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    Course Personnel Course Personnel Document Transcript

    • Updated 8/13/2010 Page 1 of 62 University of South Florida Department of Family Medicine THIRD YEAR CLERKSHIP Syllabus 2003 - 2004 Group D Rotation 2 Aug 2/04 to Sept 24/04 LATEST UPDATE: June 2004
    • Updated 8/13/2010 Page 2 of 62 Hello, and welcome to Family Medicine! Congratulations on surviving your 1st rotation of clerkship of medical school. As the director of the Family Medicine Clerkship I am pleased to welcome you. I think that you will find it to be a challenging, and hopefully, enjoyable experience. Family Medicine is a specialty like no other. As a new specialty just created in the late 1960’s, Family Medicine has a lot to offer to anyone becoming a physician. Even if you have already decided that surgery is your future, every specialty works closely with family physicians. The family physician’s role of providing comprehensive and continuous care from “womb to tomb” also offers a view of medicine that no other specialty can provide. It encompasses many of the skills of all the specialties, producing physicians that are capable of “addressing a large majority of the personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community”.1 The aim of the clerkship is to introduce you to this specialty and familiarize you with what family physicians are capable of doing and hopefully why we chose Family Medicine. You may find many similarities to the clerkships you have just completed, but that is always going to happen with Family Medicine. However, if you pay close attention you will see the differences. It is for these reasons that the clerkship is offered. The clerkship is an 8-week rotation that will provide you with the opportunity to experience the specialty of Family Medicine. Keep in mind, however, that this part of your medical education can vary. Each of you will work with different preceptors, residents, and patients. Your experiences will therefore vary. Through the use of assigned reading, didactic sessions, and our frequent contact with our affiliated residencies and faculty we hope to maintain a comparable experience for all students. Much of your experience will be in an outpatient setting, which is the setting where most of the medicine practiced today takes place. For those who like the hospital setting, don’t worry – you will be exposed to inpatient care as well. This will provide you with insight into the way family physicians are trained and the capabilities of family physicians in the hospital. I truly hope you will enjoy this clerkship. Everyone in the department works hard to make this clerkship the best possible. I look forward to working with you during this clerkship. If you have any questions or concerns, please do not hesitate to call or come speak to Cristina Spiegel or me. And please read the syllabus. Sincerely, Kira Zwygart, M.D. Director, Family Medicine Clerkship 1 Institute of Medicine, Committee on the Future of Primary Care. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press. 1996.
    • Updated 8/13/2010 Page 3 of 62 TABLE OF CONTENTS Letter from Course Director 3 Course Personnel 4 Preceptors & Residency Sites 5-8 Goals and Objectives 9 Class Policy 12 Methods of Instruction 14 Clinical Experience Residency Month Independent Project Didactic Sessions Written H&P (Include Cover sheet) Self-Education Core Reading Assignments Grading 16 Schedules Rotation Schedule 17 Calendar 20 Residencies 22 Didactic Sessions 23 USF Family Medicine Clinic 1st mo. 25 Community/Private Physicians USF Family Medicine Clinic 2nd mo. 26 Community/Private Physicians Student Advisors 27 Blackboard 28 Appendix Logbook 29 Most Common Problems Encountered in Family Medicine 34 Learner Contract 33 Midterm Feedback Form 35 Gulfcoast South & North AHEC Mileage Reimbursement 37-38 Evaluation Forms Evaluation of Student 39 Written H&P Guidelines 42 Independent Project – Community Project Guidelines 44 Caring for Adults: A Comparison of Three Residency 46 Options Responses to Questions About the Specialty of Family 50 Practice as a Career Map to YMCA – Brandon Outreach Sessions and Student’s 61 Schedule
    • Updated 8/13/2010 Page 4 of 62 Course Personnel A. Departmental Faculty B. Departmental Staff C. Private Doctors D. Community Health Centers E. Residencies A. Departmental Faculty Mailing Address: USF Department of Family Medicine 12901 Bruce B. Downs, MDC 13 Tampa, FL 33612 Kira K. Zwygart, M.D., Clerkship Director of Family Medicine, MDC 2139, 974-0594 Eduardo C. Gonzalez, M.D., Assist. Clerkship Director, Family Medicine, MDC 2118, 974-1997 H. James Brownlee, M.D., Chairman, Department of Family Medicine, MDC 2141, 974-4197 Robert J. Campbell, M.D., Assistant Professor of Family Medicine, MDC 2138, 974-5640 Eric E. Coris, M.D., Assistant Professor of Family Medicine, MDC 2163, 974-5215 Arthur H. Herold, M.D., Associate Professor of Family Medicine, MDC 2134, 974-4197 Dave Kotun, PA-C., Department of Family Medicine MDC 13, 974-6425 Richard G. Roetzheim, M.D., Professor of Family Medicine, MDC 2133, 974-1998 Laurie J. Woodard, M.D., Associate Professor of Family Medicine, MDC 2134, 974-4197 Kevin Sneed, PharmD., Department of Family Medicine MDC 13, 974-5699 Frances Sahebzamani, ARNP, PHD., Department of Family Medicine MDC 13, 974-7042 B. Departmental Staff Cristina Spiegel, M.S., Coordinator of Education & Training, Department of Family Medicine, MDC 2155, 974-8482
    • Updated 8/13/2010 Page 5 of 62 C. Preceptors Private Doctors Medical Care of St. Petersburg Chitra Ravindra, M.D. 3745 33rd Street, N. St. Petersburg, FL 33707 P(727) 525-0006 F(727) 521-3694 Family Care at Tampa Palms Colin Beach, M.D. 15285 Amberly Dr., Tampa, FL 33647- P(813) 979-6978 F(813) 975-0534 Thomas E. Carson, M.D. PA 1259 S. Pinallas Ave Tarpon Springs, FL 34689 P(727) 938-1908 F(727)938-8693 Joan Carter, M.D. 14505 University Point Place, Tampa, FL 33613 P(813) 971-8500 F(813) 971-2429 Glenn Family Medical Center Dana Glenn, M.D. 6101 Webb Rd., 308, Tampa, FL 33615 P(813) 806-1885 F(813)806-1745 Roser Park Medical Center Frederic Guerrier, M.D. & Linda Murray, D.O. 500 10th Ave , S., St Petersburg, FL 33701- P(727) 898-4461 F(727)502-0841 Oldsmar Family Preatice Ronald Vicencio, M.D. 110 State 3 East Suite A. Oldsmar, FL 34677 P(813) 814-9504 F(813) 814-0409 Carillon Sports Clinic Adam A. Brunson, M.D. 900 Carrillon Parkway St. Petersburg, FL 33716 P(727) 561-4303 F(727) 561-9299 Michael Salvato, M.D. 1601 Timberlane Dr. W., Suite 300, Plant City, FL 33566- P(813) 719-3525 F(813) 719-3175
    • Updated 8/13/2010 Page 6 of 62 John Saranko, M.D. Family Practice Center of Plant City 507 West Alexander Street Plant City, FL 33566 P(813) 754-3504 F(813) 754-0074 Dolores Lowe, M.D. Bayside Healthcare 1417 South Collins St. Plant City, FL P(813) 754-3099 F(813) 754-3608 John Murray, M.D., Pasadena Family Medical Associates 630 Pasadena Avenue S. St. Petersburg, FL66 33707- P(727) 345-7100 F(727) 345-7102 Stephen Schweinshaupt, M.D. Schweinshaupt Walk-In & Family Care 6502 Gunn Hwy Tampa, FL 33625 P(813) 969-2030 F(813) 969-2399 D. Community Health Centers Tampa Community Health Center Preceptor: Ambreen Alam, M.D. 3402 N.22nd Street Tampa, FL 33605 P (813) 272-6240 F(813) 247-5591 Tampa Community Health Center Preceptor: Nicolas Pavouris, M.D. 1229 E. 131 St. Avenue Tampa, FL 33612 P (813) 866-0950 F (813) 865-0158 Dover Health Center Preceptor: Subhakararao Medidi, M.D. 14618 SR 574; Dover, FL 33527 Mailing Address: P.O. Box 40 Dover; FL 33527 P (813) 349-7700 F (813) 349-7761
    • Updated 8/13/2010 Page 7 of 62 Tampa Community Health Center Preceptor: Cheryl Reed, M.D. Ask for Rosita 5802 N. 30th Street; Tampa, FL 33610 P (813) 236-5300 Ext. 5153 F (813) 234-2904 or (813) 236-5385 Tampa Community Health Center Preceptor: Teeresa Sisodia, M.D. Ask for Debbie 5802 N. 30th Street; Tampa, FL 33610 P (813) 236-5300 Ext. 5153 F (813) 234-2904 or (813) 236-5385 Florida Medical Clinic Family Practice Preceptor: Nancy Finnerty, M.D. Ph.D. 13417 US 301, Dade City, FL 33525 P(352) 567-1576 F(352) 521-0818 Visiting Preceptors Dr. C. Janecki, M.D. (Musculoskeletal) 607 W. Dr. Martin Luther King Jr. Suite 102 Tampa, FL 33603 P (813) 237-3300 F (813) 237-3308 Dr. Richard Schrot, M.D. (Diabetes) VA Outpatient Clinic 9836 US Hwy 441 Leesburg, FL 34788 P (352)728-4462 F (352)728-2187
    • Updated 8/13/2010 Page 8 of 62 E. Residencies Bayfront Medical Center St. Petersburg Family Practice Residency 700 6th Street, South St. Petersburg, FL 33701 Contact Person: Brenda Kimbrough Email: Brenda.kimbrough@bayfront.org Phone # 727-893-6891 Fax# 727-553-7340 Florida Hospital Family Practice Residency 2501 North Orange, Suite 235 Orlando, FL 32804 Contact Person: Jeannie Lee Email: jeannie.lee@flhosp.org Phone # 407-303-2814 Ext. 3 Fax # 407-303-2885 Halifax Medical Center Family Practice Residency 303 North Clyde Morris Blvd. Daytona Beach, FL 32114 Contact Person: Eve Ann Magoulas Email: EveAnn.Magoulas@Halifax.org Phone # 386-254-4167 Fax # 386-258-4867 Morton Plant Mease Memorial Hospital Family Practice Residency 807 N Myrtle Ave; Clearwater, FL 33755 Contact Person: Tina McDermott Email: Tina.McDermott@baycare.org Phone #727-467-2517 Fax #727-467-2471 St. Vincent's Medical Center Jacksonville Family Practice Residency 2708 St. John's Avenue Jacksonville, FL 32205 Contact Person: Diane Cook Phone # 904-308-8433 Ext. 3 Fax #904-308-2998 Tallahassee Memorial Health Care Family Practice Residency 1301 Hodges Drive Tallahassee, FL 32308 Contact Person: Linda Collier Email: linda.collier@tmh.org Phone # 850-431-5035 Fax# 850-431-6403
    • Updated 8/13/2010 Page 9 of 62 Goals and Objectives Goal The overall goal of this clerkship is to provide students an excellent education in the core principles of Family Medicine, and encourage Family Medicine as a potential future career. A high quality clerkship will have the following characteristics: A. It will expose students to Family Physicians practicing in diverse training sites, including: residency sites, private practice, academic center and community-based sites. B. It will maintain quality of education across training sites and uniformity of the core curriculum for all students. C. It will successfully model the delivery of high quality primary care by family physicians. This clerkship is an eight-week clinical experience which provides instruction in the basic knowledge, attitudes, and skills of Family Medicine which are essential to the fundamental education of all physicians. The course is designed to provide a variety of experiences with family physicians by placing students at the USF Family Medicine Clinic, affiliated Family Practice residency sites, private physicians' offices, and underserved community clinics. We hope that through this rotation students will learn to appreciate what a family physician is and what he or she does. Specific Objectives and Expected Competencies Upon successful completion of the Family Medicine Clerkship, each third-year medical student should possess an appropriate level of the knowledge, attitudes, and skills needed to accomplish the following objectives: Objective No. 1: To refine basic clinical skills that is essential to practicing Family Medicine effectively. The student will be able to: Demonstrate a basic level of competency in the history, physical examination and problem- solving skills. A. Obtain a focused, problem-oriented history and physical in an efficient manner. B. Present a patient case in an orderly, thorough, and efficient manner. C. Record a complete and organized SOAP note. Objective No. 2: To employ a primary care approach to the diagnosis and management of the most common problems seen in the Family Medicine setting. The student will be able to: Formulate a differential diagnosis based on findings on the history and physical exam. A. Initially manage common acute illnesses using a focused, problem-oriented approach. B. Make basic diagnostic and treatment decisions that consider the limitations of clinical data. C. Develop a treatment plan that is tailored to the patient’s overall health needs and resources.
