• Clinical science

Family medicine clerkship

Family medicine overview

What is family medicine? [1]

  • Family medicine is a medical specialty within the branch of primary care that provides comprehensive and continuing care to patients of all ages and health conditions.
  • Family physicians often represent the first contact of medical care for their patients.
  • Training
  • Approximately 23% of medical office visits are with a family physician, which is more than with any other specialty. [1]
  • Visits to the family physician are particularly high in rural and underserved areas.

What does a family physician do? [2]

  • Family physicians manage a wide range of acute and chronic medical conditions and coordinate care for their patients with the appropriate sub-specialists when indicated.
  • In contrast to other primary care physicians, some family physicians will also provide prenatal care and delivery of babies.
  • Family physicians also play an instrumental role in preventative care, providing services such as:
    • Routine check-ups and health maintenance
    • Immunizations
    • Screening tests
    • Counseling on lifestyle (e.g., smoking cessation, diet), family planning, and sexual health
  • Use of guidelines
    • For screening tests, family physicians often rely on guidelines (especially those published by USPSTF) to ensure all patients receive age-appropriate screening. [3]
    • Treatments can reflect the recommendations of society guidelines such as those from the American Academy of Family Physicians. However, other specialty guidelines may also be consulted due to the diverse group of illnesses that are managed by family physicians.

Family medicine clerkship overview

Clerkship structure

  • The length of the clerkship varies from school to school, but is typically 5–6 weeks.
  • Rotations may take place in all settings:
    • Outpatient and ambulatory settings (most common)
    • Inpatient setting, including emergency and delivery

Clinical skills

  • Take comprehensive histories
  • Perform physical examinations
  • Present patient cases and write notes
  • Work efficiently to handle a great number of patients within a limited timeframe

Daily schedule

  • 08:00–09:00 a.m.: arrive at the outpatient office whenever your preceptor’s first patient is scheduled to arrive
  • 09:00 a.m.–noon: see patients either by yourself or with your preceptor
  • Noon–01:00 p.m: lunch break and noon conferences
  • 01:00–05:00 p.m.: see more patients or go to afternoon lectures

Evaluation and grading

  • Varies among institutions but usually is pass/fail, and (typically) also high pass and honors. It consists of:
    • Clinical grade
    • Examination (usually shelf exam)
    • Possibly other assignments.

AMBOSS study plan

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including family medicine: https://go.amboss.com/family-medicine [4]

Clinical tasks

Objectives

  • After the family medicine clerkship, students should be able to:
    • Take a full patient history and conduct a physical examination for patients with acute and chronic diseases as expected to be seen by family physicians
    • Present outpatient cases
    • Interpret laboratory values and other test results (e.g., ECG, imaging) in the context of common diseases
    • Develop treatment plans and discuss these with patients and their families
  • Furthermore, students should have:
    • Scientific and clinical knowledge of common acute and chronic diseases in family medicine as well as preventive measures
    • Communication skills to engage professionally in conversations with patients and their families as well as colleagues and other house staff
    • Strategies for self-assessments and self-directed learning in order to recognize knowledge gaps and consult reliable resources

Pre-rounding

Rounding

Writing notes

  • It is beneficial to follow the SOAP (Subjective, Objective, Assessment, Plan) method for writing notes.
  • Ask your attending and resident for preferred note format (e.g., create a medical student note (for practice) or a note to be signed by attending and used in the patient chart).
  • Create your own templates for future notes to save time.
  • See “Writing patient notes” in the “Clerkship guide” article for more information.

Presenting patients

  • In family medicine, the presentation format and what needs to be included is highly dependent on your preceptor. Try to gauge their expectations on your first day.
  • The SOAP method is generally recommended for patient presentations.
  • Usually, presentations in the outpatient setting will only be a few minutes long. However, newly admitted patients require a longer presentation with a complete history and physical examination.
  • Prepare an outline of the presentation immediately after seeing a patient.
  • See “Presenting patients” in the “Clerkship guide” article for more information.

Placing tentative orders

Attending meetings and conferences

  • Typically, there will be a few student-specific lectures per week. It can be helpful to open AMBOSS and cross-reference the material discussed during the lectures.
  • You will also have to attend conferences and workshops.
  • See “Attending meetings and conferences” in the “Clerkship guide” article for more information.

