I had to opportunity to rotate at Dr.Difranco’s office for my Ambulatory Care rotation. When I first started out, I was expecting an urgent care facility, however, that was not the case at all. This clinic definitely functions more as a family practice, where patients have followed up for over 35 years! Dr. Difranco is one of the most competent, caring, thorough practitioners that I have encountered, and he loves to teach students. Even though there was not enough time for him to actually teach, he tried to for every chance that he could, and he did a great job on it as well. As for applying my previous medical knowledge, we were not required to provide our diagnosis and treatment plans, which I would have been okay with if it was my first or second rotation. But coming from a family practice, where I was seeing patients from start to finish, including treatment, it was a little disappointing that I was not allowed to continue this care throughout. There were many positives to this rotation that I will talk about. Overall, I really enjoyed this rotation, and I hope to become as good of a practitioner as Dr. Difranco one day.

The first day that I was there, I was taught how to preform a complete physical exam. I understand that every site has their own standard of care, so every site will have different expectations for physical exams. For exam, when I was at NYPQ, a physical exam was visual inspection of the patient, from ten feet away, while some other patients received head to toe examination due to their condition. While I was on my site of family medicine, I listened to the heart, lungs, abdomen and checked the lower extremities for edema. While at Dr. Difranco’s office, the physical exam standard was higher than any other rotation I have had. For example, we were required to listen to the heart, lungs, abdomen, while patient was fully exposed. We are also expected to percuss the abdomen, something which I feel like a lot of places to do not take advantage of, as well as palpate the abdomen. In addition, we checked the ears and felt for submandibular adenopathy. For every female patient that came in for an initial visit, well visit, or annual physical, we performed breast exams. At first, I felt like this was a lot, and I would occasionally forget something, especially percussing the abdomen. I felt like I would be taking forever to preform the physical exam, but as time went on, I became very efficient performing my exams, and I knew what was normal and what was abnormal. One of my greatest difficulties for physical exam was understanding what an abnormal submandibular adenopathy would feel like. The anatomical structure of the thyroid is not smooth at all, so when interpreting this area, it is very difficult for me to say with complete assurance that there is no submandibular adenopathy noted. One day, while performing a physical exam on a patient, I felt two palpable lymph nodes in the submandibular area, and they were not symmetrical in location. That patient was the only patient I felt that I could say with confidence that I felt something abnormal. With this being said, I would be surprised if anyone else missed this finding if they had indeed felt for lymphadenopathy, that is how obvious the finding was. If that finding is how abnormal lymphadenopathy is supposed to feel, then I could be sure that I did not missed any adenopathy, however, I am still unsure and I do not think I will be sure until I have done another thousand physical exams. Overall, I believe I have became every efficient with my physical exams. There are still areas that I want to improve on, such as adding in a quick neuro exam while doing a physical exam, but I guess that would be more helpful when I pick a specialty to advance into.

As for procedures, I had the opportunity to preform plenty of EKG’s. During my family medicine rotation, I had preformed two or three EKG’s and there was always someone supervising me, but during my ambulatory care rotation, I was given the chance to preform the procedures on my own. The first time I did an EKG on a patient at this practice, I placed the lower extremity leads on the lower abdominal area, and I palpated the patient’s chest so much in order to obtain a normal EKG. I had a difficult time putting in the patient’s information, and in general, I do not think that I did a good job. When I saw the EKG print out, I was not satisfied with the results either. I spoke to one of the medical assistants that worked at the clinic, and she had showed me how she performed EKG’s on patients. It was surprisingly different from what was taught to us in school. It seemed like the medical assistant was eye balling where the first two leads would be placed, and then from there, she placed the last four leads below the left breast in a line, going across. This seemed much easier, faster, and a lot less uncomfortable for the patient, considering that I did not have to constantly palpate the patient chest for their intercostal space. From then on, I decide if the patient was a female, I would palpate for her fourth intercostal space for leads V1 and V2, and for the rest, I would place the leads under the left breast, as I was taught. If the patient was a male, I would try to place the leads as close as possible to the textbook method of lead placement, especially because most men do not have excessive breast tissue. After we would done printing out the EKG results, we would take the results to the doctor, who would either approve of the EKG or tell us to preform another one. After I was taught how the EKG was done in the office the first time, I never had to redo another EKG again. One issue I believe that I have with EKG’s is patient gowning. This is not really an issue when it comes to men, but more of an issue when it comes to females. Even though I understand that when patients are in a gown, the opening should be in the back, but I always tell the patients to have the opening in the front, so everything could be exposed properly. I do not believe that the patients felt uncomfortable while the exam was being done, especially because it would be done in a private room, but I can see this being a problem in a busy emergency room, where there is lack of privacy. I would say that overall, I have became more confident in performing EKG’s, I would still like to master the art of handling a gown while performing procedures.

