My fifth rotation was spent at Sophia Streete-Smalls Family Medicine office.  Dr. Streete-Smalls is a wonderful provider with a strong clinical background who I felt fortunate to have the opportunity to work with for this rotation.  I was not sure what to expect ahead of starting Family Medicine and I feel Dr. Streete-Smalls helped to shape this 5-weeks into an incredible rotation.  As she runs a private family medicine practice, Dr. Streete-Smalls sees patients from birth through end of life.  I quickly informed Dr. Streete-Smalls that I enjoy treating the pediatric population and she ensured that I had opportunities to see and treat this group when they come in for evaluation.

From the first day, the expectation was that I would see patients, write the medical note in the EMR, formulate a plan and present the case to Dr. Streete-Smalls.  More than any other rotation thus far, my scribe background was very helpful.  I worked to familiarize myself with the EMR that first day to ensure I had a sound understanding of how to use it efficiently and effectively.  I decided during my first week, instead of taking hand written notes and transcribing the note later on, I would type directly into the EMR and edit as needed between patients.  In this system there were no templates for the HPI so knowing your associated review of systems for each complaint was very important.  With each week, I felt I improved at refining that list and formulating it in a way that helped highlight the true presenting illness and associated symptoms.  I want to continue to work on providing all of the relevant information for the HPI but shortening it to highlight the key factors that help to yield a diagnosis. In hospital settings, I felt like my notes were shorter but in a Family Medicine office, I thought the context was helpful.  That said, I need to ensure my notes are concise and to the point while ensuring all pertinent information is included.

For the most part, I felt as though my HPIs were longer than I would have liked to have seen them.  However, for a majority of my patients it was my first time seeing them and having that context is helpful to ensure nothing is missed.  Additionally, because it was my first time seeing most of the patients over the course of the five weeks, I felt as though patients told me ‘complaints’ that were more chronic in nature, that if it had been Dr. Streete-Smalls, they wouldn’t have shared.  This was challenging for me because I didn’t want to belittle a complaint and I didn’t want to miss a diagnosis but simultaneously had to ensure the chief complaint was addressed.  I felt comfortable with Dr. Streete-Smalls to have this conversation and confirmed with her this was the approach she wanted me to take when seeing her patients.  That said, I will definitely be more aware of this as I move throughout my rotations to ensure I am using the skills I’ve acquired and applying them appropriately.

I felt this rotation was very helpful for me to define and hone my physical exam skills.  I completed many annual physicals during my five week rotation with Dr. Streete-Smalls and often discussed with her the importance of a good physical exam.  A few times I was able to catch a murmur and hear certain lung sounds that I would not have been able to pick up a few months ago.  I also worked on my ability to describe skin rashes.  I saw a collection of different skin rashes that ranged from viral xanthems to pityriasis rosea and it was important for me to be able to document them appropriately.  Documentation of rashes is something I will continue to work on as I move into my ambulatory care rotation.  I am sure I will continue to see rashes in an Urgent Care setting and this type of documentation is important for me to master.

During this rotation, I was also able to do patient counseling from things ranging to diet modification, the importance of exercise, STD counseling and walked another patient through the menstrual cycle and how to understand ovulation.  Not only did I see well-visit patients, I saw patients who came in for sick visits.  Several times, these patients required the “special tests” we’d learned during PD class and it was a great way to see what’d we’d learned in the classroom apply to the clinical setting. Additionally, Dr. Streete-Smalls encouraged me to familiarize myself with the immunization schedule in their EMR and to write for vaccines whenever a child I saw required one.  I had to order the vaccine in the system and in her office only providers give the shot, which she allowed me to do.  I found that there were several times where a patient had missed a round of vaccines and we had to give those vaccines in addition to the one they were due for otherwise.  This wasn’t always enjoyable for the child (or me) but my approach is these vaccines help protect the child and they’re necessary to be given on the schedule.

I was only faced with one patient who refused to see me during this rotation.  It was challenging because she was asking to be ‘squeezed in’ to the schedule and was assigned to me.  If I am going to put something in my medical note, I am going to confirm it with the patient and she did not appreciate all of the questions I asked (i.e. past medical, social and family history).  Ultimately she refused to answer any questions so I excused myself from the room and let Dr. Streete-Smalls know the patient requested to see her instead.  The patient has every right to do this and I know I will encounter more patients like this throughout my career and I have to continue to tell myself not to take it personally.

Dr. Streete-Smalls had me write for prescriptions as if I were sending them.  She, of course, reviewed them and sent them once approved but this task challenged me to understand how and what medications are used for different ailments and also the appropriate doses of each medication.  We also walked through pediatric dosing on several occasions to ensure I understood how to write those prescriptions as they are weight based and important to get completely accurate.  I was always sure to double check my prescriptions knowing the side-effects that any medication can have on an individual but also the drug-drug reactions that can occur if you’re not careful.  This is something that I believe I will always be hyper-aware of in practice because harm can be done so easily if you’re not careful.

I really enjoyed myself over the last 5-weeks.  I built a great rapport not only with Dr. Streete-Smalls but the other Physician Assistants working in the office as well as the medical assistants and staff members.  I worked to engrain myself as a team member and to contribute positively every day.  As I move on to my Ambulatory rotation, I will use the physical exam skills I refined during this rotation and continue to build upon them to ensure I am providing the best level of patient care.

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