I had the amazing opportunity to rotate at Amazing Medical Services, a practice owned by Dr. Dairo, an intelligent family practice physician who also cared deeply about her patients. Coming from a background of internal medicine, I had a rough idea about how wide my differential had to be for me to provide the best care, however, internal medicine in the hospital is very different from internal medicine at a family practice facility. I felt that in family practice, the patient really needed to build a rapport in order to feel comfortable to provide information to the practitioner, whether that was me or Dr.Dairo. I also think that the practitioner to patient relationship was much more personal than it would be if the patient was in the hospital. For example, in the hospital, the primary goal is to get the patient stabilized and discharge them as soon as possible, and it is not relevant to attend to the patient’s complaints that require chronic care. However, in a family practice setting, it was very important to ask the patient about even the smallest of symptoms, and if they were positive, we would make sure to address them. This was also the area where chronic care is the main point of focus and patients should be monitored closely for any chronic diseases. As for the patients that came to the practice, it was different because all of my previous rotations had patients that were either too old, too young, or too sick to speak for themselves. The patients that I saw at the facility were healthy and age-appropriate enough to speak for themselves and provide an accurate medical history, something that is very important to me. The patients were very nice and willing to let me examine them if needed. The facility was very sweet and open to any questions or concerns that I had, and overall, I learned a lot from my site.

I biggest obstacle, hands down, was learning how to use the EMR. Out of everything that I encountered, the EMR was my worst enemy. The EMR that was used was called eClincialWorks. I have never worked with this EMR before and it was just so difficult to get used to. I had previously worked with EPIC, which was extremely easy to get used to, so switching to eClinicalworks was very difficult and different. In addition to that, my preceptor advised me to use the templates, but with extreme caution, something that I am very weak in. Almost every H&P that was templated by me, had some form of information that was either incorrect or incomplete because of the templates. It was pretty embarrassing because my preceptor would bring it to my attention every time, and I just could not figure out why I could not be more careful when using templates. On top of all this, eClinicalworks was transitioning into a new version, meaning sometimes I would be using e10 (the old version) and sometimes I would be using e11 ( the new version), both versions were 80% similar, but had many differences. I had to learn how to use both of these versions, and to be honest, I believe my first three weeks were spent trying to perfect the use of eClinicalworks. The best advise that I could give to my fellow classmate that will arrive to Amazing Medical Services after me would be, spend the first week trying to learn the EMR inside out, don’t be shy to ask for help, and when someone is helping you out, make sure you ask them to let you be hands on, because it is very easy to forget pathways if someone else is doing them for you. The staff was very helpful in guiding me on how to use the EMR and they understood my struggle, because they were also trying to adjust to the transition. This situation has taught me that the EMR could either be your best friend if used appropriately, or it can get you into a lot of trouble if not taken seriously. From now on, I know to triple check my work before signing off on anything, especially when using templates.

As for procedures, I got to preform many blood draws, but unfortunately, it was more towards the last two weeks of my rotation. When I first started my family practice rotation, I was a nervous mess. I think I was more hesitant to perform blood draws because of one main reason. All the previous rotations I had before consisted of patients that were either too sick to react, or the parents of the patient did not want me to stick their child, understandably. When I saw that these patients were relatively healthy and aware of what was going on, especially them knowing that I am a student, I became even more nervous. All I kept thinking was that, I don’t want to hurt the patient unnecessarily, especially if there is someone more experienced to do the job. However, as I became more comfortable with the staff, my surroundings, and my patients, if I saw a patient that had obvious good veins, I would perform blood draws. The very first blood draw I performed was miserable, and it was all my fault because I was not prepared. I did not set up the needed material and everything was distant from me. Thankfully, the medical assistant was in the room and she helped me. But after that first experience, I made sure that everything was less than a foot away from me, so I can reach it in a hurry. I learned that it is not always about seeing the vein, but a lot of the times, you are able to get plenty of blood from a vein that is palpable. Surprisingly, many of the patients knew that they had a good palpable vein and they would direct me to where they wanted to be pricked. I became quicker, more confident, and better at preforming blood draws, and towards the end of the rotation, I was very comfortable with blood draws and wanted to perform them all the time. From this experience, I learned that if I do not see or feel a vein, I should ask for help before pricking the patient. I learned how important it is to have all the material needed out in front of you BEFORE sticking the patient and I learned that I should not be so afraid of causing the patient minor pain, as long as I know what I am doing. Overall, I think I have made improvement from the first rotation that I encountered.

