For many medical students the family medicine clerkship is one of the more enjoyable rotations of third year. Regardless of your intended specialty, the rotation offers the opportunity to work in the outpatient environment. Since there is no overnight call or required weekend duty on the rotation, there is ample time for reading about the bread-and-butter cases in medicine, pediatrics, and obstetrics that make up the core of the clerkship.
Family medicine can also appear daunting because of its wide scope of practice. For those students completing this clerkship early in their third year – before they have been exposed to some of the other core specialties – seeing pregnant patients, small children, or chronically-ill patients can be intimidating.
In order to quell some of the anxiety that may arise, the SDN Front Page has compiled a survival guide to help you get the most out of this challenging and rewarding part of the third year. This guide is based on the author’s own experiences on family medicine clerkships and information provided by Dr. Anthony Jerant, director of the Primary Care third year clerkship at the UC Davis School of Medicine. Because not all primary care clerkships are structured the same way, you may find some differences between what is described here and your clerkship experiences at your own medical school.
If your family medicine clerkship is a primarily outpatient experience, you will be assigned to a faculty preceptor who is a family physician. Since the field is very broad and encompasses a wide variety of practice types, you may be assigned to a preceptor in solo practice, group practice, HMO setting, or academic center. Some schools may offer the option of doing the rotation at a rural site located away from the main medical campus. Often these sites will provide housing and meals and can be a great opportunity to experience what practicing medicine is like in a rural area.
At the beginning of the clerkship the faculty preceptor will usually discuss the office’s schedule with you. Some students work regular office hours on this rotation and others may be assigned to sites that work extended hours. If the preceptor has patients in the hospital or does obstetrics, you may attend hospital rounds in the morning before heading to the office, or may have the opportunity to help with deliveries at all hours of the day or night.
There may be other clinical and educational activities scheduled during your clerkship as well. At UC Davis, for example, students leave their assigned preceptors for several half-day sessions in outpatient geriatrics, hospice, home health care, and physical and occupational therapy, and also attend weekly case discussions of common topics in primary care.
Preparation for the Clerkship
There is really no specific preparation for this clerkship. The basics of taking a history and doing a physical exam that are taught during the first two years of medical school are the skills that are most important. You may find that having some clinical experiences in the outpatient setting, such as interviewing and examining patients at student-run clinics during your pre-clinical years, is helpful. Experiences from other core clerkships, including internal medicine, pediatrics, obstetrics, and surgery will also be helpful for students taking the family medicine clerkship later in the third year.
Goals of the Clerkship
This rotation seeks to increase your understanding of the primary care physician’s role in the medical system since all students, regardless of future specialty, will have some interaction with primary care during their careers. Preventive medicine is a large part of primary care, so you will become familiar with how to screen for and to counsel patients about preventing illnesses. Given that primary care physicians see a wide variety of complaints, you will learn how to diagnose and manage the most common presentations. The clerkship provides a great opportunity to work on history and physical examination skills, particularly learning to address the patient’s concerns under the time constraints of the typical outpatient office visit.
On a typical day on the family medicine clerkship, you will see patients with the faculty preceptor. Many preceptors will give you your own patients. After introducing yourself, taking an initial history, and doing a brief physical exam, you will present the patient to the preceptor. They will then help you develop a treatment plan for the patient and will then usually see the patient with you to conclude the visit. Since many practices are very busy and can see 30-50 patients daily, the preceptor may be seeing several other patients while you are seeing one. Be aware that there may be significant downtime while waiting to present to the preceptor and that the discussion may need to be brief to maintain the flow of patients. Use available time to formulate a concise presentation of the patient’s complaint and exam findings, develop a differential diagnosis, and gather any lab slips or paperwork that may be needed to expedite the remainder of the visit.
Seeing patients and presenting them to your preceptor will constitute the bulk of your day at most placement sites. You may also have the opportunity to observe and help out with office-based procedures like punch biopsies, vasectomies, circumcisions, endometrial biopsies, suturing, and incision and drainage. Once you get to know the flow of the office you may also help the nurses and medical assistants with vital signs, blood draws, and injections. Outpatient primary care preceptors typically enjoy teaching and their office staff may be used to having students. In fact, nearly all clerkships employ preceptors who volunteer their teaching time, indicating the level of dedication they have for student instruction. Do not be afraid to ask if you need help or are unsure of something.
How To Do Well
The breadth of family medicine is very wide; keep in mind that you are not expected to recognize every patient’s presentation. You will see the most common complaints and chronic illnesses, like cough, back pain, diabetes, and hypertension many times on your clerkship. However, rather than coming to view them as “old hat” or routine, the great challenge (and art) of primary care is to learn to best apply the generalized knowledge you accumulate about these common topics to the specific circumstances and needs of each individual patient. Every patient encounter is quite unique; even those concerning these common ailments. To remember this very important principle during your clerkship, you might keep the American Academy of Family Physicians catchphrase in mind: “The doctors who specialize in YOU.”
To build a knowledge base of such core concepts, you should focus on reading about some of the chief complaints you see during each day. Tying the material in to specific patients will help you remember what you read, and if you do it just after seeing a patient, it will allow you to bring up questions you have about management with your preceptor while the encounter is still fresh in your minds. Think of this time you use reading as putting in your “call” as you might on an inpatient rotation. This is just the start of the lifelong learning you will be doing as a practicing physician in your chosen specialty.
As with any other rotation, being professional — showing up on time, treating staff courteously, and dressing appropriately — will be noticed and appreciated. Remember, family medicine strives to treat every patient as an individual and to address the patient as a whole person and not just a collection of organs and symptoms. Get to know your patients as much as possible and use this rotation to strengthen your interpersonal communication and listening skills. You may have more time with the patient as a medical student, and your preceptor will appreciate hearing about the patient’s concerns that may not have been addressed at past visits due to lack of time.
Reading Materials and Examinations
To augment your knowledge, Sloane’s Essential of Family Medicine and accompanying practice question CD is used by the clerkship at UC Davis. The instructors of record advise that students spend as much time on reading and studying as they spend doing overnight and weekend call on other rotations.
Most schools have some form of a written exam at the end of the clerkship. Clerkships may create their own exam or use a National Board of Medical Examiners (NBME) exam. Be sure you stay on top of your reading because many students find these exams to be very challenging due to breadth of the material, especially if they are taking it early during third year. Ask the clerkship directors for your course or other students from your school what you can do to best prepare for the type of exam your school offers.
The following books and questions banks, listed in no particular order, have been found by some students on the Student Doctor Network to be helpful when preparing for the NBME Exam in Family Practice:
- Textbooks/Pocket Books
- Case Files in Family Medicine (presents common presentation in case-based format)
- Swanson’s Family Practice Review (designed for Family Practice board exam prep)
- Blueprints Family Medicine (very broad overview of many conditions)
- Step-Up to Medicine (outpatient medicine section)
- 1st Aid for Step 2 CK or Step 2 Secrets or Boards and Wards (outpatient medicine, Peds, and Ob-Gyn chapters)
- Question books/banks
- NMS Family Medicine Q&A
- MKSAP (Internal Medicine questions)
- Sloane’s Family Medicine Essentials CD (100 questions, comes with textbook)
The family medicine clerkship will introduce you to the most important aspects of primary care. Whether you decide to pursue a career in this area or not, use this rotation to work on your history taking and physical exam skills, and to build your knowledge base in the basic areas of medicine, pediatrics, and obstetrics and gynecology that will serve you well in all areas of medicine.