    • Updated 8/13/2010 Page 10 of 62 D. Identify serious, life-threatening conditions early in the treatment of acutely and chronically ill patients. Objective No. 3: To establish effective doctor-patient relationships by using appropriate interpersonal communication skills. The student will be able to: Demonstrate interpersonal skills that enhance communication with the patient and the patient’s family. A. Demonstrate a basic knowledge of issues of informed consent and confidentiality. B. Develop diagnostic and treatment plans in partnership with the patient and patient’s family. Objective No. 4: To gain knowledge and awareness of the principles and applications of health promotion and disease prevention in the Family Medicine setting. The student will be able to: Identify health risks in given patients, families, and communities. A. Use appropriate screening tools and protocols for health maintenance, including immunizations, in specific populations. B. Select protocols for reducing identified health risks. C. Develop effective strategies for behavioral change. D. Implement patient education in daily practice. Objective No. 5: The student will develop an awareness of, and sensitivity to, the psychosocial, cultural, familial, and socioeconomic aspects of medical problems as they relate to patient management. The student will be able to: Collect and integrate psychosocial, cultural, familial and socioeconomic data in patient care. A. Recognize the social, community, and economic factors that affect the patient’s health, access to care, and treatment options. B. Practice cost-effective patient care when making patient management decisions. Objective No. 6: To gain exposure to, and an understanding of, the practice of Family Medicine and the role of the family physician within the health care delivery system. The student will be able to: Describe the role of the family physician as a coordinator of care. A. Describe the important factors related to communication during the patient care process, including communication with other health care providers and consultants. B. Recognize appropriate consultation resources and discuss effective use of these resources. C. Understand the roles of other health care professionals and how to work with them to coordinate patient care.
    • Updated 8/13/2010 Page 11 of 62 D. Describe the various setting in which family physicians provide care. Objective No. 7: To provide comprehensive, coordinated, and continuous as well as episodic health care to the individual patient and family regardless of patient characteristics, specific disease, or setting of the patient encounter. The student will be able to: Encourage the patient seen for episodic or acute illness to seek continuing medical care. A. Document in the problem-oriented patient record appropriate information for acute and continuing care. B. Assess the patient’s adherence to a treatment plan. C. Monitor a patient’s response to treatment and modify a patient’s treatment based on his/her initial response. D. Recognize the need for the family physician’s continuing role and responsibilities in the care of patients during the process of consultations and referral. Objective No. 8: To develop knowledge and skills related to common medical office studies and procedures practiced in the family physician's office. The student will be able to: Describe the indications of diagnostic tests and common medical office procedures. A. Obtain informed consent for common office procedures. B. Demonstrate cost effective use of diagnostic tests and evaluative procedures. C. Interpret the findings of common office lab tests and studies. D. Describe the reliability, indications, and potential complications of common tests and procedures. Objective No. 9: To demonstrate knowledge and skills required for lifelong learning and the competent practice of medicine. The student will be able to: Demonstrate principles of lifelong learning including research, reading, and inquiry. A. Utilize appropriate resources to answer clinical questions. B. Record and present data in an accurate and objective way. C. Illustrate the use of universal precautions when examining patients. D. Exhibit intellectual curiosity and self-motivation to promote self-learning. E. Display attitudes and professional behavior appropriate for clinical practice.
    • Updated 8/13/2010 Page 12 of 62 Class Policy The following are guidelines that all students are expected to follow throughout this clerkship. You may find that they are also important in other clerkships as well and throughout your training. 1. Punctuality is key. Students are expected to be on time to work. Tardiness will not be favorably looked upon. Be aware of how long it will take you to get where you are expected. If you are going to be late, call those expecting you in advance. 2. Dress for the job. As per the USFCOM Dress Code Policy, medical students “are expected to maintain a proper professional image in their behavior and personal appearance at all times. Any time students have contact with patients or are in the patient care areas, shorts are not to be worn. Men should wear shirts and ties and women should wear dresses, skirts, or appropriate slacks and blouses. Also white lab coats with name tags should be worn by all students.” 3. Know when and where you need to be. Review your schedule and syllabus. Call the site or preceptor 1 week prior to starting each component of the clerkship to determine what time you are expected. This will not only allow you to be on time, but will also prevent you from wasting your own time if you are not expected. 4. Emergencies/Illnesses do occur. Your preceptors recognize that situations arise which require students to miss time from their course/clinical responsibilities. As per the USFCOM Student Handbook, when an absence is necessary “the student will telephone the preceptor and the Clerkship Director in charge to report his/her absenteeism by 8:00am on the first day of being absent. He/she should indicate the nature of the emergency. It will be prerogative of the Course Director, following consultation with the student to excuse the absence. The student absenteeism form will be completed and forwarded to the Office of Student Affairs by the Course Director.” If the student cannot reach the Course Director, he/she should call our Education Coordinator, (Cristina Spiegel, 974-8482); leave a message on the Course Director’s voicemail (Dr. Zwygart, 974-0594) and Contact the Clinic 974-6030. If a student is ill for more than one day, he/she must bring in a doctor’s note. In situations where the student knows he/she will be absent from any responsibilities for other than medical reasons, the student is required to ask the Course Director’s permission in writing at the earliest possible time and at least one week prior to the date of scheduled absence. Non- emergent requests made within 1 week will not be approved. Absences will be expected to be made up in the USF Family Medicine Clinics during scheduled breaks (Christmas and between the end of 3rd year and the start of 4th year) at the discretion of the Course Director. Make up schedules will be coordinated through the education office 974-8482. 5. Be professional. Remember you will need to earn the respect and trust of your patients. As student physicians, you will be expected to behave politely and professionally. Be courteous to the needs of patients and respect their privacy. Be careful not to discuss patient cases in public settings as their illness and history are confidential. In addition, drape patients appropriately during exams and request a chaperone when necessary.
    • Updated 8/13/2010 Page 13 of 62 6. Remember to sign all notes legibly. 7. Be prepared. This means keeping up with reading assignments and being ready to discuss topics in clinics and during case conferences. 8. Be careful. Remember that as a student, you should not act independently or without the knowledge of those legally responsible for the care of the patient. If you are uncertain whether you need a chaperone or are uncomfortable with an exam, let your preceptor know. Every patient needs to be seen by your preceptor.
    • Updated 8/13/2010 Page 14 of 62 Methods of Instruction Clinical Experience Independent Project Didactic Sessions Written H&P Self-Education Core Reading Assignments Clinical Experience 1. USF Month During the assigned month at USF students will spend two days per week at the USF Family Medicine Clinic and two days per week either at a private community physician's office or a community health center. Students will complete a learner's contract with their assigned community physician. The students, under the guidance and instruction of their preceptor, will conduct evaluations of patients and prepare treatment plans. Students will become proficient in the performance, recording, and presentation of the history and physical examination. They will formulate problem lists with plans for diagnostic and therapeutic intervention and provide health promotion and disease prevention strategies through patient education. Students will be expected to be with the private physician throughout the day to include home visits, hospital rounds, nursing home rounds, staff meetings, and surgical assisting. On Wednesdays all students will participate in didactic sessions at USF. To emphasize the importance of community service, all students will attend the Judeo-Christian Clinic or Brandon Outreach Clinic on Wednesday evenings. 2. Residency Month During the additional four weeks of the rotation, students are assigned to one of six affiliated family practice residency sites where they are exposed to both outpatient and inpatient academic family medicine. Students will see patients in the outpatient clinic with the responsibilities as listed above. They will be supervised by residents and/or attendings. Students will also become part of the inpatient service team and be given the responsibility for caring for patients. Students will perform a thorough history and physical on patients assigned to them. They will initiate plans and orders with the aid of the residents. Students are encouraged to write orders on the chart with the counter-signature of one of the residents. They should follow patients closely, perform appropriate procedures under the supervision of the resident, and write daily progress notes. All notes become part of the permanent hospital record for the patient and must be countersigned by a resident or attending. Students will be required to take call and present their cases on attending rounds to the Attending Physician. Students will admit no more than 2 patients per call day, and follow no more than 6 patients at any one time. This part of the clerkship provides students with a view of Family Practice residency training and the broad education required by family physicians. Exposure to Family Practice residencies is important in the recruitment of students into Family Medicine. Independent Project Students are also required to complete an independent project. Students will pick a health education topic during orientation and create a patient education handout for that topic. These patient handouts will be incorporated into clinics at USF and at the Brandon Outreach
    • Updated 8/13/2010 Page 15 of 62 Clinic and JC Clinic, as appropriate. The projects will be due at the final didactic session, in hard copy and on disk. Didactic Sessions Didactic sessions will be held at USF on Wednesdays. Attendance at didactic sessions is mandatory for all students during the month spent at USF. Students will meet in Conference Room MDC 2149 and have workshops on various subjects and procedures, participate in clinical case conferences, and have an opportunity to provide feedback on the course. Students are required to complete the reading assignments and answer case studies prior to each session. The answers to the questions will be discussed in the class. Morning sessions begin promptly at 8:15 am. Afternoon sessions begin promptly at 1:15pm. It is expected that students will be on time and participate fully during these sessions. Arriving late or missing part or all of a session can result in a deduction of points to the students final grade. Written H&P During the USF month, students will be required to complete and turn in a typed H&P on a patient they encountered earlier in the month. The H&P should include the history, physical, lab/diagnostic tests, differential diagnoses, and treatment/education provided to the patient. The H&Ps will be graded according to the H&P Critique Sheet in the appendix. (see Critique Sheet for more details pg. 41). The H&P is due by Friday of the second week at USF to allow for sufficient time for feedback. One point will be deducted for each day that it is late. Self-Education One of the goals of this clerkship is to have students learn the value of lifelong-learning and self-education. All of the knowledge and skills which students need to assimilate during this clerkship cannot be presented in their entirety. We encourage students to develop their intellectual curiosity and self-motivation by assuming responsibility for their own education. Core Reading Assignments Recommended Textbooks Guide to the Family Medicine Clerkship, Susan L. Montauk, M.D., 2001. This is an excellent textbook in family medicine written at a level appropriate for the clerkship. This text is available in the USF College of Medicine bookstore. Essentials of Family Medicine, 4th Edition. Philip Sloane, MD, Lisa Slatt, Med, Mark Ebell, MD, 2002. At the request of students from previous classes, another recommendation was desired for something a little more substantial to have as a reference. This book is used in Family Medicine clerkships around the country, and does come with a CD-ROM of sample test questions. Required Textbooks: Didactic Manual The didactic manual containing review articles on various subjects pertinent to Family Medicine can be purchased through the Family Medicine Department. These articles will help students to complete the case studies and prepare for the final exam. Students will be required to complete case studies and read the review articles prior to the didactic sessions. Please refer to the didactic schedule to determine which topics students need to read each week.
    • Updated 8/13/2010 Page 16 of 62 Grading A. Clinical Evaluations (40%) B. Written H&P (5%) C. Independent Project (5%) D. Participation at Brandon Outreach/Judeo-Christian Clinic (5%) E. Logbook (5%) F. Final Exam (40%) G. Final Course Grade A. Clinical Evaluations Clinical evaluations comprise 40% of the final grade. Students will be evaluated by their preceptors and residents on their medical knowledge, clinical skills (including history taking, physical examination, and verbal presentations), problem solving skills and clinical judgment (including application of health promotion, forming a differential diagnosis, use of office procedures and labs, planning treatment plans and follow-up, completion of progress notes), professional attributes (including reliability, motivation, responsibility, use of medical literature and other resources, and openness to instruction and feedback), and interpersonal relationships (with patients, colleagues, staff, and preceptors) (See evaluation form). At the discretion of the Course Director, any student who performs unsatisfactorily in any of these areas may be required to remediate the clerkship. B. Written H&P The H&P is 5% of the final grade. Students will hand in a typed H&P on a patient seen during the outpatient portion of the rotation. C. Independent Project This requirement is 5% of the final grade. Students will pick a topic from a list of health conditions or issues and develop a patient education handout for that topic. D. Brandon Outreach Clinic 5% of the final grade is from participation in patient care at the Brandon Outreach Clinic and JC Clinic. E. Logbook Students will enter data of each patient encounter during the rotation into the electronic logbook. This logbook is at our web site at: http://spider.med.usf.edu/OCME/logbookV3/ The patient logbook is worth 5% of the final grade.
