PLACE: The Family Practice Centers of the Maine-Dartmouth Family Practice Residency
l5 East Chestnut St., Augusta, Maine and 4 Sheridan Dr., Fairfield, Maine
as well as both in-patient campuses and affiliated nursing homes of the MaineGeneral Medical Center in Waterville and Augusta, Maine.
DURATION: 4-8 weeks
PREREQUISITES: Two years of medical school plus at least one major clinical rotation
ROOM/BOARD: Five bedroom, lakeside, furnished house in Belgrade Lakes, Maine, with waterfront, full kitchen, washer/dryer. Heat, lights, and local telephone service are provided. Students supply their own linens. Meals are also available at both the Augusta and Waterville campuses of the MaineGeneral Medical Center at reduced rates. Noon meals during educational conferences are provided.
CONFERENCES
Four 45 min family practice noon conferences each week, transmitted to all sites via interactive television systems.
Three 45 min end of the practice day conference weekly at each Family Practice Center with discussion of ambulatory patients seen that day. Faculty, residents, medical students and ancillary staff share in lively and informal discussions of medical, psychosocial, ethical and practice management issues of primary care.
Weekly Tuesday afternoon conferences for more extensive discussion and/or medical technique practice.
EVALUATION
Students will be evaluated by resident and faculty preceptors regarding specific patient encounters. Faculty, residents and support staff will evaluate students' overall performance. Students will meet with faculty for brief formative evaluation sessions. Final evaluation of student performance will be synthesized from these elements. Students are also asked to evaluate their clerkship experience.
SUPERVISION
Faculty supervisors includes board certified family and other physicians, physician assistants, nurse practitioners, and a clinical psychologist. Significant teaching time is also provided by a number of board certified family physicians who are based in community practice settings, in many cases local rural health centers.
AVAILABLE ROTATIONS
FAMILY MEDICINE WITH OUTPATIENT EMPHASIS
Students are assigned to either the Fairfield or Augusta Family Practice center and see ambulatory patients 6-7 half days/week, both mornings and afternoons. The student may admit and care for, under the supervision of the Senior Practice Resident and faculty, any inpatients who come out of the student's practice during the month. A typical day: 7:30 a.m. sign out; office practice at FPC 8:30 to 12:00; conference/lunch 12:00 noon to 1:00 p.m., office practice 1:30 to 4:45; and ambulatory care conference 4:45 to 5:30 p.m.
One day/week the student will either join the rural health center practice of one of the residency's part-time family practice preceptors, or participate in some other relevant community practice experience (prenatal clinic, ER, family planning clinic, etc).
Students should also cultivate clinical research and evaluation skills, and are expected to do an investigation of some primary care topic like an audit of charts at the FPC, or a primary care research project. Supervision is provided by a fulltime PhD medical sociologist, together with clinical faculty.
Objectives:
a. Familiarize the student with the flavor, process, and content of ambulatory family practice.
b. Develop an understanding of the rationale and mechanics of providing preventive services.
c. Observe and begin to understand the role of the family physician in early detection screening programs and follow-up measures for high risk individuals.
d. Develop a familiarity with and a competence in the management of acute illnesses within a family practice. This competency includes satisfactory performance of a history and physical examination and appropriate diagnostic tests considering the cost, benefits and practicality of the same. He/she should learn the rationale of therapeutic measures and the general role of consultants and other community health services, including the hospital.
e. Develop an attitude towards and competency in the management of the chrononically ill patient and family within the community setting. This includes the history and physical, learning to write a good problem oriented record and to order the appropriate laboratory tests as indicated. Experience focuses both on medical care of chronically ill patients, as well as issues specific to the long-term management of chronically ill patients involving ancillary and community services. Examples of long-term issues include planning for follow-up care, rehabilitation services and the role of consultative and community health services such as home care nursing, physical therapy, and social service.
f. Observe and begin to understand the role of teaching and learning in an ambulatory care setting and the role of patient education in a family practice.
g. Observe and begin to understand the organization and delivery of medical care on an ambulatory basis. This will include how primary care physicians work together and cover each other's leisure time and each other's patients, the role and contribution of nurse practitioners, nurses, public health nurses, social workers, and office personnel; the use of the problem-oriented medical record in an ambulatory setting. In addition, the medical student will be exposed to the influence of fee-for-service on the doctor-patient relationship, the cost of medical care and the role of third party payors.