In regard to physical examination, I have learned to make sure to examine the patients skin very carefully. During the second week of my rotation, a man presented with a complaint of a rash that was itchy and on his back. I asked the man to show the rash and he pulled up his shirt a little, but I was not able to see the rash much. I saw a little bump that was some what erythematous, but I would not call it a rash. I documented my findings on the EMR, and I went to consult my preceptor about it. I told the preceptor the history and my findings, letting her know that I did not really see a rash. The preceptor went to evaluate the patient herself, during that time I was finishing up some notes. All of a sudden, I hear my preceptor calling my name and she was pretty upset. When I arrived into the room, the patient’s shirt was completely off, there was a light that was directed towards the patient’s back and the rash was clear as day. My preceptor questioned me as to why I had not asked the patient to remove his shirt, and to be honest, I did not want the patient to feel uncomfortable. It was wrong of me to assume that the patient would be uncomfortable removing his shirt, especially because I did not ask. I understood why my preceptor was upset, and it is because when I described the patient, the treatment was completely different from what the actual treatment was. If my preceptor had trusted my perception, that patient would have been prescribed the wrong drug, and it could have made his rash and symptoms much worse. I learned from this experience that when it comes to rashes, the entire area, no matter where the rash is, needs to be properly exposed and there needs to be good lighting directed towards the patient. I learned that it is okay to ask patients to remove some clothing so they can be better examined and treated. I promised myself from that moment on that if a patient came to me with a rash, I would make sure that I would do everything I can to have an accurate perception of the rash or any other compliant, for that matter.

One of the traits in my personality is that I am very “easy-going”. I don’t ever force anyone to do anything, nor do I push them to do it. Instead, I give people a variety of options, I give them my opinion, as to what I think is the best, and I give them their choice. This concept also applies to patients, and I feel as though it is not always the best way of handling situations. Many patients come to family practice for chronic care and if these patients do not take their medications or are unwilling to make changes in their lives, these chronic diseases can turn detrimental. The reason why I say this is because there were many patients that I encountered that had elevated levels of some test, and they should have either started a medication or they should have increased the dosage of their already existing medication. A majority of patients were very willing to increase their dosage of medication or start a new medication. There were some patients that completely refused to start any knew medications or increase the dosages, because they were already suffering from side effects and did not want to deal with anymore happening with them, understandably. But then, there are those patients that keep saying that they are willing to make lifestyle modifications, and do not want to take a medicine for the rest of their lives. For example, there was a patient that I had seen for elevated A1C and lipid panel. She was in her late 50’s and was not taking any medication. My preceptor has told me that this patient needed to be started on statins because she has had elevated lipids for a while. However, when I spoke to the patient about her abnormal labs, she was very adamant about not starting medications and she kept saying that she will cut everything bad out of her diet. This was my first time seeing this patient, and maybe because of that reason, I was willing to accept her proposal of life style modifications, but after the patient left, I realized that not pushing the patient to start statins was not the right thing to do. I should have at least reasoned with her to start, given her a week’s supply of statin and see how she complies. But I did not. I just accepted that the patient did not want to start medication without encouraging her at all. I learned from this experience that sometimes the practitioner has to encourage the patient to try things that they are unwilling to do, for the patient’s best interest. I know this is an ongoing issue with me, because I remember Professor Herel pointing it out during my patient interviewing assessment with him. I hope that as I keep practicing, I become firm in my treatment plans, pushing patients to take care of themselves in the best way they can.

As for myself, I realized something that I did not know was there. Even though I have always been interested in a fast pace practice, such as urgent care or emergency room, I do not apply that interest when it comes to my patients. I found myself spending an extensive amount of time with patients that I thought needed it and I really liked to get to know the patient. I liked to hear the patient’s story, of whatever happened to them that brought them to the clinic, when all the symptoms started, when they had any imaging done, and anything that was relevant to their case. Even though my preceptor did want me to hurry up, she always said that I wrote good HPI’s because they I provided much detail about the patient’s current complaints. I honestly did not mind sitting there for 30 minutes and listening to the patient, and I know the patient would appreciate it too because they would always give a compliment about me to my preceptor on how much patience I have. But I really wanted to get to know the patient well before I made a diagnosis or plan because I believe that of the emotions and stressors the patient has in their live should reflect the treatment. With this being said, I was not sure how I would feel about working in a Family Practice. I liked seeing patients being satisfied with me, but at the same time, I kind of did not want to see them again. Does that make me a horrible person? I’m not sure, but that is why I think I would work best in an emergency setting. I like treating the patient to the best of my abilities and then I hope I never have to see them again, not because I don’t like the patient, but because I do not want the patient to get sick again. At the end of the day, I am still confused as to what specialty I want to pursue, but I know that I want it to be where I can really sit down and listen to the patients concerns and treat them with the utmost care. Whether that is in family medicine, the emergency room, or maybe even psych, I hope to achieve satisfaction in my professional career by improving the lives of others.

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