    • Updated 8/13/2010 Page 17 of 62 F. Final Exam At the end of the rotation, students will complete a final written exam on Family Medicine that comprises 40% of the final grade. This exam will consist of two parts. Part I is the National Board of Medical Examiners mini-board. It is the policy of the College of Medicine that students must achieve at least 17th percentile on this examination to pass the course. They must achieve at least 45th percentile to receive a Pass with Commendation grade for the course, and a 70th percentile to receive Honors for the course. Part II is a departmental exam, which consists of questions based on the didactic manual and didactic sessions. Students must obtain at least a 70% on the departmental exam in order to pass the course. Students who fail either part of the exam will be required to repeat the portion of the exam that was not passed. If a student is required to repeat the examination, it must be taken by the "uniform testing" date established through Student Affairs. If a student does not pass the repeat examination, he/she will obtain a failure (“F”) for the clerkship and will be required to repeat the clerkship. Students who pass the repeat examination will obtain a pass (“P”) for their final exam grade. If a student fails both exams, he/she will be required to remediate at least one month as well as repeat the exams. G. Final Course Grade The final course grade is determined by the Clerkship Director and is based on the various clerkship activities as well as overall performance as presented above. A written summary is then submitted to the registrar's office. A student may appeal a course grade in writing to the Clerkship Director within 2 weeks after receipt of the grade if the student has evidence that the grade was assigned in a malicious, capricious, or erroneous manner. This is not a process for appeal of established departmental grading policies.
    • Rotation Schedule Orientation Orientation will be from 8:15 AM to 3:00 PM in MDC 4054 on the first day of each rotation except when otherwise notified. All students required to attend orientation. Students will report to their designated assignments following orientation. Didactic Sessions All students assigned at USF are required to attend didactic sessions that month. Didactic sessions are scheduled on Wednesday of each week. Didactic sessions begin at 8:15 AM in MDC 2149. Afternoon sessions begin at 1:15 PM. Be prepared to discuss the case studies for each week's didactic topics. Brandon Outreach Clinic Sessions Students scheduled for Brandon Outreach are expected to report to Clinic on the first Wednesday evening of the month by 5:15 PM. There is a map to the clinic located on page 61 of this syllabus. Judeo Christian Clinic Sessions Students scheduled for JC Clinic are expected to report on Wednesday evenings by 5:15 PM. USF Clinic Sessions All students are expected to report to the USF Family Medicine Clinic (Zone D) on their assigned days at 8:00 AM. Afternoon sessions begin at 1:15 PM. Clinic Orientation for second half of the group is on at 7:15 AM on the first Monday or first Tuesday of your outpatient month. Please note the time/day of clinic orientation on the following calendar, if you are at USF for the second month. Feedback Session All students will return to USF to complete evaluation forms and attend a feedback session on the last Thursday morning, {Date}. Feedback sessions will take place in MDC 2301 at 11:00 a.m. unless otherwise notified (check your blackboard for announcements). Final Exam The final exam will take place on the last Friday of the rotation, {Date} The mini board will start at 8:30 AM Room MDC TBA and the Family Medicine departmental exam will start at 1:00 PM unless otherwise notified in MDC TBA. Students have two hours to complete each portion of the final exam. Forms to be Completed 1. The Learner Contract should be reviewed and signed by the student and his/her assigned community physician on their first day of contact. This form will be collected on the first Wednesday didactic session of the month. 2. During the USF month, students will take the Midterm Feedback Confirmation Form to their assigned advisors after the 2nd week of the month and have a feedback session with their advisors. 3. During the residency month, students will complete another Midterm Feedback Confirmation Form with an attending or resident at that site. These forms should be turned in to Cristina no later than the last week of the rotation. (See page 34 for forms)
    • 4. Students traveling to the AHEC Community Health Centers can get reimbursement for their mileage. They should fill out the appropriate AHEC Mileage Reimbursement form and mail it directly to the AHEC address on the form. (See page 36 for forms)
    • Sample of an August Calendar 1st Rotation of the Academic Year Aug 2004 Monday Tuesday Wednesday Thursday Friday 2 3 4 5 6 Orientation 8:30 am – 3:00 Report to Residency 8:30 – 10:30 Interpreting EKG’s 11:00 – 11:45 Low Back Pain pm MDC 4054 Site 12:00 Student Lunch on your own 1:15 – 2:30 Practical Approach to Contact Residency site and Hypertension Community Preceptor after 2:45 – 4:00 Pediatric Pearls See schedule for Brandon Outreach Orientation COMPLETE DIDACTIC EVALUATIONS 9 10 11 12 13 8:15 -12:00 noon * Musculoskeletal*- Dr. H & P Due 12 noon Janecki (pls. wear shorts and tank tops Room 2155 (outside the for this lecture) 12:00 Lunch on your own door place in the box) 1:15 – 2:30 pm Diabetes & Hypotheyroidsim 2:45 – 4:00 Health Maintenance COMPLETE DIDACTIC EVALUATIONS 16 17 18 19 20 8:15 – 9:30 am Common Skin Conditions 9:45 – 11:30 am Upper Respiratory Tract 12:00 Student Lunch on your own 1:15 -2:30 pm Dyspnea 2:45 – 4:00 Chest Pain COMPLETE DIDACTIC EVALUATIONS 23 24 25 26 27 8:15 – 10:30 am Interpreting X-rays Reminder to all: 10:45 -12:00 am Headache 12:00 -1:30 pm Student Lunch on us – Reminder to all Call your Preceptors CHINA BUFFETT on Fowler students: and/or Residency sites 1:45 – 3:00 pm Insulin Resistance & COMPLETE DIDACTIC for the next month Metabolic Syndrome EVALUATIONS ½ day at clinic Community Project Due /preceptor site
    • Sample of the second half of the 4 weeks in the 1st Rotation Aug and Sept Monday Tuesday Wednesday Thursday Friday 30 31 Sept 1 2 3 Orientation at 7:15 pmUSF Orientation at 7:00 am – 8:30 – 10:30 am Interpreting EKG’s Month Students – Zone D for 10:45 -11:45 am Low Back Pain Zone D for Tues/Fri Mon/Thur students with Dr. 12:00 Student Lunch on your own Zwygart students 1:15 – 2:30 pm Practical Approach to Hypertension 2:45 – 4:00 pm Pediatric Pearls Report to Residency site COMPLETE DIDACTIC EVALUATIONS and Community Preceptors 6 7 8 9 10 8:15 – 12:00 pm * Musculoskeletal*-Dr. H & P Due 12 noon Janecki Room 2155 (outside the (Pls. dress in tanks and shorts) 12:00 Student Lunch on your own door place in the box) 1:15 – 2:30 pm Dibetes & Hypothyroidism 2:45 -4:00 pm Chest Pain COMPLETE DIDACTIC EVALUATIONS 13 14 15 16 17 8:15 – 9:30 am Common Skin Conditions 9:45 -11:30 am Upper Respiratory Tract Conditions 12:00 Student Lunch on your own 1:15 – 2:30 pm Dyspnea 2:45 – 4:00 pm Health Maintenance 20 21 22 23 24 8:15 -10:30 am Interpreting X-rays Feedback Session 8:00 a.m. – Mini Board 10:45 -12 noon Headache 12:00 -1:30 pm Lunch on us China 11:00 a.m. Room TBA Buffet on Fowler MDC 2301 1:00 a.m. – Dept Exam 1:45 – 3:00 pm Insulin Resistance & TBA Metabolic Syndrome Reminder to all Independent Project Due students: COMPLETE DIDACTIC EVALUATIONS
    • Year III Clerkship –Residency Sites - Rotation 2 Group D Aug 3 to Sept 22 Halifax Bayfront Mayo Clinic Morton Florida Medical St. Vincent’s Medical Jacksonville Plant Hospital Center Aug 3 to {Student {Student {Student {Student {Student Aug 27 Names} Names} {Student Names} Names} Names} Names} Aug 30 {Student {Student {Student {Student {Student to Names} {Student Names} Names} Names} Names} Sept 22 Names}
    • SAMPE OF DIDACTIC SESSIONS Year III Clerkship Didactic Sessions Rotation 2 Family Medicine Conference Room, MDC 2149 (Unless Otherwise Posted) First Four week Session Week of Aug 2 to Sept 27 Aug 4 8:30 – 10:30 am Interpreting EKG’s- Dr. Zwygart 10:45– 11:45 am Low Back – Dr. Ramirez 12:00 Lunch on your own 1:15 – 2:30 pm Practical Approach to Hypertension – Dr. Sneed 2:45 – 4:00 pm Health Maintenance – Dr. Roetzheim COMPLETE DIDACTIC EVALUATIONS Aug 11 8:15 – 12:00 pm **Musculoskeletal** - Dr. Janecki & Dr. Coris (Please Dress in Tank Tops and Shorts) 12:00 Student Lunch on your own 1:15 – 2:30 pm Diabetes & Hypothyroidism – Dr. Schrot 2:45 -4:00 pm Pediatric Pearls – Dr. Gonzalez COMPLETE DIDACTIC EVALUATIONS Aug 18 8:15 – 9:30 am Common Skin Conditions- Dave Kotun, PA 9:45 – 11:30 am Upper Respiratory Tract Conditions – Dr. Herold 12:00 Lunch on your own 1:15 – 2:30 pm Dyspnea – Dr. Coris 2:45 – 4:00 pm Chest Pain – Dr. Woodard COMPLETE DIDACTIC EVALUATIONS Aug 25 8:15 – 10:30 am Interpreting X-rays- Dr. Campbell 10:45 – 12:00 am Headache- Dr. Brownlee 12:00 – 1: 30 pm Lunch on us – China Buffet on Fowler 1:45 – 3:00 pm Insulin Resistance & Metabolic Syndrome- Frances Sahebzamani, ARNP, PhD COMPLETE ALL PRECEPTORS, RESIDENCY AND DIDACTIC EVALUATIONS!! Thank you. ** Please dress in tank tops and shorts for examination of the shoulder, knees and ankles. Thank you.
    • SAMPE OF DIDACTIC SESSIONS Year III Clerkship Didactic Sessions Rotation 2 Family Medicine Conference Room, MDC 2149 (Unless Otherwise Posted) Second Four week Session Week of Sept 1 to Sept 24 Sept 1 8:30 – 10:30 am Interpreting EKG’s – Dr. Zwygart 10:45– 11:45 am Low Back Pain – Dr. Ramirez 12:00 Student Lunch on your own 1:15 – 2:30 pm Practical Approach to Hypertension – Dr. Sneed 2:45 – 4:00 pm Pediatric Pearls – Dr. Gonzalez COMPLETE DIDACTIC EVALUATIONS Sept 8 8:15 – 12:00 pm **Musculoskeletal** - Dr. Janecki (Please Dress in Tank Tops and Shorts) 12:00 Student Lunch on your own 1:15 – 2:30 pm Diabetes and Hypothyroidism – Dr. Schrot & Dr. Coris 2:45 -4:00 pm Chest Pain – Dr. Woodard COMPLETE DIDACTIC EVALUATIONS Sept 15 8:15 – 9:30 am Common Skin Conditions- Dave Kotun, PA 9:45 – 11:30 am Upper Respiratory Tract Conditions – Dr. Herold 12:00 Student Lunch on your own 1:15 – 2:30 pm Dyspnea – Dr. Coris 2:45 – 4:00 pm Health Maintenance – Dr. Roetzheim COMPLETE DIDACTIC EVALUATIONS Sept 22 8:15 – 10:30 am Interpreting X-rays – Dr. Campbell 10:45 – 12 am Headache – Dr. Brownlee 12:00 – 1: 30 pm Lunch on us – China Buffet on Fowler 1:45 – 3:00 pm Insulin Resistance & Metabolic Syndrome- Frances Sahebzamani, ARNP, PhD COMPLETE ALL PRECEPTORS, RESIDENCY AND DIDACTIC EVALUATIONS!! Thank you. ** Please dress in tank tops and shorts for examination of the shoulder, knees and ankles. Thank you.
