Debriefing Outpatient Medicine and Looking Ahead to Family Medicine

On Friday, I finished my first clerkship of third year, Outpatient Medicine. At University Medical School, our medicine rotation has been divided into three parts: an eight week inpatient block (“Medicine”), a four week Adult Outpatient block and a four week Family Medicine block. During the eight week inpatient Medicine block, students rotate among the various inpatient medicine teams, whereas students remain at a single clinic for the four week Adult Outpatient block and at another single clinic for the four week Family Medicine block. I previously posted some interim thoughts on my Adult Outpatient rotation on this blog.

I approached the rotation with the following goals (self assessment in bold):

1. Improve my patient-facing skills (H&P, general skills). I received only good feedback from my preceptor, my patients and office staff. I still have a lot that I want to work on:

-Fundoscopic exam. I can find an optic disc in about 1 in 4 eyes. My goal by the end of family medicine is to be above 75%. Before this rotation, I had never seen an optic disc in a non-dilated eye before, and I’m starting to get the hang of it.

-Cardiac Auscultation. I can hear some murmurs (certainly flagrant aortic stenosis/mitral regurg, any >III/VI murmurs), but I want to get more familiar with the cardiac exam maneuvers to elicit murmurs and when to use those clinically.

-Breast/Rectal exams. Personally, I have no desire to ever do either of these. However, they’re among the most important preventative/screening tools. Having performed a lifetime total of 1 of each, I need a lot more practice.

-Pediatric exam. Haven’t ever done this. Obviously that will change.

2. Improve my comfort and confidence interacting in a health care setting (e.g. finding labs, working with medical assistants, NP/PAs, navigating around new hospitals). In general this went very well and by the end of the rotation I was beginning to get comfortable using each of the facets of the new hospital’s EMR (radiology, labs, orders, ER system, etc.). I enjoyed working with the office team at my practice and managed those relationships and interactions well (or, at least, not badly enough that anyone said anything).

3. Improve my note-writing and patient presenting skills. A mixed bag here. On the one hand, the feedback I received on my notes was positive. On the other hand, I know that some of my presentations were not adequate (this was my first rotation and I got the distinct feeling I would have been ripped a new one by more aggressive attendings). Definitely need to improve my oral presentations before starting OB/GYN in September.

4. Learn how to study as a third year student. I learned how hard this is, but I’m not sure that I found a solution. I started with the “easiest” rotation of third year (only 45-50 hours/wk) and still found it hard to study during the week. I had allowed myself to believe that the course lectures, my clinical experience, reading for 3-5hours/wk and doing most (400) of the MKSAP questions would prepare me for the shelf. I was wrong. The shelf exam (NBME) presented questions at a level of difficulty and complexity that I was completely unprepared for. It felt like the Step 1 CBSSA that I took in December of MS2 year -. I don’t want to ever feel that way again.I felt that my OSCE (standardized patient encounter) and written essay exam (write out an entire treatment plan for a patient with untreated/poorly controlled hypertension diabetes hyperlipidemia obesity and needing all preventative health screenings) both went well, but the shelf clubbed me like I was a baby seal.
So, in setting my goals for Family Medicine, I’ve thought about the following:

1. Better patient summaries. My verbal summaries kind of suck right now. I often forget things and find it difficult to encapsulate everything in 2-3 sentences.

2. Quicker notes and a better exam routine. An uncomplicated physical still takes me too long.

I’m sure I’ll find many more things to work on as the clerkship proceeds.

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