Outpatient tasks

General considerations

  • Know the workflow: Knowing how things are run at your clinic will help you plan your day efficiently and contribute better to the team. At the beginning of every day, you should ask yourself:
    • Will I be seeing the patients before the attending?
    • Will I be taking turns seeing patients with fellow students?
  • Keep organized
    • If you know which patients you will see during the day:
      • Spend time reviewing all patient charts in the morning or on the day before.
      • Write down a few important points about each patient.
    • If you do not know which patients you will be seeing at the beginning of your day, try to spend at least a few minutes reviewing the patient chart before the visit.
    • Use AMBOSS articles to review symptoms and diseases that you will see.

Preparing for a patient visit

  • Review the chart or electronic health record of the patient that you are going to see.
  • Review the patient’s most recent clinic note, so that you are up to date on their most recent medical history (e.g., the reason for their last visit, treatments provided)
  • In addition, check for:
    • The most recent lab work
    • Current medications and other treatments
    • Other clinics visited by the patient
  • Try to get an overview of the patient's past medical history and current health concerns.
  • If you are required to write a note for each patient, start drafting the note before seeing the patient.
  • Example: “This is a 55-year old man with a history of coronary artery disease and congestive heart failure last seen 3 months ago. The patient was referred to a cardiologist due to abnormal echocardiographic findings. He has since been seen by a cardiologist and received a diagnostic angiogram. Today, he is here for a scheduled 3-month follow-up visit and to repeat lab work including CBC and BMP.”

As a primary care physician, you do not only want to treat a specific issue but also keep track of all of your patient’s health conditions as well as the treatments they are receiving from other providers.

Seeing clinic patients

  • Ask your attending how much time you should take to see each patient.
  • Ask your patients if they mind you taking notes during the interview.
    • If they say it’s okay, pull up the patient's chart and add your note to it while you're interviewing the patient.
    • It is important that you maintain frequent eye contact with your patient and engage in the conversation while taking notes.
  • Organize your patient's visit by prioritizing current problems and addressing one concern at a time.
    • Decide which concerns you will address during this clinic visit.
    • Move through each concern systematically.
    • Get a detailed history on each concern (see medical history article for more information).
  • Develop a differential diagnosis.
  • Move on to the next concern and repeat the steps above.
  • Then, perform a physical examination focusing on the chief concern (see the physical examination article for more information).
  • Reevaluate your differential diagnoses.
  • Consider additional testing (e.g., ECG, lab work, imaging).
  • Counseling and treatment plan
    • As a new third-year medical student, it is okay not to address the assessment and plan during your visit.
    • Tell your patient that you will discuss the findings with your attending and that you both will come back to address further management.

Presenting patients in the outpatient setting

  • Use your notes: You will already have a brief summary documenting the patient’s last clinic visit, their progress since the last visit, and why they are here to see you today.
  • Structure
    • Start your presentation with a chief concern followed by your summary.
    • Go through each problem systematically.
    • Describe the patient's physical exam starting with vitals followed by the relevant positive and negative findings.
  • Conclude your presentation
    • Give a brief assessment and plan regarding today’s encounter.
    • A problem list based assessment and plan is a commonly used structure.
  • Example: If a patient has abdominal pain and has a history of coronary artery disease and congestive heart failure, start with subjective symptoms, history, and review of systems. Continue with the objective symptoms and findings observed in physical examination, imaging, and lab results. Present your assessment and plan by starting with your differential diagnosis regarding abdominal pain and what treatment you would provide before moving on to chronic issues such as coronary artery disease. Discuss any medication the patient is already on, any new treatments since the last visit, and any changes you would propose.

Clinical skills (H&P)

Being able to take a thorough medical history and to perform a comprehensive physical examination are key when working in family medicine.

Appropriate professional conduct

See "Appropriate professional conduct" in the “Clerkship guide” article for more information.