    • Clinic and Private Physician Rotation for Week of 08/02/04 to 08/27/04 Monday Tuesday Thursday Friday AM AM PM AM PM AM PM Student PM Dr. {INSERT Dr. Dr. Dr. STUDENT Woodard Roetzheim Brownlee Woodard NAMES} Dr. Dr. Dr. Dr. Woodard Roetzheim Brownlee Woodard Dr. Dr. Dr. Dr. Herold Gonzalez Roetzheim Zwygart Dr. Dr. Dr. Dr. Herold Gonzalez Roetzheim Zwygart Dr. Dr. Dr. Coris Dr. Coris Brownlee Zwygart Dr. Dr. Dr. Coris Dr. Coris Brownlee Zwygart Dr. Dr. Dr. Herold Dr. Herold Roetzheim Brownlee Dr. Dr. Dr. Herold Dr. Herold Roetzheim Brownlee Dr. Dave Dr. Dr. Wathingto Kotun, PA Gonzalez Gonzalez n Private Physicians Tuesdays & Fridays Mondays &Thursdays F. {INSERT STUDENT NAMES} {INSERT STUDENT NAMES} Guerrier D. Lowe A. Brunson D. Glenn L. Murray Community Health Center A. Alam N. Finnerty C. Reed T. Sisodia
    • Clinic and Private Physician Rotation for Week of 08/30/04 to 09/24/04 Monday Tuesday Thursday Friday AM AM PM AM PM AM PM Student PM {INSERT Dr. Dr. Dr. Dr. STUDENT Brownlee Roetzheim Roetzheim Zwygart NAMES} Dr. Dr. Dr. Dr. Brownlee Roetzheim Roetzheim Zwygart Dr. Dr. Dr. Herold Dr. Coris Gonzalez Zwygart Dr. Dr. Dr. Herold Dr. Coris Gonzalez Zwygart Dr. Dr. Dr. Dr. Coris Brownlee Woodard Gonzalez Dr. Dr. Dr. Dr. Coris Brownlee Woodard Gonzalez Dr. Dr. Dr. Dr. Herold Gonzalez Woodard Wathington Private Physicians Tuesdays & Fridays Mondays &Thursdays F. {INSERT STUDENT NAMES} {INSERT STUDENT NAMES} Guerrier D. Lowe C. Beach D. Glenn C. Ravindra Community Health Center C. Reed T. Sisodia
    • USF Family Medicine Student Advisors 08/02/04 to 08/27/04 Dr. Brownlee {INSERT STUDENT NAMES} Dr. Coris Dr. Gonzalez Dr. Herold Dr. Roetzheim Dr. Woodard Dr. Zwygart 08/30/04 to 09/24/04 Dr. Brownlee Dr. Coris Dr. Gonzalez Dr. Herold Dr. Roetzheim Dr. Woodard Dr. Zwygart
    • Blackboard Access Instructions getting onto Blackboard: 1. Access: https://my.usf.edu/webapps/portal/frameset.jsp 2. Bookmark or save the site to your “favorites.” 3. If logon and password needed, use your e-mail logon and password. 4. Click on tab at top = courses 5. Scroll down and open BCC6175.732. M04: Family Medicine Family Medicine Clerkship. 6. Click on Family Medicine Clerkship for Your Rotation. 7. Click on Assignments to do your evaluations. 8. Choose the surveys applicable to you and please fill them out.
    • Appendix LogbookV4 The College of Medicine (COM) requires students in all clerkship programs to maintain a logbook of their experiences and activities. The hard copy logbook is a requirement of the Family Medicine Clerkship. Both must be completed by the end of rotation. The Logbook Application was developed to gather information about the types and quantity of patient contacts med students encounter during their various clerkships. This document can be used as a quick reference guide on using this application. The first screen that appears when this application is opened is the Main Menu screen. This screen controls most features for the application. From the Main Menu a user can navigate to other screens. Main Menu Form The Main Menu has the following options: • Patient Logs • Upload • Reports Menu • Export • Help • Exit Access Patient Logs - This option leads to a new form entitled Clerkship. Once the Clerkship form is opened, the user must select the desired clerkship. Click on Submit. The Patient Logsform now appears. This is where users will spend most of their logbook time. For detailed information about this form read text below entitled "Patient Logs Form". Reports Menu - This option leads to the Reports Menu Screen. This screen lists all the reports that can be generated for hardcopy printing. Upload - When you select this option, several actions are performed: a patientInfo.txt file (which contains all the patient data) is created, the connection with the Spider Web page is established (the computer must have an active internet connection - telephone or network jack properly set), and the patientInfo.txt is uploaded to the server. Export - This option allows the user to export the patient data into a 'comma-separated-values' file (.csv). This file can be imported into any custom database or spreadsheet.
    • Exit Access - Select this option to close all logbook forms and exit Access. Clerkship Form Select the desired clerkship and click on Submit. Patient Logs Form Once the user has completed all the patient information fields, the user has two choices:  Save Record - Select this option to save current information and start a new patient entry. When the user selects this option, all the fields are cleared and new information can be added.  Main Menu - Select this option to save current information and exit the form. Data Entry Fields in Detail
    •  User Name - Type in your HSC account user name. (Example: The user's email is jsmith@hsc.usf.edu; the user name is jsmith).  Record #- The patient's medical record number  Patient Initials - The patient's initials (3 characters).  Age - The patient's age (in years, months, or days)  Care From - The date the patient was first seen.  (Care) To - The date the care ended.  Full Evaluation/Follow Up - Check if the visit was a Full Evaluation or a Follow Up.  Inpatient/Outpatient - Check if the visit was an Inpatient or Outpatient.  Gender - Indicate the patient's gender: male or female.  Clerkship - You DO NOT need to select the clerkship. The clerkship was already selected in the previous form.  Attending Physician - Select the physician's name from the list or type the physician's name if not in list.  Site - Select the site's name from the list or type the new site.  Diagnoses - Select the diagnosis from the list or type the new diagnosis.  Procedure - Select the procedure from the list or type the new procedure. Once the procedure is entered, you will be asked to enter the Involvement. You CANNOT type a Procedure without an Involvement.  Involvement - Select an Involvement option from the list. You CANNOT type a new Involvement.  Comments - Use this field to add comments to your patient entry. Special Control - Toggle Button Many of your entries are probably going to hold the same information throughout a particular clerkship. For example, your username will always stay the same, and the same might happen to other fields. In order to set these values as a default and avoid having to type these fields each time you enter a new record, do the following:  first enter a record  next click the toggle button (these buttons are located next to each relevant field) for those fields that are going to have the same value(s) in the successive new record(s);  once theses button have been clicked their appearance changes to this to indicate that these values are going to be the default value(s) for all new record(s) created during the session;  to change these settings just click the toggle button and the default values are cleared.
    • Special Case: Certain menu choices are not listed. Though great effort has been made to accurately provide all of the clerkship information in the menu choices, some items may not be listed. For example, you might find that a specific diagnosis you encountered may not be listed in the "Diagnoses" drop down menu. In such a case type in the new information. Once you are done, a pop-up window opens to confirm if this choice is to be added to the existing list. Select yes and continue with your work. Contact Information If you need assistance with the Logbook Application or have questions, please contact ocmetech at the Office of Curriculum and Medical Education: tel 974-7413 email ocmetech@hsc.usf.edu
    • Family Medicine Logbook Diagnosis List Abdominal Pain GERD Other Renal (Enter Below) Allergies Headache Other Rheumatology (Enter Below) Anemia Health Maintenance Otitis Externa Anxiety Hyperlipidemia Otitis Media Arrhythmia Hypertension Pelvic Pain Arthritis Hyperthyroid Peptic Ulcer Disease Asthma Hypothyroid Pharyngitis Back Pain Irritable Bowel Syndrome Pneumonia Breast Mass/Lump Menstrual Problem Pregnancy Bronchitis Musculoskeletal Injury/Pain STD CHF Obesity Seizure COPD Other Cardiac (Enter Below) Sinusitis Cancer Other Dermatology (Enter Below) Skin Infection Chest Pain Other GI (Enter Below) Stroke Coronary Artery Disease Other GYN (Enter Below) Upper Respiratory Infection Depression Other Infectious (Enter Below) Urinary Tract Infection Diabetes Mellitus Other Miscellaneous (Enter Below) Vaginitis Diarrhea Other Neurology (Enter Below) Viral Syndrome Fatigue Other Pulmonary (Enter Below) Family Medicine Logbook Procedures List Anoscopy Foley Catheter Rhinolaryngoscopy Arterial Puncture Gram’s Stain Skin Lesion Excision/Biopsy Bone Marrow Biopsy Hemorrhoid Incision and Extraction Spirometry Central Line Placement I & D Abscess Splinting/Casting Cerumen Removal From Ear Injection Suturing Chest Tube Insertion IV Placement Thoracentesis Colposcopy Joint Aspiration/Injection Toenail Removal Cryosurgery KOH prep (skin) Venous Puncture Endometrial Biopsy Lumbar Puncture Vaginal Wet Prep/KOH Endotracheal Intubation OB Delivery X-ray Reading EKG Interpretation Pap Smear Other Exercise Treadmill Test Paracentesis Flex Sig PPD Placement
    • USF DEPARTMENT OF FAMILY MEDICINE THIRD-YEAR CLERKSHIP LEARNER CONTRACT Purpose: To establish policies/procedures with the student. Preceptor should discuss: ______ A. Days/Hours student is expected to be in the office. ______ B. Office attire and appearance. ______ C. Procedure if student is absent or tardy. ______ D. Office conduct to include the title by which the student should introduce himself/herself to the patient. ______ E. Student's role in the office, to include the amount of responsibility to be assumed by the student. ______ F. Preceptor and student's expectations of learning experience. Establish learning goals and objectives. ______ G. The pre-assessment questionnaire with the student to assess the student's skills, degree of confidence and aptitude. ______ H. Other/Additional responsibilities outside the medical office to include hospital rounds, nursing home visits, home visits, meetings, etc. Preceptor's Signature/Date Student's Signature/Date
    • 3rd Year Clerkship Mid-Month Feedback Form At the end of the second week the USF Clinic month, students are encouraged to schedule a meeting (about 15 minutes) with your USF advisor AND your residency attending. It is your responsibility to schedule the meeting. Bring this form to the meeting. The purpose of mid-month feedback is to make you aware of how your performance is perceived and to develop suggestions for how you might improve your skills. This meeting should further the two-way communication about the clerkship begun on your first day in the office. The form will help focus the discussion on your strengths and specific suggestions for improvement in the specified areas. Your preceptors will expect you to present the form and meet with them at the half-way point. AREAS OF EVALUATION Briefly List Strengths and Specific Suggestions for Improvement Relationship to Patients: Health Care Team Participation: Professionalism: History Taking: Physical Exam: Case Presentations and Write-ups: Clinical Judgement & Problem-solving Skills: Progress Notes/Charts: General Medical Knowledge: Initiative and Dependability: Procedural Skills: ____________________________________ ____________________________________ Preceptor's Signature Student's Signature (and Printed Name) _________________ Date
    • 3rd Year Clerkship Mid-Month Feedback Form At the end of the second week the USF Clinic month, students are encouraged to schedule a meeting (about 15 minutes) with your USF advisor AND your residency attending. It is your responsibility to schedule the meeting. Bring this form to the meeting. The purpose of mid-month feedback is to make you aware of how your performance is perceived and to develop suggestions for how you might improve your skills. This meeting should further the two-way communication about the clerkship begun on your first day in the office. The form will help focus the discussion on your strengths and specific suggestions for improvement in the specified areas. Your preceptors will expect you to present the form and meet with them at the half-way point. AREAS OF EVALUATION Briefly List Strengths and Specific Suggestions for Improvement Relationship to Patients: Health Care Team Participation: Professionalism: History Taking: Physical Exam: Case Presentations and Write-ups: Clinical Judgement & Problem-solving Skills: Progress Notes/Charts: General Medical Knowledge: Initiative and Dependability: Procedural Skills: ____________________________________ ____________________________________ Preceptor's Signature Student's Signature (and Printed Name) _________________ Date
    • Gulfcoast South Area Health Education Center, Inc., AHEC TRAVEL REIMBURSEMENT FORM FOR COMMUNITY-BASED CLINICAL EXPERIENCES One of the goals of the USF Area Health Education Center (AHEC) Program is to encourage and facilitate community- based clinical training in underserved sites. Because you are completing such an experience, Gulfcoast South AHEC will provide you with a fixed reimbursement to assist with your expenses related to travel to and from the underserved site. The amount of reimbursement is based on the distance of the site from campus and whether or not housing was made available to you at the site. Please see the reverse side of this form for the reimbursement amounts. After you have completed the scheduled clinical experience, please submit this form to: Gulfcoast South AHEC, Inc., 2201 Cantu Court, Suite #117, Sarasota, FL 34232. Your reimbursement check will be mailed to the address provided within two weeks after receipt. If you have questions, please call (941) 361-6602. ____________________________________________________________________________________ (Please print) Name:_______________________________________SS#____________________________________ Address:____________________________________________________________________________ City: ____________________________________ State: _________________________Zip:_________ Phone:_______________________________ E-Mail: ________________________________________ Name of School or Residency Program:____________________________________________________ Type of Student: _____ Medical Resident (circle one: Family Medicine Internal Medicine Pediatrics Psychiatry) _____ Medical (circle one: MS I MS II MS III MS IV) _____ Nurse Practitioner (circle one: ANP FNP GNP PNP) _____ Physician Assistant _____ Nursing _____ Public Health _____ Pharmacy Type of Rotation: _____ Residency rotation (circle one: Required Elective) _____ Medical Student 4th year elective (circle one: Family Med Internal Med Pediatrics Psychiatry) _____Medical Student 3rd year clerkship (circle one: Family Med Internal Med Pediatrics Psychiatry) _____ Nursing/Nurse Practitioner/Physician Assistant practicum _____ Public Health fieldwork experience _____ Pharmacy Clinical Clerkship (Circle one: Ambulatory Medicine, General Medicine, Pediatrics, Other)
    • REIMBURSEMENT FORM Name and City of Clinical Site:___________________________________________________________ ____________________________________________________________________________________ Dates of clinical training (list all dates you were at site): _______________________________ Student’s Signature Date FIXED TRAVEL REIMBURSEMENT AMOUNTS For travel to DeSoto Memorial Hosiptal/Clinics or DeSoto County Health Department (Arcadia): Housing Offered 1-2 week rotation - $50 4 week rotation - $100 8 week rotation - $150 12+ week rotation - $200 For travel to Manatee County Rural Health Services (Parrish, Palmetto, Bradenton, Oneco): Housing Offered No Housing Offered 1-2 week rotation - $ 25 $25 per roundtrip 4 week rotation - $ 50 (maximum $200.00) 8 week rotation - $ 75 12+ week rotation - $100 For travel to Suncoast Community Health Centers, Inc. ( Dover, Ruskin, Plant City) $15 per round trip For travel to Health Resource Alliance, Inc or Family Medical Center (Date City, Zepherhills) $15 per round trip
    • (Insert Student Evaluations) next 2 pages
