I saw this lady in clinic recently who had neck pain. She said, “I feel like something’s wrong with my neck veins. There’s something pulling in my neck.” I was fairly certain she just had a muscle strain, but I listened to her carotids to assuage her worries about her neck vasculature. I mean, she was in her 60s, was a smoker with hypertension, and was obese. That warranted an exam, I thought. Sure enough, in addition to her muscle strain, she had bruits over both carotids, although it was much louder on the left. (Bruits are like heart murmurs over blood vessels…they are a shwooshing sound you hear when blood flow is turbulent from narrowing arteries). Her only symptom that could be attributed to the bruit in any way was frequent headaches. I told the resident that I found the bruit, and she listened and agreed. She noted that there was no record of it in her chart before. We sent her for a carotid ultrasound just to assess the degree of stenosis in her carotids.
For my non-medical friends, if your carotids become too narrow, you end up cutting off blood flow to the brain and get a stroke. A lot of times there are no symptoms beforehand; sometimes people present with transient blindness, speech problems, or facial weakness.
Anyway, today I got the following text message from the resident I was working with last week:
"Remember the lady you saw in the office last week with the carotid bruit? I just got a stat page. She had her U/S today and it found 80% stenosis on the left and she is going to vascular surgery immediately today. You really may have saved her life! Good job! I’ll let you know how it goes."
So yay me. It’s amazing the good you can do just by doing a simple physical exam!
UPDATE: After the resident mentioned above graduated, this patient was assigned to me (because of this very encounter as a medical student). On my first visit with her as her PCP, we discussed her carotid disease. As it turned out, she had refused surgery in 2011 because she believed that her carotid stenosis was not a problem (and actually, we don’t recommend surgery for asymptomatic carotid stenosis). The resident who was her PCP at the time continually tried to push her to have surgery, but with no success, so she maximized her medication therapy, hoping it would be enough to slow the progression of her stenosis.
During our visit, I asked her about several specific stroke symptoms. After inquiring about episodes of blindness, she said, “yeah, actually I get this brown sheet that comes down over my eye and stays there for about an hour and then it goes away. That’s my cataracts, right?”
I explained to her that cataracts cause slow progression of blindness with haziness of the vision, not a “curtain pull” effect, and that these episodes were indeed caused by her carotid stenosis. I emphasized the fact that since these episodes were becoming more frequent, she would most likely become permanently blind or would have a larger, more debilitating stoke in the very near future.
She finally agreed to see a vascular surgeon, and now, just over 2 years after our initial encounter, she has had her endarterectomy! When I got the report from the surgeon, I had a little celebration at my desk. This is why persistence, continuity of care, and good follow up with a PCP matter.
I’m currently a medical student applying to family medicine programs this year and reading your stories, I know you’ll be a great family doc and I hope to be like that some day. But, right now I’ve been writing and re-writing and editing my personal statement for residency programs and it isn’t that great. Do you have any suggestions or tips on what would help make it a good personal statement for family programs? -anon
Family med programs are looking for applicants who:
So it helps to show that you have these qualities in your personal statement without listing them out like on your CV. You need to show how family medicine (and not some other specialty) fits your personality.
Remember that your reader is probably a residency director who is tired of reading personal statements, so don’t write a research paper.
Weave stories and examples throughout your writing. Many people will also somewhat tailor their personal statement to the programs they apply to. For example, if you apply to a program that is geriatrics-heavy, you might want to mention your interest in geriatrics more in the PS you send to them. The same would go for OB or sports medicine or global health or any other side interest within family medicine.
Ultimately, your goal in a personal statement is to make the reader want to know more about you—and therefore invite you for an interview. Leave some mystery in it, but give them a taste of how awesome you are ;).
"I’d blow my brains out if I had your job. Your job sucks. When someone refers a patient to me, it’s a compliment. When they refer to you, it’s an insult." -sentiment from a surgeon
I was a bit offended by this doc’s comment to me. I like my job, and for the most part, I like my patients. He didn’t mean it as an insult to me, though. It was meant to be more of an observation about the state of the medical system in this country.
He has a point. When a local primary care physician refers a patient to a surgeon or specialist, it’s because that specialist has a skill or expertise that the PCP doesn’t have.
