My third rotation was Ambulatory Care at Dr. DiFranco’s office. This was my first outpatient rotation as my previous two rotations were at QHC and VA. On my first day, my preceptor walked us through the EMR system and charts and recommended us to go over physical examination because she said we will be doing a full physical exam on almost all pts we see. Due to our current pandemic situation the office at Dr. DiFranco’s did not accept any pts with fever. Most of the pts we saw during this rotation came in with general symptoms such as abdominal pain, headaches, vomiting, cough, and back pain, but we also had a lot of pts who came in for follow ups and annual visit exams.

Every morning we would come in 30 min before the first patient to review the charts and get the examination rooms ready. Genna and I would then split the patients that were scheduled for that day and ask each other for help if needed. Once we saw our patient, wrote the HPI, performed physical exam, did EKG, reviewed medication with each patient and developed a plan for their treatment, we would then call in either the NP or Dr. DiFranco and they would make sure everything was okay and in order before sending that patient home.

One element that I liked during this rotation was the degree of freedom we had as students. At times, especially during my last 2 weeks there, I felt as I was actually working at Dr. DiFranco’s office and not a student. I really liked that exposure because not only it helped me with my interviewing skills but I also learned how to be more efficient and faster with my physical exam. Such exposure also helped me get a lot better in developing future plans for these patients and where exactly to refer them after their visit. I also appreciate that the NP there encouraged us to order labs, imaging and prescribe medication for all of our patients. We actually never placed such orders in the system but would write them on a word document and have her take a look at it before she made the final decision. Another element that I also liked during this rotation was the on-site learning. Although it was busy, NP and Dr. DiFranco would always find the time to ask us questions about a specific disease or have us evaluate an abnormal EKG. NP also had us look up different diseases and conditions at home and present it to her the next day which I thought it was very helpful and a great way to learn new things.

One memorable experience during this rotation was when I got to evaluate a patient with Limbal Stem Cell Deficiency. Limbal stem cell deficiency is a very rare condition and prior to seeing this patient, Dr. DiFranco gave me a heads up to read a bit on this condition before seeing the patient. Patient’s limbal stem cell deficiency was due to her PAX6 gene mutation and during physical exam I was able to note full conjunctivalization of her right eye and partial conjunctivalization of her left eye, making her fully blinded on her right eye and partially blind on her left eye. Up to that point I had never seen conjunctivalization or knew about this rare condition of limbal stem cell deficiency.

One challenge that I experienced during my ambulatory care rotation was creating a follow up plan for each patient. For each patient we had to look at all their past lab results, past referrals, and past imaging such as x rays or CT scans and figure out if they needed new ones. Average age for our patients was around 50-60 and for all the female patients in that age range, we had to look up their past mammogram/ ultrasound of the breast, colonoscopy, their last time at OBGYN, last chest x ray (especially if they were a smoker) last time they saw an ophthalmologist and their last EKG. If patient presented with a specific problem such as thyroid issues or past history of thyroid nodule or mass, we then had to make sure they saw an endocrinologist and get a U/S of their thyroid. For the first 2 weeks this was quite a challenge as I was trying to also not spend an hour just to look up their past medical records and do a full physical exam. However, overtime I learned to be more efficient with my time and became better at multitasking. Going forward, I hope to start getting more experience in my clinical skills such as drawing blood and inserting IV lines. Although my past 2 rotation have definitely helped me in developing my patient interaction and history taking skills, I haven’t been able to get much practice with blood draw, suturing or IV lines so I hope I soon will get the chance to do those as well. Overall, this has been a great leaning experience and I’m excited to start my next rotation in family medicine.

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