    • WRITTEN H&P CRITIQUE SHEET (Due by Friday of 2nd week of USF month) Student : . (please print) Required Information: POINTS S: 1. Introductory information and chief complaint 2 2. History of present illness- 4 or more 4 a. Location b. Quality c. Severity d. Duration e. Timing f. Context g. Modifying factors h. Associated signs and symptoms 3. Past Medical History 1 a. Prior illnesses and injuries b. Operations and hospitalizations c. Immunizations d. Current medications e. Allergies 4. Family History 1 a. Health status and cause of death b. Specific diseases related to problem 5. Social History 1 a. Use of drugs, alcohol, or tobacco b. Occupational history c. Sexual history 6. Review of systems 1 a. Constitutional (fever, weight loss) b. Eyes c. Ears, nose, mouth, throat d. Respiratory e. Cardiovascular f. Gastrointestinal g. Genitourinary h. Musculoskeletal I. Integumentary (skin and/or breast) j. Neurologic k. Psychiatric l. Endocrine m. Hematologic/lymphatic n. Allergic/immunologic
    • O: 1. Constitutional a. Vital signs (including height and weight) 1 b. General appearance 1 2. Organ system examination 3 a. Ears, nose, mouth and throat b. Eyes c. Respiratory d. Cardiovascular e. Gastrointestinal f. Genitourinary g. Musculoskeletal h. Skin I. Neurologic j. Psychiatric k. Hematologic/lymphatic/immunologic 3. Lab or other studies A: Assessment /Differential Diagnosis 1 P: 1. Lab or other diagnostic studies 1 2. Treatment/Prescriptions 1 3. Education 1 4. Follow up 1 Quality of H&P: 1. The H&P was well organized and easy to follow 1 2. The HPI included all pertinent positives and negatives 1 3. The H&P was neat and comprehensible 1 4. The H&P included appropriate wording and abbreviations 1 5. The H&P included a thorough assessment/differential diagnosis 1 Total score: /(25) COMMENTS: Signature: ________________________________
    • FAMILY MEDICINE CLERKSHIP COMMUNITY RESOURCES PROJECT Please search the internet (and other resources, as appropriate) for information and a patient handout on your particular subject. Review the handout and revise it as appropriate based on the following requirements and your research of the topic. You may instead create an original handout if you wish. You need to list a minimum of three sources for references. A hard copy of your handout as well as a copy on floppy disk will be collected when you present your project. Student: _______________________ Topic: _______________________ I. The first section will look for the presence of required material. Must have at least five elements. Note: Some of the required elements may not be pertinent for certain topics. 1. Subject 2. Epidemiology 3. Symptoms 4. Rationale for using suggested resources or activities 5. Minimum of three community resources, with discussions of each resource 6. Treatments 7. Side effects of treatments 8. Benefits to use of suggested resources or activities 9. Drawbacks to use of suggested resources 10. Minimum of three references II. The next section involves the overall quality of the handout. Poor Fair Good Excellent 1. Content appropriate for lay person 0 1 2 3 2. Wording appropriate for lay person 0 1 2 3 3. Organized and easy to follow 0 1 2 3 4. Accurate and thorough information 0 1 2 3 5. Use of current and reputable references 0 1 2 3 III. Extra credit of one (1) point may be given for eye appeal/appearance Total Score ____________________________/(25) Evaluator _____________________________
    • Techniques to Improve Patient Education Handout for Patients 1. Define the purpose of the material. Decide when and how the brochure will be used and provide behavioral objectives by giving "how-to" information. For example, instead of writing "The medication should be taken twice a day with food," write "Take one pill with breakfast and one pill with supper every day." 2. Use short, eight- to10-word sentences. When possible, use simple words with one or two syllables, write in the active voice and use a conversational style. For example, instead of writing, "Use of nasal saline lavage, followed by nose blowing, greatly decreases nasal congestion," write this: "Spray the salt water into your nose and then blow your nose. Now you can breathe better." 3. Select a type style that is easy to read. Write subheading in uppercase and lowercase letters, and use bold type to emphasize key information in the text. Avoid using italics and abbreviations. 4. Use a great deal of white space between segments of information. Use shorter paragraphs. This appearance is less threatening to readers with low literacy levels. 5. Provide a question-and-answer page for patient interaction. If teaching with a booklet, underline key points with a pen or highlighter. 6. Include simple, meaningful, culturally sensitive graphics. It’s important that artwork includes a variety of races and cultures, particularly the ethnic or cultural groups most common in your practice. The text should also reflect the target audience’s cultural beliefs and values. 7. Use cues such as arrows, underlines and bullets to help the reader’s eye focus on the most relevant information. Choose paper colors that appeal to the target audience. The cover of the brochure should be colorful and appealing, and a heading should briefly indicate the message in the text. 8. If possible, use language in the text that your patients would use. This familiar language allows them to focus more on the message and less on decoding the words. (From Mayeaux EJ, Murphy PW, Arnold C, et al. Improving Patient Education for Patients with Low Literacy Skills. American Family Physician 1996;53:205-211.)
    • Commentary Concerned about the information medical students receive when making residency choices, the Association of Professors of Medicine (APM)—the national organization of chairs of departments of internal medicine at U.S. medical schools and several of their affiliated teaching hospitals— commissioned a series of three commentaries aimed at providing students and their advisors valuable information regarding three specialties whose practitioners care for adults: internal medicine, family medicine, and combined internal medicine/pediatrics. This commentary details the differences in residency training between internal medicine, family practice, and medicine/pediatrics. The series will continue next month with an article that addresses the qualitative and quantitative differences in the clinical practice of the three disciplines. In April, the final article will articulate the clinical philosophies of internal medicine, family practice, and medicine/pediatrics. APM hopes these commentaries will serve to help medical students gain a clearer understanding of the options available in primary care as they make their career selections. Caring for Adults: A Comparison of Three Residency Options CASE SCENARIO A programs. third-year medical student is referred to your office for discussion of future residency The student has decided that her medical career must include caring for adult patients. After a recent pediatric rotation, she also gets excited about possibly adding pediatrics. She is now left with the dilemma of internal medicine alone, combined internal medicine/pediatrics, or family medicine. She understands that you have helped other students compare and evaluate these three career paths, and she hopes to obtain an objective comparison. This paper explores the objective differences and similarities between residency education in internal medicine, combined internal medicine/pediatrics, and family practice. How do the objective differences shape the outcomes from postgraduate education? What advice should be offered to students who seek help in deciding the best personal career option? GOALS, ACCREDITATION, AND CERTIFICATION The most obvious differences between the three residency programs include the length of training and the stated goals of residency training. Internal medicine residency is 3 years in length and requires the ‘‘study and practice of health promotion, disease prevention, and diagnosis and treatment of men and women from adolescence to old age, during times of health and through all stages of acute and chronic illness’’ (1). Family practice residency requires formal rotations in internal medicine, pediatrics, obstetrics, gynecology, and surgery over 3 years. ‘‘The goal of the family practice training program is to produce fully competent physicians capable of providing care of high quality to their patients. Family practice residency programs should provide opportunity for the residents to learn, in both the hospital and ambulatory settings, those procedural skills that are within the scope of family practice’’ (2). The combined internal medicine/pediatrics residency programs are 4 years in duration with the stated objective of ‘‘training. . .general physicians for practice/academic careers addressing the spectrum of illnesses in the newborn, children, adolescents, and adults’’ (3). In all programs, it is preferable to complete one’s education in the same residency program to facilitate continuity of patient care over several years. The guidelines for both family practice and combined internal medicine/ pediatrics specifically address this issue. Accreditation of internal medicine and family practice residency programs is conducted by
    • the constituted Residency Review Committee (RRC) for each specialty. Combined internal medicine/pediatric programs are not accredited by an individual RRC, but the medicine component and the pediatric component of the combined program are separately accredited by the RRC responsible for the sponsoring categorical programs. Moreover, combined internal medicine/pediatrics programs function under guidelines approved by the American Board of q1998 by Excerpta Medica, Inc. APM Association of Professors of Medicine Pediatrics (ABP) and the American Board of Internal Medicine (ABIM). It is expected that upon completion of the family practice program, the candidate will pass the examination given by the American Board of Family Practice; similarly, candidates from internal medicine are expected to pass the examination prepared by ABIM. Residents finishing approved combined internal medicine/pediatrics programs may take the certification examinations from both ABIM and ABP. In the case of the combined residencies, a senior resident may not take either specialty examination until he/she completes the full 4-year integrated program. CURRICULUM Medicine Training The curricular requirements between the three residencies vary dramatically (Figure). The family practice resident is required to have a minimum of 8 months of formal training in adult medicine. Six of the 8 months must be in the inpatient setting; of the 8 months, there is 1 month each of required critical care experience and required cardiology experience. Internal medicine residents, as of July 1998, will be required to spend 12 months on inpatient rotations and a minimum of 12 months in the ambulatory environment. Internal medicine residents will be required to have 3 months of intensive care experience (but no more than 6 months). They will also need to have demonstrated significant experience in cardiology and an experience in geriatric medicine. In contrast, combined internal medicine/pediatrics residents must obtain 20 months of experience with ‘‘meaningful patient responsibility’’ (responsible for decision making, order writing, and planning follow-up care) in the domain of internal medicine. These 20 months include a specific rotation in geriatric medicine and 2 months of intensive care experience. The number of inpatient months are not specified, but, since residents in internal medicine programs will be required to have a minimum of 12 months in the inpatient setting, the internal medicine/pediatrics resident should have a minimum of 8 inpatient months. The remainder of the experience in internal medicine must include significant exposure to cardiology and 6 months in ambulatory settings to include subspecialty internal medicine clinics as well as continuity care. Four months of the total 24 months may include internal medicine subspecialties and horizontally related specialty rotations, such as psychiatry, during which the resident may have less personal patient responsibility. Pediatric Training Combined internal medicine/pediatric residents spend 24 months in a pediatric setting with 50% of the time spent in an ambulatory setting. The pediatric inpatient ward experience requires 5 months with at least 2 months in a supervisory role. Three months of neonatal intensive care unit are required, as is 1 month in a pediatric intensive care unit. In addition, the medicine/pediatrics resident is required to experience minimally 1 month specifically in the care of a normal newborn infant. The medicine/ pediatrics resident is also required to
    • participate in at least 4 months of pediatric subspecialty experiences. Pediatric experience in family practice includes 4 months of block inpatient or outpatient formal experience as well as the continuity care of children over the 3 years of residency. There is no pediatric requirement for residents in internal medicine programs, though education in the care of adolescents is required and a clinical experience is strongly suggested. Figure. Comparisons among training components of residency programs. Flexible rotations refer to other core curricula, enrichment rotations, and electives. Association of Professors of Medicine 110 February 1998 THE AMERICAN JOURNAL OF MEDICINEt Volume 104 Emergency Medicine Training Emergency medicine is required in all three residency programs. Family practice requires a minimum of a 1-month block experience, while the internal medicine regulations require at least 4 weeks of direct experience in blocks of not less than 2 weeks. Internal medicine/pediatrics also requires two emergency medicine block experiences during the 24 internal medicine months as well as an additional 3 months of acute illness care during the pediatric component (1 month of which must be in an emergency department receiving emergency medical systems transport). The remaining 2 months of pediatric acute illness experience could be in a walk-in clinic, an urgent care center, or an emergency department. ‘‘Training in minor surgery and orthopedics should be included in this rotation’’ (3). Gender-Specific Care Training Formal education in the care of women differs between residency programs. Family practice requires a minimum of 2 months of experience in maternity care ‘‘including the principles and techniques of prenatal care, management of labor and delivery, and postpartum care. This must involve sufficient instruction and experience to enable residents to manage a normal pregnancy and delivery’’ (2). A continuity experience of rendering prenatal, natal, and postnatal care to pregnant women is also required. In addition, the family practice resident must have a minimum of 140 hours of ‘‘structured experience in the care of the gynecological system in non-pregnant women’’ (2). Separate from the experiences in obstetrics and gynecology, the family practice requirements clearly articulate the need for ‘‘education in the prevention and detection of diseases in women’’ (2), including societal issues, effect of the community on women’s health, and mental health issues of women. Internal medicine requirements include the area of ‘‘gender-specific health care’’ (1). It delineates the need for residents to receive instruction in the ‘‘prevention, counseling, detection, and diagnosis and treatment of women’s and men’s health’’ (1). It suggests the use of ‘‘women’s health clinics, obstetric or gynecologic clinics [sexually transmitted disease] clinics, general medicine clinics, urology clinics, and other specialty clinics’’ (1) for related clinical experiences. Medicine/pediatrics guidelines do not specify time for experience in gender-related illnesses but the expectation is to parallel the requirements as specified for the categorical internal medicine programs. Specialized Training Family practice programs must adhere to other time-defined requirements in a broad range of specialties. All residents must have a structured 2-month experience in surgery including ambulatory and operating room experience. A minimum of 140 hours is dictated in a structured experience in the care of orthopedic disorders in addition to a sports medicine experience. Sixty hours of dermatology and 60 hours of formal instruction in practice management are defined. Other curricular experiences in the care of the older patient, community medicine (including occupational medicine and disease prevention/ health promotion), and diagnostic imaging and nuclear medicine are required without specific time allocation. The family practice resident is encouraged to learn the ‘‘procedural skills within the scope of family practice’’ (2). Internal medicine training
