A DAY IN THE LIFE OF A FAMILY PRACTICE RESIDENT ?????????????

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A DAY IN THE LIFE OF A FAMILY PRACTICE
RESIDENT?????????????
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Terminology????

• Resident a post-graduate undergoing a period
  of advanced training, gaining supervised
  practical experience in a medical specialty that
  normally follows graduation from medical school
  and licensing to practice medicine
• ?????????????????????????????????????????????????
  ?
• Intern a first-year resident???????????

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• Education in the US?????
• High school, lasting 4 years to age 18
• ??,4???,??18?
• University, lasting 4 years to age 22
• ??,4???,??22?
• Medical school, lasting 4 years to age 26
• ???,4???,??26?
• Family Medicine Residency, lasting 3 years to age
  29
• ????????,3???,??29?

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Three-year program3???

• Year One Rotations ?????
• Family Medicine Inservice (4 months)??????(4??)
• Pediatrics (2 months)??(2??)
• Obstetrics (2 months)??(2??)
• Emergency Room (1 month)???(1??)
• Surgery (1 month)??(1??)
• Community Medicine (1 month)????(1??)
• Community resources ????
• Crisis Pregnancy ????
• Hospice ????
• PT/OT????

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Three-year program3???

• Year 2-3 Progressive Responsibility on the Family
  Medicine Inservice????????2-3?????
• 1month rotations?????
• Second-year resident in ICU and OB supervising
  interns????????ICU????????????
• Third-year Senior supervising second-year and
  first-year residents????????????????????
• Night Call ????
• Same as On-Call team responsibilities?????????
• Only one resident in-house????????????
• Height of progressive autonomy??????
• In-house attending physician ??????????

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Three-year program3???

• Year 2-3 Rotations ?2-3???
• one-on-one with attendings????????
• both inpatient and outpatient?????????
• 1 month 1??
• Critical Care (ICU/Pulmonology)??????(ICU / ??)
• Gynecology??
• Surgery??
• Gastroenterology????
• Cardiology????
• Behavioral Medicine?????

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Three-year program3???

• Longer Rotations?????
• Obstetrics (2 months)??(2??)
• Orthopedics (1.5 months)??(1.5??)

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Three-year program3???

• Shorter rotations (1/2 month)?????(???)
• Neurology???
• Ophthalmology??
• Dermatology???
• Ear/Nose/Throat????
• Urology???
• Sports Medicine?????
• Practice Management ????

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Three-year program3???

• Year 2-3 Electives (3 months total)
• ?2-3???(?3??)
• Foreign medical work (with board certified
  teaching physician)??????(??????????????)
• Rheumatology????
• Nephrology/Renal???
• Infectious Disease???
• Cardiovascular Surgery?????
• Anesthesia???
• Procedural Training ????

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FIRST-YEAR RESIDENT (THE INTERN)
???????(????)

• 430 AM YOU AWAKEN 430 AM ??
• 530 AM YOU ARRIVE AT THE HOSPITAL 530 AM
  ????
• 6 PATIENTS ON THE WARD, 1 IN THE INTENSIVE CARE
  UNIT TO SEE
  ????6???,1?????????????
• YOU MUST WRITE PROGRESS NOTES AND ORDERS FOR EACH
  PATIENT
• ?????????????????

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SOAP note SOAP???

• S Subjective S???
• O Objective O???
• Vital signs, ventilator settings
• ????,?????
• Physical Exam????
• Labs?????
• Studies????
• A Assessment (diagnoses, progress)
• A ??(??,??)
• P Plan for each assessment
• P ????????

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• Checking labs, studies, monitors?????????????

Checking with ICU nurses for overnight
updates?ICU???????????
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• Checking on your patients (pediatric/adult,
  medicine/surgery, ICU)????(????????????ICU)

Reviewing specialist recommendations?????????
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CODE BLUE!!!????

• 645 AM ONE OF YOUR PATIENTS BECOMES A CODE
  BLUE 645 AM??????????
• YOU RUN THE CODE AS FIRST RESPONDER RESPIRATORY
  THERAPY, ANESTHESIA, AND CODE TEAM ASSIST
  
• ????????????????,??,??????
• PATIENT REVIVES ????
• TRANSFERRED TO THE INTENSIVE CARE UNIT
  ????????