One of the exams that I had to become very proficient in was the breast exam. This was the first time, I believe, that I had to preform breast exams, all throughout my rotations. I had not received an opportunity like this before, so I obviously embraced it. I was taught how to preform a proper breast exam one time and then I was able to preform them on my own. One of the things I noticed about myself was that if I had the mammogram/sonogram results of a patient in front of me, and it showed that a patient had a mass on imaging, I believe that I would try much harder to find that mass on physical exam, even though there is nothing that could be visualized or palpated. I guess it was a psychological aspect, that I felt like I needed to palpate something in order to satisfy me. This obviously was not the case, because all of the breast exams that I had performed, were all normal. I wanted to make sure that I did not miss any findings, but now that I think back, I would have been better off not knowing any results, making my breast exam non-bias. Even though we have learned how to preform breast exams in school, preforming them in person, on an actual patient, is much different. You start to realize the consequences that could occur if you miss something as a practitioner, which provides motivation to work harder not to miss anything. The most interesting breast exam that I had preformed was on a patient that had a bilateral mastectomy, and both of her nipples were excised. It was somewhat difficult to write the findings on this patient, just because there were so many scars from so many different surgeries. Something that I learned about when preforming breast exams was that it is always a good opportunity to inform the patient about self-breast exams. This is also a great time to ask the patient if they have any family members that have had breast cancer in the past, because there are many times patients do not remember when asking about past family history, and all of a sudden they remember when they are having a breast exam done. I would inform the patient that even though it is not necessary for them to preform breast exams on themselves, it is very important that they become familiar with their breast, knowing what is normal and what is abnormal for them. I am grateful that I had this chance to preform so many breast exams, and I hope the skills that I learned will come in handy one day.

One of the biggest issues that I had coming into this rotation was time. When I think of ambulatory care, I think of urgent care, but that is not what I saw when I first arrived to the clinic, and I believe it was for the best. I think I take way too much time with patients and I am not really sure why. I know that part of it has to do with the fact that I am just a slow person overall. I am slow at understanding certain things, I am slow at social ques, jokes, explaining things, and so on. So I know that there is an element of indolence to the equation, but I do not believe that’s the whole story. I believe my issue is that I can not settle for an incomplete job. I think that is just my personality, it is very rare that I turn in something that is incomplete, or not up to par, which is different from not turning something in at all, which I have done. For example, when we are interviewing a patient, we have to ask them if they are still following up with their specialist, whether it is an endocrinologist, nephrologist, urologist, cardiologist, pulmonologist, and so on. A lot of the times that patient will say, “Yes. I do”. Even though that response itself satisfies the criteria of the form that needs to be filled out, it does not satisfy me. So what I will do is further question them when the last appointment was, or if they have an upcoming scheduled appointment. If the patients states that they do not follow up with the specialist anymore, I will ask them why they do not. Even though none of these questions are required of me, I still feel obligated to ask the patient because there always has to be a reason. Sometimes, the reason is because they cannot afford the co-pays, which is very legitimate. Sometimes the patients would become very aggravated that I am spending so much time with them, they would just want to see the doctor and leave, but many of the patients were very appreciative of my services, and would often compliment how thorough I was when questioning them. I hate to brag, but sometimes compliments like these would be the only thing that would help me feel a little bit better about spending so much time with the patients, because more than half the times, I would feel horrible knowing that I spent half an hour with a patient, while there are ten more patients lined up outside. I have realized through this experience that I probably would function best in an internal medicine specialty within a hospital because I know that my patients are not going anywhere, and they don’t need to be anywhere else. I could spend as much time as I need with them without feeling guilty.

Overall, I believe that this rotation has really helped me to become more confident in my exams. Even though I was unable to diagnose or provide treatment, I was still able to develop a rapport with the patient, which is always a goal that I like to accomplish. I am very grateful for the supportive staff whom were very helpful in answering any questions that I had and also helped me to advance my medical knowledge. I had a great time at Dr. Difranco;s office and I hope that I will be able to provide great care like he does.

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