    • requirements define structured educational experiences in consultative medicine, adolescent medicine, preventive medicine, sports medicine, school health, and non-internal medicine specialties including psychiatry, dermatology, medical ophthalmology, otorhinolaryngology, orthopedics, and rehabilitation medicine as necessary for the practice of internal medicine. The requirements do not dictate length of rotation or method of learning. Internal medicine residents are required to develop technical proficiency in advanced cardiac life support, techniques to obtain venous and arterial blood, abdominal paracentesis, thoracentesis, arthrocentesis of the knee, central venous line placement, lumbar puncture, and nasogastric intubation. Proficiency in additional procedures should be determined by ‘‘the training environment, residents’ practice expectations, the availability of skilled teaching faculty, and privilege delineation’’ (1). Combined internal medicine/pediatrics guidelines do not specify the required procedures but because the programs are accredited with the categorical program, it is expected that the combined residents will fulfill the same procedural and general curricular requirements. The RRC for family practice precisely outlines the curriculum required in human behavior and mental health. This educationisto be primarily accomplished in the ambulatory setting through both longitudinal clinical experiences and didactic sessions supervised by family physicians, psychiatrists, and behavioral scientists. The RRC for internal medicine is less proscriptive in its description of the ‘‘psychosocial curriculum,’’ but does demand that the resident ‘‘receive instruction and feedback to master the interviewing, communication, and interpersonal skills that are necessary to elicit and record athorough and accurate history, establish and maintain a therapeutic physician-patient relationship, and initiate or motivate the patient to implement optimal medical management’’ (1). In addition to covering these specific internal medicine requirements, the combined medicine/pediatrics resident receives specific instruction in the psychosocial problems of the adolescent and must complete a1-monthstructured experience in behavioral/ developmental pediatrics (Table). Ambulatory Continuity A major difference that divides the three residency programs is the proscriptive concerning the continuity ambulatory requirement. All programs require the resident to follow a panel of undifferentiated patients over the complete length of training and limit block interruptions to maintain continuity. All programs dictate a minimum of 1 half-day per week of continuity experience beginning in the first postgraduate year. Divergence of the proscriptive experience includes the minimal continuity time for senior residents, the number of patients seen, and the setting in which the experience may occur. Combined internal medicine/pediatrics residents must minimally attend a half-day per week of continuity experience throughout 4 years. This experience may either be in a weekly combined medicine/pediatrics practice or by alternating weekly medical and pediatric continuity experiences. Experiences may be in hospital clinics, free-standing health centers, or private practices. Residents are encouraged to follow their patients throughout any hospitalization. Internal medicine residents may also be assigned to continuity experiences in hospital general medical clinics, free-standing health centers, or private offices as long as the resident follows a panel of patients for which he/she has responsibility. The duration of assignment is for the entire 3-year residency program to provide for observation of the natural course of disease. Residents are to be assigned on average not less than one new patient and three return patients each half-day. Family practice dictates that the first-year resident must be assigned three patients each half-day (defined as at least 3 hours) of continuity practice. In the second year of training, residents must be assigned to their continuity practice minimally 2 half-days per week and see a minimum of six patients per session. In the third postgraduate year, the resident is assigned minimally 3 half-days to the practice and must see eight patients per session. The unique aspect of family practice programs is that the continuity experiences must be in approved family practice centers. As the core of every family practice program, the center is designed to be the ‘‘primary setting for training in the knowledge, skills, and attitudes of family practice’’ (2). The center
    • must be ‘‘for the exclusive use of the residency, i.e., all activities in the family practice center must be residency-related and under the direction of the program director’’ (2).TheRRC for family practice specifically outlines the staffing, resident workspace, number of examination rooms, faculty offices, and Table. Comparison of Prescribed Curricula in Human Behavior and Mental Health Family Practice Internal Medicine Medicine Pediatrics Medical ethics, including patient autonomy, confidentiality, and quality of life issues Clinical ethics to include the principles of bioethics Clinical ethics to include the principles of bioethics Alcoholism and other substance abuse Substance abuse disorders Substance abuse disorders Patient/physician relationship Patient/physician relationship Patient/physician relationship Patient interviewing skills Patient interviewing skills Patient interviewing skills Family violence including child, partner, and elder abuse (physical and sexual), as well as neglect Principles of recognition and management of domestic violence and sexual, family, and elder abuse Principles of recognition and management of domestic violence and sexual, family, and elder abuse Psychopharmacology Physician impairment Physician impairment Emotional aspects of non-psychiatric disorders End-of-life care End-of-life care Normal psychosocial growth and development in individuals and families Adolescent psychology Stages of stress in a family life cycle Behavioral/developmental pediatrics Sensitivity to gender, race, age, sexual orientation, and cultural differences in patients Counseling skills Diagnosis and management of psychiatric disorders in children and adults Factors influencing patient compliance educational space required. Although other health professionals might be educated within the center, the ‘‘efficiency and education of the family practice residents must not be compromised by the training of other health care professionals’’ (2). Qualitative Differences The qualitative differences among the residencies are reflected in the written requirements and the nonverbal expectations expressed by program faculty. The family practice ethos is repeatedly documented in the RRC requirements. ‘‘Continuity of care and family-oriented comprehensive care must be integral components of all programs. Residents must be taught throughout their training to demonstrate and to articulate clearly the following philosophy and concepts of family practice to patients and colleagues. The family physician assumes responsibility for the total health care of the individual and family, taking into account social, behavioral, economic, cultural, and biologic dimensions’’ (2). The RRC restates the same precepts: ‘‘The program should implement a plan to ensure that residents retain their identity and commitment to the principles and philosophic attitudes of family practice throughout the training program, particularly while they rotate on other specialty services’’ (2). The success of the continued emphasis on keeping the resident directed toward the goals of the specialty are definitely reflected in the outcome of the residency programs. Greater than 95% of the graduates practice as family physicians and remain in the specialty. Internal medicine’s requirements are much less identity-directed and reflect the roots of internal medicine in the study of human physiology and the internal organs. This emphasis is reflected in the RRC statements: ‘‘The basic sciences should be integrated into the daily clinical activities by clearly linking the pathophysiologic process and findings to the diagnosis, treatment, and management of clinical disorders. Residents should acquire an in-depth understanding of the basic mechanisms of normal and abnormal human biology and behavior and the application of current knowledge to practice’’ (1). The roots of the specialty are further emphasized in the requirement that ‘‘conferences should include information from the basic medical sciences, with emphasis on the pathophysiology of disease and reviews of recent advances in clinical medicine and biomedical research’’ (1). With the greater time spent in intensive care units, inpatient wards, and subspecialty services, the majority of internal medicine graduates have entered subspecialty postgraduate programs. Given the change in medical practice with a much greater proportion of diagnostic workups and a majority of chronic medical management completed in the ambulatory setting, there has been a resurgence of graduates remaining in general internal medicine. The most current report from ABIM demonstrates 47% of recent graduates entering subspecialty programs (4). Combined internal medicine/pediatrics programs were first begun in the early 1970 stoofferanin-depth pathway to the care of patients of all ages. Current studies demonstrate that 88% of graduates care for both adults and children,with70%caring for patients in a primary care setting (5). Data obtained in the late 1980s demonstrated that students who opted for medicine/pediatrics had considered
    • internal medicine as a second option, not family practice (6).Although the pool of applicants for family practice and combined medicine/pediatrics overlap, many program directors believe that the applicant pool substantially differs based on personal approach to medical problem solving and comfort in caring for the undifferentiated patient. The need to know the physiological and biological basis for disease is offset by one’s ability to handle uncertainty. Some describe a deductive versus inductive approach to patient care. Where an individual falls along the continuum will often dictate their final choice of career. Response to the Student A good advisor understands the differences in the specialty career paths and remains aware of the continuous changes that occur in accreditation requirements and the variability between individual programs. The advisor can serve as the guide for the student as he explores his personal approach to learning and patient care. The answer to the correct career path lies with the individual characteristics of the physician as he/she relates to the differences in the specialties. It is fortunate that several options are available to physicians who wish to be personal physicians for adults and/or their families. Barbara Schuster,M.D. Mark Clasen, M.D., PhD Gary Onady, M.D., PhD Dr. Schuster chairs the Department of Internal Medicine at Wright State University School of Medicine. Dr. Clasen is the Chair of the Department of Family Medicine at Wright State University School of Medicine. Dr. Onady serves as Program Director for Internal Medicine/Pediatrics at Wright State University School of Medicine. REFERENCES 1. Accreditation Council for Graduate Medical Education. 1998 Program Requirements for Residency Education in Internal Medicine. Approved June 10, 1997. 2. Accreditation Council for Graduate Medical Education. 1997 Program Requirements for Residency Education in Family Practice. Approved September 1996. 3. American Board of Internal Medicine. Guidelines for Combined Internal Medicine/Pediatrics Residency Training. Approved ABIM September 1996, Approved ABP April 1997. 4. American Board of Internal Medicine. ABIM News Update. Summer 1997. 5. Kimball HR. The med/peds physician in contemporary medical practice. Am J Med. 1997;102:1–5. 6. Schubinar H, Schuster B, et al. The perspectives of current trainees in combined internal medicine-pediatrics. AJDC. 1993;147:885– 889. Association of Professors of MedicineFebruary 1998 Responses to Questions About the Specialty of Family Practice as a Career JULEA G. GARNER, M.D. American Academy of Family Physicians Kansas City, Missouri JOSEPH E. SCHERGER, M.D., M.P.H. University of California, Irvine, College of Medicine Irvine, California JOHN W. BEASLEY, M.D. University of Wisconsin Medical School
    • Madison, Wisconsin WM. MACMILLAN RODNEY, M.D. University of Tennessee, Memphis, College of Medicine Memphis, Tennessee DAVID E. SWEE, M.D. University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School New Brunswick, New Jersey ELIZABETH A. GARRETT, M.D., M.S.P.H. University of Missouri-Columbia School of Medicine Columbia, Missouri NORMAN B. KAHN, JR., M.D. American Academy of Family Physicians Kansas City, Missouri This article provides answers to many of the questions medical students ask about the specialty of family practice. It is the fourth update of a previous article and was developed in response to feedback from medical students at the 1997 National Congress of Student Members held by the American Academy of Family Physicians. Students at the 1998 Congress also identified areas of interest and concern. This article discusses the hours and income of the family physician, the scope of medical practice in the specialty, required continuing medical education and board certification, family practice residency training and combined-specialty training. (Am Fam Physician 1999;60:167-74.) Medical students frequently have questions about the specialty of family practice and what a family physician does. As defined by the American Academy of Family Physicians (AAFP), the family physician is one who has been educated and trained to provide continuing and comprehensive medical care, health maintenance and preventive services to all members of the family regardless of sex, age and type of problem (i.e., biologic, behavioral or social).1 This article is the fourth update of an earlier article and provides the most current information about family practice. It was developed after feedback on the previous article was obtained from students who attended the AAFP's 1997 National Congress of Student Members (NCSM). Medical students at the 1998 NCSM also identified the areas they considered to be of most interest and concern. Much of the core information about the specialty of family practice and the values of the family physician remains unchanged. The family physician continues to be trained to care for patients of all ages in the family practice center, the emergency department, the hospital, the nursing home, the sports field and the family home. The family physician can manage 90 percent of patients' health problems, accessing consultants as necessary.2 Although the face of health care as a whole has changed dramatically in the past few years, the need and demand for family physicians by the U.S. population and health care delivery system remain great.3 What is life like for a family physician? Is there enough time for a good personal life? Balancing a busy professional career with a satisfying personal life is a challenge for all physicians. Being family- and community-oriented, family physicians strive to achieve this balance. The work schedules of family physicians vary considerably, depending on the practice setting and type of medical group. With greater numbers of women entering family practice and the increased prevalence of two-career families, flexible models of practice, including part-time and shared arrangements, have become more common.
