Student Scene
 Tarayn Grizzard Photo by Jeff Cleary |
Family Medicine Broadens Foundation of Medical Training
Pausing at the door of the room where my first patient of the morning waits, I leaf through her chart, sheaf upon sheaf of progress notes and lab reports, looking for clues to guide my under-caffeinated brain through an urgent-care visit for a strained shoulder. Walking into the room, I greet her in Spanish and begin to interview her, identifying when the pain started, when it's worse, injuries, surgeries, current medicines, and other medical problems--the usual list.The patient is a young Honduran women with a lovely shy smile and a rowdy 18-month-old baby on her lap, whose sole interest this morning is attempting to divest me of my stethoscope while I talk to her mother. The woman tells me that she works 90 or more hours a week as a housecleaner, including Saturday and Sunday, a necessity now that her husband is no longer working. Her painful, nonmobile right shoulder and neck, along with her swollen knees, had always bothered her after a long day at work cleaning houses, but now her neck and shoulder pain is unbearable and keeps her from sleeping.
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In the clinic's rooms and halls, the essence of the doctor-patient relationship--caring for another human being--is valued, taught, and reinforced daily. --Tarayn Grizzard |
Sweating Bullets
While I am giving instructions and chatting with the patient, trying to finish up the visit in the allotted 15 minutes, there's a rap at the door. My hyperkinetic preceptor pops in the room, greets her long-term patient, and asks me for my "bullet" on the patient's current issues. In English I give her the rundown of the day's care plan, with which she agrees. She signs my prescriptions, while she and the patient begin to intimately discuss the woman's long-term problems with sleep and depression.I excuse myself to the next room, where a 32-year-old Brazilian man with multiple recent episodes of syncope is waiting. I greet him in Spanish and the three words of Portuguese I currently know--"No falo Português," or "I don't speak Portuguese"--and start the interview anyway. I try to use the words in Spanish that I have been told are most similar to Portuguese, staying away from idioms and speaking as simply as possible. I inwardly and reverently thank God that most Brazilians speak some Spanish. Fortunately, my preceptor soon interrupts the somewhat-painful interview, asks me for a quick assessment, and begins to explain to the patient in her fluent Portuguese our plan for the day. I sit back, relieved to be able to sit and observe my preceptor for a change.
A Welcome Onslaught
As a third-year clerk at a busy urban family medicine clinic, this is just an average morning. At the end of the day, I am a bit disheveled, sweaty even, with ink-stained hands and a head that's swimming with new bits of Spanish, Portuguese, and the occasional Hindi/Urdu or Bengali.My training thus far had not prepared me for the intricacies of multicultural outpatient care, but already after two and half weeks, I am feeling better toned and prepped for the typical things, medical or cultural, that our patients bring to their office visits. It has been an amazing month so far, and even if I didn't have a pretty good idea that I was going to become a family physician, I think I would feel this way. Compared with many outpatient settings, the clinic where I work is more multicultural and a bit more harried. It sees many more women and their children, including pregnant women, since most of the family doctors there offer obstetrics as part of their practice. All of this makes for an exciting, if tiring, workplace.
The core difference, though, is that the clinic is truly community-oriented, with doctors who speak Spanish and Portuguese, multilingual medical assistants from the community, and a concept of care that embraces and works from within the community's cultural orientation. These factors all combine to provide remarkably good, personal health care.
In the clinic's rooms and halls, the essence of the doctor-patient relationship--caring for another human being--is valued, taught, and reinforced daily, a welcome contrast to some hospital-based care that I have experienced. As a third-year, I have spent seven months in the hospitals of the Longwood Medical Area, dealing with medical problems complex or rare enough to warrant admission to a place like the Brigham, with patients I would rarely, if ever, see again, nor would treat for more than their current medical issue.
This month, however, I've learned instead to care for patients throughout their lifetime, to care for them within the context of their family, when medical problems necessitate a specialist, and what common barriers to care physicians can help patients deal with. Having completed most of third year from a hospitalist's viewpoint, I am finally getting the other side of the story--what happens with patients before and after their hospital admission, an invaluable experience in and of itself and particularly important for putting hospital care in perspective.
The Family Medicine Imperative
This type of intensive clinical experience in primary care is important for specialists and generalists alike to gain a broad view of the health care system. For this reason, most medical schools require a family medicine month as well as the traditional medical and surgical hospital-based clerkships. Harvard, along with a handful of other private schools, does not require a family medicine clerkship prior to graduation, however, making this experience one that many HMS students don't receive.There are many reasons for this, one of which is that HMS does not have a Department of Family Medicine to support such a clerkship. It wouldn't be impossible, however, for a core group of course directors to set up students with family medicine preceptors throughout the state in a clerkship even without a formal department--many other courses (e.g., Patient-Doctor II) coordinate clinical work for students without the oversight of a single department. There are more than enough family physicians that practice throughout the state, enough so that Tufts and Boston University schools of medicine can require students to complete a family medicine rotation.
Whatever the reason that HMS de-emphasizes family medicine in the medical curriculum, future generalists and specialists alike end up with an incomplete education, with repercussions for both physicians and patients. Requiring a three- or four-week clerkship in family medicine would allow medical students to learn about care as the majority of our patients experience it, an invaluable perspective for a lifetime of practice in any specialty.
--Tarayn Grizzard, a third-year medical student at HMS
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.