The specific areas which will be likely covered are perinatal care, immunization,family planning, including insertion of IUD's, postpartum care, care of the newborn,well child care, acute care for many common illnesses, such as otitis media, upper respiratory infections, pharyngitis, lower respiratory infections, gastrointestinal diseases, urinary tract infections, common gynecological problems; and chronic care of diseases such as hypertension, diabetes, alcoholism, heart disease, cancer; and, preventive medicine including routine physicals. There will be a significant number of behavioral problems encounters, both on an acute and chronic basis. There are occasional home and nursing home visits.
GERIATICS
Students will see patients in the mornings for routine and acute care at the local nursing homes under the supervision of the geriatric resident and faculty in geriatrics. One afternoon will be devoted to home visits, and one morning to work in a residency family practice center. Two afternoons a week will be spent with the Alzheimer Evaluation team and one afternoon working an ongoing research project. The student will do history and physicals on new admissions to nursing homes, approximately six per rotation.
Students should also cultivate clinical research and evaluation skills, and are expected to do an investigation of some primary care topic like an audit of charts at one of the family practice centers or nursing homes, or a primary care research project. Supervision is provided by a fulltime PhD medical sociologist, together with clinical faculty.
Objectives:
a. The medical student should understand the demographics, geographic distribution, living arrangements and family arrangements of the aging patient.
b. The medical student should understand the normal aging process and be familiar with the issues of retirement and bereavement.
c. He/she should be able to apply proper health maintenance and screening protocols in the geriatric age group.
d. He/she should understand the principles of geriatric rehabilitation. The medical student should be able to assess the disabled patient and begin to set rehabilitation goals with the patient.
e. He/she should be able to evaluate and come up with an outline of therapy for the patient with confusion and depression.
f. The medical student should realize that thyroid disease, infections, cardiovascular disease and acute abdomen pulmonary embolism, malignancy, drug addiction illness, as well as many other medical diseases have an altered presentation in the elderly.
g. The medical student should be able to recognize and treat specific genital and urinary problems of the elderly. These problems include urinary incontinence, sexual dysfunction, recurrent urinary tract infections.
h. He/she should begin to manage elderly patients with multiple problems, recognizing co-existing diseases and treatments may lead to difficult management problems and polypharmacy.
i. He/she should begin to prevent and treat accidents in the elderly. The medical student should be aware of common presentations of falls, motor vehicle accidents,burns, elderly abuse.
j. The medical student should maintain a level of interest in common complaints of the elderly, such as constipation, aches, pains, stiffness, memory loss, tremor, anorexia, weakness, sleep disorders and skin problems.
k. The medical student should begin to develop an appreciation for some of the ethics/legal problems in the field of geriatrics, namely the issue of cardiopulmonary resuscitation.
FAMILY MEDICINE SUBINTERNSHIP (4th yr or late 3rd yr students only)
Students will become a member of the FPC faculty and resident team which has prime responsibility for the practices' inpatients in the mornings and sees their continuity patients in the afternoon. They will care for 1-3 inpatients, and see a full panoply of outpatients in the afternoons. Students will take practice night call once a week with a senior resident and faculty member.
Comments from student evaluations:
How were you accepted by patients? "They made me welcome! It was great.....I saw family medicine practiced the way I hope to do it, with compassion and with rigorous attention to the recent literature."
Suggestions: "Sell this rotation...send info with comments and pics to students across the country. People will come and fall in love with the place."
Social life: "Fun...made great friends I'd like to spend more time with....loved resident dinners."
Would you recommend this subinternship to other students and why? Yes. "You get to be a Sub-I, not just a student. Good variety of patients, excellent teaching, and good relations with ancillary staff".
Ginger Ruddy, Baylor College of Medicine
Comments from student evaluations:
"Residents went out of their way to teach. Attendings were attentive, good teachers and supportive."
Did you benefit from the experience? "Yes, I did my first dictations of discharge summaries....the experience was valuable for getting a big picture view of a patient's experience in the hospital."
How will this experience influence your future career? "I feel even more strongly that I will pursue Family Medicine. I loved the variety of experience, eg. checking on a patient with r/o MI, going to the delivery of a baby, going to clinic to look at a rash. Fun stuff."
Assets: "Great people to work with (Docs, Nurses, Support),
I felt welcomed from the start. Great teaching.
Would you recommend this clerkship to other students? "Yes...there was a nice combination of simulating the intern experience with showing the benefits of living in this area."
Andrew Ashcroft, Dartmouth Medical School