    • TABLE 1 Family Medicine Fellowships as of Family physicians work an average of 53 hours per January 1, 1998 week, with about 43 of these hours spent in direct patient Number of institutions care. On average, they work 48 weeks per year, which Type of fellowship offering fellowships* leaves four weeks for vacation and continuing Faculty development 40 education.4 These numbers are in the middle range for all Sports medicine 37 physician specialties.5 Geriatrics 19 Obstetrics 20 In the past, solo family physicians were on call for their Research 8 patients after office hours. Currently, most family Rural medicine 5 physicians share responsibility for after-hour emergency Substance abuse 2 calls with a group. This arrangement greatly reduces Adolescent medicine 1 interruptions of their personal time. Preventive medicine 1 Other 38 What is the average income of a family physician? As a *--The numbers do not add to a total because the family physician, will I be able to repay my student loans responding institutions may offer more than one type of and live a comfortable lifestyle? fellowship. Respondents were mainly family practice residency programs but also included departments of The income of family physicians has risen rapidly during family medicine, other agencies within medical the 1990s. According to Medical Economics, family schools, clinics, substance abuse treatment centers and physicians led the list for advances in income among all others. primary care disciplines, with a 24.8 percent increase Adapted from Facts about family practice, 1998. between 1990 and 1995.6 As of 1997, the average net Kansas City, Mo.: American Academy of Family income for family physicians not doing obstetrics was Physicians, 1998:204. $136,002 (compared with $139,879 for internists and $131,803 for pediatricians).7 The average net income for all specialties in 1997 was $220,476.7 Although dramatic increases in financial compensation probably will not be sustained, the need and demand for family physicians will provide continued income support. Moreover, the current surplus of sub specialists has placed downward pressure on their income. Along with higher initial earnings, starting family physicians are gaining a greater amount of income compared with more established physicians.8 Most newly graduated family physicians have used this higher income to pay off their student loans more rapidly. Furthermore, many underserved communities offer loan forgiveness programs to attract family physicians. Given the multitude of practice arrangements available, family physicians can expect to achieve a comfortable lifestyle and pay off student loans. What is the scope of practice for family physicians? Family physicians engage in a broad range of clinical activities. A family physician may choose the most comprehensive style of family practice, in which he or she is the only local source of health care for a community. This type of practice includes providing care for patients in the office, the hospital critical care unit and local nursing homes, providing support for local sports teams, managing trauma patients, performing surgical procedures and delivering infants (including cesarean sections). At the other end of the spectrum is the family physician who limits his or her practice to outpatient care, often in the setting of a multispecialty group.9 In either extreme, the family physician may be a practice owner or an employee. Most family physicians have a practice that is somewhere between the two extremes. These family physicians have a comprehensive office practice with or without low-risk maternity care. They assist with cesarean sections and minor surgeries, care for their hospitalized patients with consultants as necessary, perform a wide range of office procedures, make nursing home and home visits, and may serve as team physician for the local high school. This type of practice is found in a variety of locations in all parts of the United States.
    • TABLE 2 Performance of Diagnostic Some family physicians develop an area of special Procedures in Family Physicians' interest and expertise, such as sports medicine, geriatrics, Offices as of May 1997* preventive care, international health, women's health, Percentage adolescent health or research. Others choose career paths performed in Diagnostic procedure the office in public health, administration, emergency medicine, part-time urgent care or teaching.9 Fellowships after Electrocardiography 82.7 Dermatologic procedures 75.3 residency are available to further develop a particular Endometrial sampling 56.8 area of interest10 (Table 1).4 Spirometry 55.4 The types of procedures performed by family physicians Audiometry 53.8 are as varied as the scope of practice (Table 2).4 The Flexible sigmoidoscopy 45.6 Chest radiography 44.7 range of procedures includes, but is not limited to, Other radiography 44.7 assisting in major surgeries and performing cesarean Tympanometry 40.6 sections, vasectomies, flexible sigmoidoscopy, Colposcopy 32.6 colposcopy, skin biopsy and lesion removal, cryotherapy Vasectomy 30.8 of skin lesions and the cervix, cervical biopsy, Tonometry 25.7 endometrial biopsy, spirometry, exercise treadmill Holter monitoring 25.0 testing, splinting and casting, obstetric ultrasound and Rigid sigmoidoscopy 15.8 endoscopy of the nasopharynx, larynx and Laryngoscopy 13.6 gastrointestinal tract.9,11-27 Cardiac stress testing, treadmill 12.9 Loop electrosurgery 12.7 The AAFP's philosophical statement on the scope of Ultrasonography (obstetric) 10.3 family practice notes that "the specialty is three- Nasopharyngoscopy 8.9 dimensional, combining knowledge and skill with a Mammography 6.5 unique process. The patient-physician relationship is Colonoscopy 4.3 central to this process. ... Knowledge and skills vary Echocardiography 3.9 among family physicians according to their patients' Esophagogastroduodenoscopy 3.6 needs and the ability to incorporate new information into Cardiac stress testing, two step 3.0 their practices. Above all, the scope of family practice is dynamic, expanding, and evolutionary."28 How can I possibly keep current with medical advances in the care of children, adolescents, adults, older adults, men, women and pregnant women? Family practice was the first specialty to require continuing medical education (CME) and the first specialty board to require periodic recertification. As part of the seven-year recertification process, each family physician must complete 50 hours of CME for each subsequent year after residency completion.29 This education enables family physicians to keep their knowledge base current. CME credits can be obtained from a variety of sources, including journals, courses, national, regional and local lectures, teaching, audio and video programs, telemedicine, CD-ROMs and Internet services. Many family physicians access information from computer-based medical programs and Internet services on a regular basis. Physician-to-physician communication and focused consultations are other excellent ways to learn and stay current. In addition, a teacher learns twice. Many family physicians precept and teach. These physicians continually add to and reinforce their own knowledge base. Their participation in the instructional process keeps them current and intellectually refreshed. What is involved in family practice residency training?
    • The number of family practice residency programs has continued to grow. As of 1998, a total of 475 accredited programs provided more than 10,500 residency positions.30 Graduates of U.S. medical schools fill 85 percent of these residency positions. Family practice residencies are based in academic medical centers, community hospitals, community health centers, health maintenance organizations and U.S. military installations. Residency training provides future family physicians with integrated inpatient and outpatient learning over a period of three years. Family practice residencies give extensive in-hospital training in the care of adults and children, maternity care, emergency and critical care, and other inpatient situations. Equally important, family practice residencies have a strong focus on learning in the outpatient setting. Thus, residents have an opportunity to learn by providing continuous care to a population of families. Family practice residents learn how to comprehensively manage the multiple problems of patients and their families, including health risks and psychosocial problems. They develop meaningful relations with their patients over time, and they also engage in community health experiences. Most programs provide opportunities for family practice residents to do research and to teach medical students and more junior residents. Different residencies provide varying opportunities to develop specific procedural skills, but all provide enough training for residents to develop a high level of technical skill in a broad range of common procedures. Newer training models, including rural training tracks, provide exceptionally rich clinical experiences with a wide variety of populations of all economic strata and levels of medical need. Learning to address the needs of ethnically and racially diverse patients is considered an important aspect of family medicine training, as is learning to care for the medically underserved. Although good stewardship of health care resources and cost containment are part of the curriculum of most programs, family practice residency training focuses on providing the skills needed to be the patient's advocate. In addition, newer curricula in managed care are directed at going beyond a strictly clinical role within managed care settings to a role in shaping the future of health care organizations. Satisfaction with family practice residency training tends to be high. Graduates indicate that their residency did an "excellent" or "good" job of preparing them for practice, especially with regard to coordinating care with community resources, providing preventive care and providing cost-effective care.31 What is the difference between a family practice residency and combined residencies in internal medicine and pediatrics, family practice and psychiatry, and family practice and internal medicine? During the past several years, modest growth has occurred in the development of residency education programs that use other models for generalist training, such as combined residencies in internal medicine and pediatrics or family practice and another specialty. Combined specialty programs must be approved by each respective board in order for graduates to be eligible for certification. In dual certification, each board makes an independent ruling on the eligibility of every candidate for board certification. The American Board of Family Practice and the American Board of Internal Medicine each offer certification to graduates of a handful of programs that provide for completion of four years of combined training. Currently, fewer than five such programs are available in the United States. The certifying boards of family practice and psychiatry and neurology each offer certification for the completion of at least five years of training in a combined residency. At present, fewer than 15 of these programs are available in this country. The American Board of Internal Medicine and the American Board of Pediatrics offer certification for the
    • completion of a combined residency that includes two years in each specialty, for a total of at least four years. In 1998, there were approximately 100 such programs.32 Compared with family practice residencies, dual certification programs tend to emphasize inpatient medicine. They also tend to offer broader exposure to the "specialist aspects" of each specialty. They tend to place less emphasis on continuity of care in the outpatient setting. No evidence shows that the graduates of any of these combined programs are more effective in practice or obtain more privileges than those who graduate from a family practice residency program.33 In fact, evaluations of these programs often use family practice as the benchmark. Only about 68 percent of physicians trained in internal medicine and pediatrics, for example, actually practice primary care medicine, and only about 55 percent practice both internal medicine and pediatrics.34 In contrast, family medicine is practiced by more than 91 percent of the physicians who received training in a family practice residency during the first 25 years that the training was offered, and family medicine is practiced by more than 93 percent of current graduates of family practice residency programs.35,36 Graduates of dual certification programs face some special challenges. Some have complained about difficulties in being listed by managed care organizations under both specialties at the same time. They must maintain certification with two boards and membership in two national organizations. They also must obtain coverage for patients during off hours. Unless another physician with the same dual certification is available, coverage must be obtained from two physicians at the same time. However, family physicians are able to provide coverage for patients of almost all dual-certified physicians who are practicing primary care medicine. What is the future of family practice? The AAFP has analyzed the physician work force and called for U.S. family practice residency programs to graduate 3,700 to 4,100 family physicians each year to meet the need for these physicians in the United States (i.e., a goal of 35.1 family physicians per 100,000 people).37 A total of 3,380 family physicians graduated in 1998, and 3,570 to 3,580 family physicians are projected to graduate this year and in 2000.37 These projections take into consideration the number of general internists and general pediatricians, as well as the growing number of physician assistants and nurse practitioners.37 Family physicians have been (and are still) the most recruited physicians for managed care systems, as well as for rural and inner-city practices.38,39 Opportunities and challenges for family physicians persist, more than for any other specialty. Family physicians are suited for practice in the smallest and largest communities, in partnerships, in single specialty or multispecialty group practices, and in fee-for-service or managed care systems. The challenge is to continue to distribute family physicians in the same percentages as the U.S. population so that every American has access to cost-effective, comprehensive, continuous primary care services. The family practice specialty has gone a long way toward meeting the nation's health care needs. Indeed, family practice is the only medical specialty in which physicians distribute themselves in the same geographic proportions as the American people.40 Family physicians will continue to work with other health care providers to ensure that all Americans have access to primary care. What career opportunities will be available to me as a family physician? Family physicians continue to have great career flexibility, with documented needs in a variety of areas. Most family physicians care for patients in group and private practices. Another option is academic medicine. A 1994 survey of family practice residencies and academic departments revealed a short-term need of nearly 1,200 faculty positions.41,42 In addition, there is a critical need for more investment in and support
    • for primary care research.43 The major research initiative launched by the AAFP in 1997 has underscored the need for more family physician researchers. Important contributions in teaching and research are not limited to full-time faculty positions. As many as 30 percent of community-based family physicians teach medical students in their offices, and an increasing number are participating in practice-based research networks.44,45 In addition, 51 percent of U.S. family physicians include some emergency room care in their practices, with as many as 88 percent providing this type of care in some states.4 A full-time career in emergency medicine was chosen by 4 percent of physicians who completed family practice residencies in 1969 through 1993.35 Many managed care organizations consider family physicians to be the specialist of choice because of their breadth of skills, the quality of care provided and their skills in preventive care.46,47 Family physicians with interest and expertise in public policy and administration can find challenging careers at all levels of influence, from the local community to state and federal agencies. For example, family physicians are directors of state health departments, legislators, administrators in managed care organizations and heads of federal bureaus. A family physician, David Satcher, M.D., became Surgeon General of the United States in 1998. International opportunities are especially exciting at this time, with many initiatives in progress to develop family medicine training programs and models of care in countries around the world. These opportunities are in addition to the more traditional roles of practicing physicians in a multitude of settings in developing countries.48 How satisfied are family physicians with their career choice? Family physicians are as satisfied and in some cases more satisfied with their participation in managed care organizations than consulting subspecialists.49 As more physicians have moved into the status of employees rather than business owners, no change in physician satisfaction has become apparent. A nonsignificant loss of perceived physician control among employed physicians is compensated for by significantly more satisfaction with leisure and family time.50 The results of a recent survey published in Medical Economics suggest that generalists are more satisfied with their freedom to make treatment decisions than are subspecialists.51 A survey of younger physicians in California found that 92 percent of family physicians were satisfied with their practice choices.52 With the profession of medicine changing so rapidly, perhaps a more important question is "How satisfied will family physicians be in the future?" It appears that family physicians are faring better than most physicians in the evolving medical environment. Certainly the demand for family physicians has increased dramatically because of the cost-effective care they deliver.53 Their ability to coordinate care, to take responsibility for patient care, to use resources wisely and to be efficient and comprehensive bodes well for the future. Finally, it should be noted that family physicians have great control over their level of satisfaction in their professional lives. Family physicians who include maternity care in their practice and who are in small group practices are generally more satisfied.54 Physicians whose main value is benevolence (e.g., as contrasted to power) are the most satisfied.55 As a whole, family physicians report being extremely satisfied with their general professional life, intellectual stimulation, status within the community, clinical competence and long- term relationships with their patients.56 The authors thank Diana Swafford for assistance in the preparation of the manuscript. *--The data were derived from the responses of active members of the American Academy of Family Physicians.
