoma in-situ (DCIS) · lobular/ductal carcinoma · breaking bad news · mastectomy · lumpectomy · sentinel lymph node biopsy · axillary lymph node dissection · radiation therapy · chemotherapy
I spent a day in a breast diagnostic clinic at a community hospital. I worked with a general surgeon, along with a radiologist, nurse, and a social worker. Patients seen at this clinic were usually those with abnormalities (DCIS, carcinoma, etc) on routine mammogram screening. During their appointment, the patient’s history was reviewed (where I spent most of my time) and a physical exam was performed (I became more comfortable with breast exams by the end of this), diagnostic images were read by our in-house radiologists, pathology results were reviewed, and the surgeon talked through the best course of action with the patient (i.e., mastectomy vs. lumpectomy with axillary lymph node dissection +/- radiation therapy, etc.). This was quite emotional for a lot of patients, and I really liked how the clinic was set up to ensure patients felt supported throughout this process. As an example, conversations were had in a quiet private room and despite how busy the clinic was, it never felt super rushed and we were also able to connect patients with a social worker before they left the clinic.
This rotation came with a lot of autonomy, which was initially daunting, but something I came to appreciate by the end of the 6 weeks. I liked that I was in the same clinic, working with the same staff for majority of the rotation, this allowed me to have a lot of continuity with both staff and patients. I was able to follow a particular patient who had an open wound for a month; not only was it cool to see the stages of wound healing but also quite gratifying to watch her get back to some of the daily activities she loved doing once things cleared up. I learned how to clinically approach many common problems and how to make effective referrals to appropriate specialists. However, due to the pandemic, I didn’t get as much practice with physical exam skills as I would have liked but my preceptors tried their best to get me to see as many in-person patients as they could.
The most exciting part of this for me was still the well-baby visits.
~ Gold RimMD
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