Rotating at Dr. Smalls Office in Jamaica site for my Family Medicine rotation was a wonderful experience. After my first rotation, I think my apprehension of actually seeing patients disappeared. So this time around, I was more comfortable asking questions, and delving into the history and patient complaints. My first day, Dr. Smalls did a run through of my schedule and how every week would go. The first week, I interviewed patients to better my history taking skills, and when Dr. Smalls came in I would present my case and the pertinent positives and negatives. At this office, time wasn’t rushed, I could take as much time as I needed with the patient inquiring of their complaints, talking personally with them, and discussing their living/family situations. At first, I was drawn back because of the long wait times, however, once the patients were seen by Dr. Smalls, they appreciated that all their issues were heard. It was indeed like a family practice, and it felt very calm.
In the beginning, it was harder to present cases, because many of the patients were coming for follow-ups, so there wasn’t updates on their medical history and they didn’t have any acute symptoms. But I gained a lot from these encounters. For instance, I always reviewed medications for patients that presented to the clinic for routine checkup. And I began informing these patients of their use which many were unaware of. I think this was a great way to educate patients in regards to adherence and compliance. This was a great way to go over different medication use for myself as well. There were many times when I stopped and would ask why Dr. Smalls would prescribe one medication over another. Every provider works differently and some illnesses that I encountered before were treated differently and I think this aspect of medicine comes with years of practicing. It was interesting when I would write up the chart, I would include symptoms as part of the ICD-10 for the assessment, like body mass and previous diagnosis of DM, HTN, since that’s how I learned the previous rotation, I didn’t realize but Dr. Smalls would say I should diagnose with a condition. That is something I have to clear up everytime when documenting. Lastly, Dr. Smalls mentioned some pearls, which I also took notes regarding.
This rotation, I also continued to practice more of my clinical skills. On my first day, one of the MAs had difficulty obtaining a vein and I was able to draw blood on that patient, and that was definitely exciting. I continued to do venipunctures and injections, I was very proud that I managed to give intramuscular infections to children/nfants and update them on their vaccines by myself. Also, unlike the Urgent care, in house urine dipsticks were done by hand, so I used the color charts and interpreted the results myself. I also helped in EKGs and did manual BP pressures which I think was a good practice, because sometimes machines can give bad readings, and its best to confirm if a patient, especially when your patient is hypertensive. A few more skills that I gained in this rotation specifically were breast exams, bimanual pelvic exam and GYN exams. The first GYN exam, I watched and assisted Dr. Smalls, but after that I was driving on my own. In the beginning I was figuring things out, because everyone’s anatomy can be slightly differently. We actually had an encounters with a patient who had an “off centered” cervix so it was difficult to located at first. Dr. Smalls guided me throughout explaining and I was able to appreciate different size uteruses and I also felt a patient without one as well. I thought it was fun doing pap smears on patients. Most of the female patients that I did pap smear on were very nice, it is an uncomfortable procedure, but I made sure to be gently and very assuring. I didn’t have trouble inserting my speculum, visualizing, and taking cultures.
After some time, I started seeing sick visits often as well as same day visits, which I think helped in terms of developing my differential diagnoses. Dr. Smalls would ask what I thought the top three assessments would be after I presented. She helped me to analyze which illnesses would be higher on the list, and I would indicate how I was thinking while presenting my HPIs since many of the illnesses would be ruled out when I would say that the patient denies these symptoms. This also helped to focus my physicals, cater in terms of their presenting symptoms. However, I realized that many patients although sick visits, still complained of their chronic issues and when I updated their histories, Dr. Smalls was like I should focus only on the sick aspect of it.
One memorable patient I encountered in this rotation was a 55 year-old, heavy smoker, with diabetes and hypertension, with a 11 year old son. He was here for a routine physical however, I was updating his chart, pertaining to his fasting blood sugars and his blood pressure readings at home. I began asking CAGE questions for his nicotine dependence. He told me his history and how he has been told numerous times to quit, and even had several unsuccessful attempts. I reassured him that it wasn’t his doing and that there are multiple ways to approach this. He stated that I was the first person to actually listen and say it wasn’t his fault. I was a bit shocked at that. I offered different alternatives, cutting back ten cigarettes and putting them away as to not be tempted to smoke them, finding hobbies to take on,, hanging out with his child more often, taking care and ownership of his own health. I spoke to him like I would with my dad, he’s around the same age and he suffers from that too. I understand patients can be difficult at times, but dismissing their circumstances and concerns, is not a way to practice. It is a challenge but we’re here to fix people, not to worsen them. Being humble and realizing everyone is human, and if he didn’t care about his health before, who cares, he does now and he wants to change. We can’t force change, we can just inspire it, by being kind to others through our actions. Like Dr. Smalls says “different strokes for different folks”
In this rotation, I learned a great deal on how to manage chronic conditions like a family physician. Coming from the quick paced environment of Urgent care, it was transition. However, with this rotation, I began asking more pertinent questions in regards to symptomology, why certain medications were prescribed over others, I began relating and listening more to the patient complaints. I think I should again go over certain practices in terms of documenting with each rotation before I start transcribing. Overall, this was a great rotation, it was a great way to approach family practice, because I saw a bit of every population and the care is very all encompassing.