    • Adapted from Facts about family practice, 1998. Kansas City, Mo.: American Academy of Family Physicians, 1998:98. The Authors JULEA G. GARNER, M.D., currently has a private practice in Arkansas. Previously she served as assistant director of the Division of Education of the American Academy of Family Physicians, Kansas City, Mo. JOSEPH E. SCHERGER, M.D., M.P.H., is associate dean for clinical affairs and chair of the Department of Family Medicine at the University of California, Irvine, College of Medicine. JOHN W. BEASLEY, M.D., M.P.H., is associate professor of family medicine at the University of Wisconsin Medical School, Madison, director of the Madison Family Practice Residency Program and director of the Wisconsin Research Network. WM. MACMILLAN RODNEY, M.D., previously served as chair of the Department of Family Medicine at the University of Tennessee, Memphis, College of Medicine. He continues part-time practice of emergency and family medicine in rural Tennessee with his group, Advanced Family Medicine Specialists. DAVID E. SWEE, M.D., is professor and chair of the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, and chief of the Department of Family Medicine at Robert Wood Johnson University Hospital. ELIZABETH A. GARRETT, M.D., M.S.P.H., is professor of family and community medicine at the University of Missouri-Columbia School of Medicine. NORMAN B. KAHN, JR., M.D., is vice president of education and science for the American Academy of Family Physicians. Address correspondence to Julea G. Garner, M.D., P.O. Box 75, Hwy 62/412 East, Glencoe, AR 72539. Reprints are not available from the authors. REFERENCES 1. American Academy of Family Physicians. Kansas City, Mo.: The Academy, 1993; AAFP reprint no. 300. Retrieved May 1999 from the World Wide Web: http://www.aafp.org/about/300_c.html. 2. Institute of Medicine, Division of Health Manpower and Resources Development. A manpower policy for primary health care: report of a study. Washington, D.C.: National Academy of Sciences, 1978:30. 3. American Academy of Family Physicians. Family physician workforce reform: recommendations of the American Academy of Family Physicians. Kansas City, Mo.: The Academy, 1995; AAFP reprint no. 305a. 4. Facts about family practice, 1998. Kansas City, Mo.: American Academy of Family Physicians, 1998. 5. Owens A. Are you taking enough time off? Med Econ 1990;67:54,58-62,66. 6. Rice B. Winning times for primary care physicians. Med Econ 1997;74:88-90,85-6,99. 7. Dunevite B. Physician compensation stays flat for a second year. MGMA Update 1998;37:1,9. 8. Carlson RP. How salary trends are affecting family practice. Fam Pract Management 1996;3:22-9. 9. Scherger JE, Beasley JW, Gaebe GI, Swee DE, Kahn NB, Rodney WM. Responses to questions about family practice as a career. Am Fam Physician 1992;46:115-25. 10. Fellowship directory for family physicians. Kansas City, Mo.: American Academy of Family Physicians, Society of Teachers of Family Medicine, 1998. 11. Harper MB, Mayeux EJ Jr, Pope JB, Goel R. Procedural training in family practice residencies: current status and impact on resident recruitment. J Am Board Fam Pract 1995;8:189-94. 12. Driscoll CE, Rakel RE, eds. Patient care procedures for your practice. Oradell, N.J.: Medical Economics, 1988. 13. Gordon PR, Weiss BD. Family physicians' colposcopy practices. J Am Board Fam Pract 1992; 5:27-30. 14. Rodney WM, Prislin M.D., Orientale E, McConnell M, Hahn RG. Family practice obstetric ultrasound in an urban community health center. Birth outcomes and examination accuracy of the initial 227 cases. J Fam Pract 1990;30:163-8. 15. Hocutt JE Jr, Corey GA, Rodney WM. Nasolaryngoscopy for family physicians. Am Fam Physician 1990;42:1257-68.
    • 16. Rodney WM, Hocutt JE Jr, Coleman WH, Weber JR, Swedberg JA, Cronin C, et al. Esophagogastroduodenoscopy by family physicians: a national multisite study of 717 procedures. J Am Board Fam Pract 1990;3:73-9. 17. Rodney WM. High tech is most effective when blended with high touch and vice versa: office technology in the 21st century [Editorial]. Fam Pract Res J 1991;11:235-9. 18. Wadland WC, Havron AF, Garr D, Schneeweiss R, Smith M. National survey on hospital-based privileges in family practice obstetrics. Arch Fam Med 1994;3:793-800. 19. Phillips WR. Diagnostic and screening procedures in family practice. Past, present, and future use. Arch Fam Med 1993;2:1051-7. 20. Pfenninger JL, Fowler GC, eds. Procedures for primary care physicians. St. Louis: Mosby, 1994. 21. Conner PD, Deutchman ME, Hahn RG. Training in obstetric sonography in family medicine residency programs: results of a nationwide survey and suggestions for a teaching strategy. J Am Board Fam Pract 1994;7:124-9. 22. Zuber TJ, Pfenninger JL. Interspecialty wars over endoscopy. J Fam Pract 1993;37:21-2. 23. Rodney WM. An approach to hospital privileges. Proc Skills Off Tech Bull 1997;10:106. 24. Larimore WL, Griffin ER. Family practice maternity care in central Florida: increased income, personal satisfaction and practice diversity. Florida Fam Physician 1993;53:25-7. 25. Rodney WM. Flexible sigmoidoscopy and the despecialization of gastrointestinal endoscopy. An environmental impact report. Cancer 1992;70(5 suppl);1266-71. 26. Norris TE, Felmar E, Tolleson G. Which procedures should be taught in family practice residency programs? Fam Med 1997;29:99-104. 27. Rodney WM. Family practice procedures [Letter]. J Fam Pract 1995;40:223-4. 28. American Academy of Family Physicians reference manual, 1998-1999. Philosophical statement on the scope of family practice. Kansas City, Mo.: The Academy, 1998:33. 29. American Board of Family Practice. Requirements for recertification. Retrieved May 1999 from the World Wide Web: http://www.abfp.org/recertif.htm. 30. American Academy of Family Physicians' residency census survey. Kansas City, Mo.: The Academy, 1998; AAFP reprint no. 150. Retrieved May 1999 from the World Wide Web: http://www.aafp.org/resident/rep-150.html. 31. Cantor JC, Baker LC, Hughes RG. Young physicians' views of their professional education. JAMA 1993;270:1035-40. 32. Graduate medical education directory 1998-1999. Chicago: American Medical Association, 1998: 1043-4. 33. Bowman MA. The quality of care provided by family physicians. J Fam Pract 1989;28:346-55. 34. Schubiner H, Lannon C, Manfred L. Current positions of graduates of internal medicine-pediatrics training programs. Arch Pediatr Adolesc Med 1997;151:576-9. 35. Kahn NB Jr, Schmittling G, Ostergaard D, Graham R. Specialty practice of family practice residency graduates, 1969 through 1993. A national study. JAMA 1996;275:713-5. 36. American Academy of Family Physicians. Report on survey of 1997 graduating family practice residents. Kansas City, Mo.: The Academy, 1997; AAFP reprint no. 155-W. 37. American Academy of Family Physicians. Delegates support Board Report G, "family physician workforce reform." In: 1998 congress summary. Retrieved May 1999 from the World Wide Web: http://www.aafp.org/MEMBERS/congress/1998/index.html. 38. Seifer SD, Troupin B, Rubenfeld GD. Changes in marketplace demand for physicians: a study of medical journal recruitment advertisements. JAMA 1996;276:695-9. 39. Miller RS, Dunn MR, Whitcomb ME. Initial employment status of resident completing training in 1995. JAMA 1997;277:1699-704. 40. Physician characteristics and distribution in the United States 1997/98 ed. Chicago: American Medical Association, 1997-98. 41. Holloway RL, Marbella AM, Townsend JM, Tudor JM, Tollison JW, Saultz JW, et al. Defining the need for faculty in family medicine: results of a national survey. Fam Med 1995;27:98-102. 42. Kahn NB, Barnes ND. Family medicine faculty recruitment crisis of the '90s [Editorial]. Am Fam Physician 1996;53:1514-7. 43. Task Force on Building Capacity for Research in Primary Care. Putting research into practice. Minneapolis: The Task Force, 1993:1-20. 44. Vinson DC, Paden C, Devera-Sales A, Marshall B, Waters EW. Teaching medical students in community-based practices: a national survey of generalist physicians. J Fam Pract 1997;45:487-94.
    • 45. Nutting PA. Practice-based research networks: building the infrastructure of primary care research. J Fam Pract 1996;42:199-203. 46. Burg B. Will you wind up on the unemployment line? Part I: what jobs are out there now. Med Econ 1995;72:170-6,181. 47. Mangan D. Will you wind up on the unemployment line? Part II: which jobs will be there tomorrow. Med Econ 1995;72:186-8,195,199-200passim. 48. Haq C, Ventres W, Hunt V, Mull D, Thompson R, Rivo M, et al. Where there is no family doctor: the development of family practice around the world. Acad Med 1995;70:370-80. 49. Schulz R, Scheckler WE, Moberg DP, Johnson PR. Changing nature of physician satisfaction with health maintenance organizations and fee-for-service practices. J Fam Pract 1997;45:321-30. 50. Kikano GE, Goodwin MA, Stange KC. Physician employment status and practice patterns. J Fam Pract 1998;46:499-505. 51. Managed care. Is physician discontent beginning to boil? Med Econ 1997:74:40. 52. California physician survey results of young physicians: more than 1100 young doctors reveal what they like and don't like about practicing medicine. Calif Phys 1995;12:22-35. 53. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA 1995; 274:1436-44. 54. Hueston WJ. Family physicians' satisfaction with practice. Arch Fam Med 1998;7:242-7. 55. Eliason BC, Schubot DB. Personal values of exemplary family physicians: implications for professional satisfaction in family medicine. J Fam Pract 1995;41:251-6. 56. Skolnik NS, Smith DR, Diamond J. Professional satisfaction and dissatisfaction of family physicians. J Fam Pract 1993;37:257-63. Copyright © 1999 by the American Academy of Family Physicians. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non- commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
    • Map of Brandon Outreach Clinic 517 N. Parsons Ave Brandon, FL 33510-3611 813-654-1388 I-75 S t.o Brandon Blvd./HWY 60 Head East on Brandon Blvd to Parsons Ave Head North on Parsons Just past the RR Crossing on your right/ Student Schedules for Brandon Outreach: Date Time Students Aug 4 5:15 to 7:30 {INSERT STUDENT NAMES} Sept 1 5:15 to 7:30 Judeo Christian Health Clinic 41201/2 N. McDill Avenue Tampa, FL 33607-6717 813-875-1968 Take I-275 to Dr. MLK Blvd. Head West on MLK to McDill Ave
    • Head South on McDill Clinic is behind the church Student Schedules for JCC: Date Time Students Aug 11 5:15 to 7:30 pm {INSERT STUDENT NAMES} Aug 18 5:15 to 7:30 pm Sept 8 5:15 to 7:30 pm Sept 15 5:15 to 7:30 pm