Reflection: Family Medicine Rotation
Family medicine proved to be one of the most unique and challenging rotations of the clinical year. The setting I found myself in provided plenty of opportunity to function as a provider and work with patients very independently. That being said, there was of course appropriate oversight for each patient seen, but being permitted extensive time alone with patients was somewhat unique to this rotation. My other clinical sites, such as long-term care, allowed for plenty of direct patient interactions, but in family medicine there was that special scenario of having a patient present with you from the moment you introduce yourself to the outlining of a plan for treatment or management. Additionally, there were often chances to improve on practical skills such as blood draws and ECG.
Drawing blood has always been a challenge, to the point I’ve felt more comfortable drawing an ABG or suturing than a simple blood draw, but there were many chances to work on this in family medicine and I feel I made a lot of progress. The medical assistant on hand was very skilled in this area and was kind enough to offer plenty of advice, tips, and demonstrations for improvement. Additionally, there were numerous times that patients were in need of an ECG and proper placement of pads could be worked on. On top of this, I was able to take a first glance at the print out and assess for any immediate threats that were present before going over the results with the doctor.
There were a few challenges unique to my rotation in family medicine. The first, and most challenging to me personally, would be getting acquainted with the EMR software. I found this to be especially challenging when combined with the sheer volume of patients and attempts to be expeditious while fumbling through unfamiliar software. On top of this, there were often very little indicators in the chart for exactly what reason the patient was there that day, with patient’s themselves not always sure exactly why they were called in that day. This was an opportunity to really hone that ‘detective work’ skill where I’d often have to judge from their last visits note (or most recent lab work, recently received diagnostic imaging or hospital discharge summaries) why they were there that day. Patients often required quite a bit of counseling on their health conditions as well, with some having very little understanding of their immediate or even chronic health issues. This was a great chance to work on the skill of boiling down information to a form that a patient can easily understand while attempting to inspire them to take the steps needed to best manage their health. I really got to enjoy seeing patients (some multiple times during these last 5 weeks) and this time I was allowed to spend with them independently helped make this one of my favorite rotations of clinical year.
Journal Article With Summary
The article I chose was entitled “Reduction in HbA1c Using Professional Flash Glucose Monitoring in Insulin-treated Type 2 Diabetes Patients Managed in Primary and Secondary Care Settings” published in the journal Diabetes and Vascular Disease Research in July of 2019. The study was a multicenter, pilot randomized controlled trial conducted at 18 primary healthcare centers and 5 secondary care centers with a total of 175 participants between April 2015 and October 2015. According to the study, this is the first randomized control trial that has investigated the efficacy of flash glucose monitoring devices such as the Libre Pro in type 2 diabetes mellitus patients.
In this study they used several devices, including the Libre Pro. I found this study to be especially pertinent for this reason, as my patient had been using this exact device. According to the study’s introduction, these devices require no intervention from the patient and are worn for 14 days at a time, storing data on patients’ blood glucose every 15 minutes. Patient’s included in the study had A1C in a range of 7.5-12. When compared to control, they found no difference in the ‘time in range’ or “TIR”, meaning duration of time within an acceptable range of serum glucose. A1C, however, was found to be reduced in those with devices when compared to control, and hyperglycemia time was reduced, although this was determined to not be statistically significant. Overall, the treatment satisfaction was increased in device group when compared to control. There were only 2 mild adverse events possibly related to the sensor, consisting of superficial thrombophlebitis and itching/rash all of which resolved spontaneously.
The study concluded that the use of such devices was associated with a statistically significant reduction in A1C and an improvement in treatment satisfaction among patients using these devices. That being said, there was no significant effect on time in range or in reduction of hypo- or hyperglycemia. Considering the excellent safety profile and the aforementioned results, the devices seem to be a great option for patients who are interested. Patient’s seemed to be quite happy with their Libre devices in my experiences on this family medicine rotation.
Site Evaluation Summary
I had site evaluations with PA Sadat, who I also had during my ambulatory care rotation. PA Sadat provided plenty of opportunity for discussion of our patient H&Ps and related journal selections that were very engaging and informative. My first H&P involved a 79 year old male patient with a history of hypertension, chronic kidney disease, and type 2 diabetes presenting with symptoms of heart failure. As a group we thoroughly discussed the various methods of diagnosing heart failure in such a patient and evaluated what value chest radiographs may have when addressing such scenarios. My second H&P involved a 62 year old male patient with a history of hypertension, hyperlipidemia, and type 2 diabetes presenting for follow up after 3 vessel CABG procedure. From this H&P came a discussion on counseling patients when it comes to significant events such as this, especially when they are known to relapse in their control over chronic health conditions. My third H&P involved a patient with past medical history of hypertension, hyperlipidemia, and diabetes for follow up 10 days after visit to the ED for chest pain with a new diagnosis of stable angina. Through in depth discussion and a very open format I found these site evaluations to be especially thought provoking and engaging.