- captainmudphud said: Gracias. I appreciate the info. I’m probably missing something, but why do y’all do a surgical rotation?
We do a surgery rotation to get more experience doing small procedures and to learn more of the care of the pre- and post- surgical patient. It also helps you get a better grasp of which patients need a surgery referral. Honestly, that’s why we do subspecialty rotations. You learn a little for your everyday practice, and then you learn how much you don’t know and what you should refer out.
How is a family medicine residency different from an internal medicine residency in terms of what services you rotate through? -captainmudphud
The main difference is that Family medicine is going to be more outpatient-focused and is going to probably have more variety in rotations. FM residencies are required to have continuity clinics where residents see the same patients over the course of their 3 years (adding more each year). I’m not sure if IM has this requirement.
For a breakdown of intern year schedules,
Sample Family Med intern year:
**I am aware that this adds up to 13 months. A rotation is 4 weeks, so it makes room for a 13th month.
As the years progress, you have less of the “core rotations” in family med (the first 3) and more elective time. Over the 3 years we are also required to do a month of surgical subspecialty, 2 months of medical subspecialties, almost 3 total months of sports med and ortho; 1 month of geriatrics, psych, and practice management; an extra month of ER and outpatient peds; and 2 months of “ambulatory med” which encompasses our general clinic and subspecialty clinics.
Sample Internal Med intern year (from 2 friends in different Medicine residencies)
My friend says her program requires them to do Pulm, ID, Nephro, Rheum, Geriatrics, Heme/Onc, Neuro, and Cards rotations, and the rest is up to them.
Friend #2 says she has 4 months general wards, 3 mo med subspecialties, 1 mo ICU, 1 mo ICU stepdown, 1 mo ER, 2 clinic months (1 residency clinic, 1 VA), 1 mo geriatrics. Her program offers a “primary care track” that requires more outpatient blocks.
If we’re talking general adult medicine, then the most common things I see are:
Yesterday I felt like an old timey family doctor. I had morning clinic, and then my afternoon clinic got cancelled by some stroke of luck.
I could have gone home and spent the afternoon doing worthwhile things like reading or yardwork.
But instead I went on a home visit (aka “house call”) to my most complicated patient’s house. It turned out really well, and I learned that he was actually in much better shape than I had perceived him to be. After the home visit I went to the hospital. I had 2 patients admitted from clinic that morning—one in the ICU and one on the floor—so I went to check on them.
Meanwhile in the background of all of this I had a continuity OB patient in labor who I was checking in on every 3 hours or so. At the end of the official work day, I went to a meeting at the Free Clinic, and then back to the hospital to deliver the baby, at which point I became covered in fluid and meconium, but that’s a story for tomorrow… Also, I was supposed to go to the nursing home as well, but I didn’t make it (because meconium).
Anywho, I wish every day was sort of like that. Yeah, it’s hectic, and I don’t technically see as many patients, but I feel like I take better care of people that way. As soon as I got to one place, I needed to go somewhere else.
I wish we didn’t have to worry so much about paperwork, insurance, and legal issues and could just see patients. Those would be good days for sure.
What are your favorite and least favorite parts of family medicine? ars-scientiaque
aconn51 asked:assuming I get into medical school, I’m interested in going into primary care with a focus on women’s health or do ob/gyn while also doing a full range of primary care for female patients. Any insight as to the best way to go about doing that? Would I need to do an internal med/ family med residency and then just focus on female patients? or is this something where I would need to do a dual/combined residency (does such a thing even exist?). Anything you can offer would be super helpful!
If you did internal med, you wouldn’t be able to do the OB/GYN care. If you just did OB/GYN, you wouldn’t be able to manage all their other conditions (ya know, since ladies are more than boobs and uteruses).
So…shameless plug, family sounds like the way to go. No dual-residency required. Female-only practices are a thing now (my mom and sister actually go to a combined Family Med /OB practice that only sees females aged 12 and up) and are growing in popularity. Actually even now in residency I see a lot more females than males.
My grandmother, about my grandfather.
Sometimes your patients’ complaints are voiced just to make themselves feel better. They’re not always a request for medication.