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CODE BLUE!!!????

• Advanced Cardiac Life Support (ACLS)????????
• Pediatric Life Support (PALS)??????
• Advanced Life Support for Obstetrics
  (ALSO)????????
• Algorithms ???
• Team Approach????

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• 745 AM YOU ARRIVE AT THE REPORT
• ROOM FOR ROUNDS
• 745 AM ????????????
• YOU UPDATE YOUR SUPERVISING SENIOR RESIDENT ON
  YOUR PATIENTS
• ????????????????????

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Team??

• -Senior 3rd-year resident ???(3??)????
• Oversees whole service ?????????????
• -Senior 2nd-year resident ???(2??)????
• Oversees Intensive Care and Obstetrics
• 
  ??????????
• -Interns/1st-year residents (4) ????/1??????
• Report on the patients they saw in the morning
  (SOAP)
• ???????????(SOAP)
• Senior residents help to refine interns
  assessment and plan ??????????????????????

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• 800 AM YOU AND YOUR RESIDENT TEAM SET ASIDE
  TIME TO
• 800 AM ??????????????
• THANK GOD FOR HEALING??????
• TO PRAY FOR WISDOM????
• TO REFLECT THAT HE IS IN CONTROL
• ??????
• TO ACKNOWLEDGE THAT ALL GOOD THINGS COME FROM
  HIM, INCLUDING MEDICINE
• ?????????????,?????

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• 830 AM Residents read an up-to-date article
  regarding one medical problem per night and
  discuss with each other, led by seniors
• 830 AM ???????????????????,?????????????,????
  ??
• Basics??
• Signs/Symptoms??/??
• Etiology??
• Diagnosis (Differential, Work-up)??(????,?????)
• Treatment??
• Medications??

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• 900 AM YOUR ATTENDING PHYSICIAN ARRIVES
  ????????
• THE TEAM QUICKLY UPDATES HIM ON THE STATUS OF THE
  PATIENTS???????????????
• THE ATTENDING PHYSICIAN, SENIOR RESIDENT, AND
  INTERNS ROUND ON PATIENTS
• ?????????????????????

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Attending Rounds??????

• 930 AM Go to patients bedside and see patients
  with attendings, especially
• 930 AM ?????????????,???
• new patients ???
• patients with classic findings????????
• Patients with atypical findings????????
• Discuss together????
• Inpatient Pharmacist?????
• Checks drug interactions????????
• Recommends treatment????

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Rounds??

• Intern reporting to Attending???????????

Intern presenting x-ray on electronic imaging
hospital program????????????????X????
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• 1100AM YOU AND THE OTHER 3 INTERNS RESUME
  CARING FOR YOUR INDIVIDUAL PATIENTS
• 1100AM?????3??????????????
• DISCHARGING 2 PATIENTS, AND CHECKING ONCE AGAIN
  ON YOUR MORE CRITICAL ONES ?????????,??????????
  ?
• 1200PM YOU RETURN TO THE REPORT ROOM FOR
  TEACHING ROUNDS
• 1200PM??????????????

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Noon Teaching????

• Case presentation by interns to team????????????
• Special patients????
• Guest Speakers????
• Review Questions????
• Grand Rounds???
• Special topics????
• Newest treatments/developments????/??
• New policies???
• Case presentations????

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• 100 PM YOU CHECK-OUT YOUR PATIENTS TO YOUR
  SENIOR RESIDENTS BEFORE LEAVING FOR CLINIC
• 100 PM ??????????,???????
• 130 PM YOU ARRIVE AT CLINIC 130 PM ????
• ALREADY, THREE PATIENTS ARE WAITING FOR YOU
  ???3???????
• A PATIENT WITH GASTROESOPHAGEAL REFLUX DISEASE
  ???????????
• AN EXERCISE TREADMILL TEST
  ???????????
• A CIRCUMCISION ???????

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Clinic, where residents and attendings practice
medicine together. ??,??????????????????
You discuss each case with your preceptor.

????????????
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Clinic Training ????