Top 10 family medicine topics

  1. Diabetes mellitus
  2. Hypertension
  3. Congestive heart failure
  4. Pneumonia
  5. Asthma
  6. Chronic obstructive pulmonary disease
  7. Breast cancer
  8. Anemia
  9. Overview of antibiotic therapy
  10. The menstrual cycle and menstrual cycle abnormalities

Evaluation and grading

General

  • Your grade in family medicine will likely be determined foremost by the evaluations you receive from your preceptors.
  • Other components can be your shelf exam results and graded assignments.
  • See “Your grade and evaluation” in the “Clerkship guide” article for more information.

Top tips to impress your preceptors

General tips

  • Get a head start to read up on common topics in family medicine (see “Top 10 family medicine topics” above).
  • Stick to a predictable schedule to minimize stress.
    • The family medicine rotation typically has a fairly predictable schedule already (9:00 a.m.5:00 p.m.), which facilitates things in comparison to other rotations.
    • Familiarize yourself with diseases and symptoms that you might see the next day by reading relevant AMBOSS articles.
  • Utilize your time effectively
    • Try to use your time in-between patient visits to read up on your patient's conditions.
    • Keep in mind that studying during the work day will decrease the amount of work you will have to do once you arrive home.

Preparing for attending questioning (sometimes referred to as “pimping”)

  • Quickly skim the AMBOSS articles on the condition you think the patient is most likely to have before meeting your preceptor to present the patient.
  • Take the time you need to prepare and rehearse a concise and well-structured presentation, but don't get hung up on details.
  • Top tips:
    • Study your patients.
    • Pay attention to questions.
    • Begin your shelf studies early.
  • See “Clinical evaluation: how to impress your preceptors” in the “Clerkship guide” to learn more about preparing for attending questions.

The shelf exam [5]

  • For more information about the shelf exam, see the “Clerkship guide” article.
  • The general topics and systems you should thoroughly study for your family medicine shelf exam are:
    • General principles, including normal age-related findings and care of the well patient (5–10%)
    • Cardiovascular, respiratory, GI, endocrine, and musculoskeletal systems (5–10% each)
    • Behavioral health and social sciences (5–10% each)
    • Skin and subcutaneous tissue (3–7%)
    • Other systems (immune, blood and lymphoreticular, nervous, renal and urinary, female reproductive and breast, male reproductive; 1–5% each)
    • Epidemiology and population health (1–5%)

AMBOSS study plan

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including family medicine: https://go.amboss.com/family-medicine [4]

Resources

  • AMBOSS: You can use AMBOSS both as a clinical companion on the wards and a reliable study guide for your family medicine shelf exam.
    • Access hundreds of family medicine articles in the knowledge library when you're with patients or rounding with your team.
    • Practice for the shelf exam with more than 900 questions in the Qbank.
  • Professional organizations
    • American Academy of Family Physicians (AAFP): Membership includes access to the online journal American Family Physician. [6]
    • American College of Physicians: Membership includes access to Annals of Internal Medicine and DynaMed. [7][8]
    • American Academy of Pediatrics (AAP): Membership includes access to PediaLink® for Medical Students. [9]
    • American College of Obstetricians and Gynecologists (ACOG) [10]
  • Aquifer family medicine (formerly fmCASES) [11]
  • Guidelines
    • AHRQ ePSS (provides USPTF guidelines) [3]
    • ACP guidelines [12]
    • CDC vaccine schedule [13]
  • Case files family medicine [14]
  • Anki decks [15] with AMBOSS add-on
  • See “Study resources” in the “Clerkship guide” article for more information.

Preparing for residency application

Considerations if you want to specialize in this field

  • Inform your preceptors and residents that you wish to pursue family medicine as a career and are willing to take on additional patients and seek further learning opportunities.
  • Current residents are a great resource for advice as they have just recently gone through the process of deciding for a career in family medicine and applying for residency.
  • Away rotations are not required, but extremely helpful if you wish to match at a specific program or place.
  • See the article “Residency applications” for more information.

Other tips

  • As a general rule, always show interest in your current rotation even if you are sure you want to pursue another field of medicine.
    • There is something for everyone to learn from family medicine that will benefit them as pediatricians, obstetricians, surgeons, internists, etc.
    • Moreover, appearing disinterested will reflect poorly on your clinical evaluations.
  • The wide range of patient types in family medicine will help you expand the horizons of your medical knowledge and career perspectives.