• Continuity clinics ????????
• First Year 1-2 half-day clinics/week?????1-2????
  ????
• 3?6 patients per half day?????3-6???
• 140 patient visits ??140???
• Second Year 2-3 half-days ???2-3???
• 7?10 patients per half day?????7-10???
• 500 patient visits ??500???
• Third Year 3-4 half-days ???3-4???
• 11?15 patients per half day ?????11-15???
• 1000 patient visits ??1000???

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YOU SYNCHRONIZE YOUR POCKET PC ??????????
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Personal Digital Assistant?????? (PDA)

• Data base meta-analysis Up-to-date
• ???meta????
• Internet??
• Books dictionaries, texts????,??
• Tools OB wheel, algorithms
• ?????????
• Most updated drug interface epocrates
• ????????? epocrates
• Diagnosis??
• Therapy??
• Symtoms??
• Labs?????
• Med Calculations????
• Tables??

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Use of Electronic Medical Records (EMR),
initiated in the U.S. by Family Medicine
Physicians ??????????????????
Air panels to use within patient rooms for all
documentation??????????????
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• 500 PM FINISHED WITH CLINIC, YOU RETURN TO THE
  HOSPITAL FOR CALL
• 500 PM ??????,??????
• 530 PM YOU RETURN TO THE HOSPITAL AND CHECK
  OUT WITH YOUR COLLEAGUES
• 530 PM ??????????
• 600PM YOU ARE PAGED TO SEE TWO PATIENTS IN THE
  EMERGENCY ROOM
• 600PM ??????????????

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Admissions???

• Throughout the day????
• Emergency Room physician stabilizes patient and
  transfers patient to the family medicine
  team?????????????????????
• Residents review ER events and patients work-up
  ??????????????????
• Call for old records???????
• Full work-up History and Physical?????????
• Intern sees patient first, unless critical
  (senior resident would go with intern
  then)??????,????????(??????????????)

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History Physical?????

• Chief Complaint??
• History of Present Illness???
• Past Medical / Surgical History????/???
• Allergies / Medications???/???
• Review of Systems????
• Social History ???
• Tobacco/alcohol/drugs?/?/??
• Family situation???
• Sexual history????
• Spiritual history????

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History Physical?????

• Vital Signs????
• Physical Exam????
• Labs?????
• Studies??
• Assessment????
• Plan????
• Discuss with senior, fine tune plan??????????,????
  ??
• Intern and senior discuss with attending
  physician ???????????????????

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• 730 PM YOU FINISH WRITING ORDERS FOR TRANSFER
  TO THE INTENSIVE CARE UNIT ON YOUR NEW PATIENT
  WITH DIABETIC KETOACIDOSIS
• 730 PM??????????????????????????????
• 800 PM YOU AND YOUR SENIOR ARE FINISHING IN
  THE EMERGENCY ROOM WHEN YOU ARE PAGED TO A
  DELIVERY
• 800 PM ?????????????????????,????????
• HEART TONES DECLINE, REQUIRING VACUUM ASSISTANCE
  
• ????,???????
• YOU REPAIR A SECOND DEGREE PERINEAL LACERATION
  
• ???????????

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• 930 PM YOURE PAGED TO THE NURSERY TO SEE THE
  NEWBORN YOU JUST DELIVERED
• 930 PM ???????????????????

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• 1015 PM ANOTHER PATIENT WITH ALCOHOL
  WITHDRAWAL SEIZURES AWAITS YOU IN THE EMERGENCY
  ROOM
• 1015 PM ????????????????????????
• 1100 pm FINALLY YOURE DONE TIME TO CATCH 5
  HOURS OF SLEEP BEFORE STARTING YOUR DAY ALL OVER
  AGAIN! 1100 pm ?????????????????????5???

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SECOND YEAR RESIDENT???????

• 630 AM YOU AWAKEN TODAY
• YOULL BE WORKING AT THE
• MATERNAL HEALTH CLINIC
• 630 AM ?????????????
• 800 AM THIRTY PATIENTS ARE
• WAITING TO BE SEEN
• 800 AM ?30??????
• 6 ULTRASOUNDS TO DO
  6?6?????
• ONE PATIENT IS BLEEDING
  ???????
• 1200 PM FINISHED WITH
• PATIENTS, YOU WORK A LITTLE
• ON YOUR RESEARCH PROJECT
• 1200 PM ????,????????
• ?????

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• 1230 PM YOU SPEND THE AFTERNOON WITH DR.
  YODER, A PRIVATE GASTROENTEROLOGIST
• 1230 PM?????????????Dr.YODER??????
• 6 COLONOSCOPIES, 3 UPPER ENDOSCOPIES, 1 CONSULT
• 6??????,3????????,????
• 500 PM YOU RETURN TO THE CLINIC TO PICK UP THE
  CELL PHONE AND PAGER FOR PHONES-CALL
• 500 PM ??????????????????

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• 530 PM DINNER WITH YOUR FAMILY IS CONSTANTLY
  INTERRUPTED BY PHONE CALLS FROM PATIENTS WITH
  CONCERNS
• 530 PM ?????,??????????????????
• EAR INFECTION ????
• CHRONIC BACK PAIN ????
• ANXIETY ATTACK ????
• 900 PM YOU ARE PAGED TO INFORM YOU THAT ONE OF
  YOUR PRIVATE OBSTETRICAL PATIENTS IS IN LABOR
• 900 PM ???,????????????????
• 1130 PM BABY DELIVERED, PHONES-CALL OVER, YOU
  RETURN HOME TO A SLEEPING FAMILY
• 1130 PM ????,??????????,??????????

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THIRD YEAR RESIDENT???????

• 630 AM YOU AWAKEN GETTING READY TO LEARN ALL
  MORNING FROM ORTHOPAEDIC SURGERY AND CLINIC WITH
  DR HOLT, A TEACHING PHYSICIAN
• 630 AM ??,??????????
• ???? DR HOLT??????
• 100 PM FINISHED WITH ORTHOPAEDICS, YOU DRIVE
  ACROSS TOWN TO START YOUR OWN FAMILY MEDICINE
  AFTERNOON CLINIC
• 100 PM ??????,??????????????????
• OBSTETRICAL PATIENT ????
• VASECTOMY ??????
• OTHER VARIED PROBLEMS HYPERTENSION, DIABETES,
  SKIN CONDITIONS, UPPER RESPIRATORY INFECTIONS
  ?????????,???,???,??????

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• 400 PM QUARTERLY MEETING WITH YOUR ADVISOR
• 400 PM ????????????
• REVIEWS YOUR PROGRESS AND EVALUATIONS
  ??????????
• INQUIRES ON YOUR JOB SEARCH
  ?????????
• CHECKS ON YOUR STUDY PLAN FOR PASSING THE FAMILY
  PRACTICE BOARD CERTIFICATION EXAM IN JULY
• ??????7????
• ??????????????
• 600 PM YOU VOLUNTEER YOUR TIME AT THE MOBILE
  CLINIC FOR INDIGENT NON-PAYING PATIENTS
• 600 PM ???????????????
• 20 PATIENTS ARE WAITING
• 20???????

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• ONE PATIENT ARRIVES WITH PAINFUL BAKERS CYST
  BEHIND HER KNEE ?????????Bakers?????
• ANOTHER PATIENT IS AN ALCOHOLIC WANTING TO QUIT
  ?????????????
• 930 PM FINALLY FINISHED, THE MOBILE CLINIC
  CLOSES UP AND DRIVES OUT OF THE CHURCH PARKING
  LOT
• 930 PM?????,??????,???????
• YOU HEAD HOME YOUR DAY NOW DONE ????,?????

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Progressive Learning?????

• Building Knowledge????
• Acquiring Skills????
• Learning and Teaching?????
• Becoming comfortable with the actual practice of
  medicine (not just didactic)???????????(??????)
• Advancing to Autonomy, Proficiency ??????????

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Most Importantly?????

• LEARNING HOW TO LEARN ???????
• LEARNING WHERE TO LOOK FOR NEEDED INFORMATION
  ????????????

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The challenge of family medicine???????

• Generalist know something about
  everything????????????
• Continuity care?????
• Care for the whole person?????
• Care for the entire family???????
• Challenging but ever exciting career!
• ??????????????!