Family Medicine Clerkship Guide
You will be completing a 12-week rotation in Family Medicine as a clinical clerk. This rotation is an excellent opportunity to build your foundation skills in primary care and physical exams caring for patients of all ages and a broad spectrum of acute and chronic conditions.
Here we’ll cover:
What is Family Medicine? Definition of the specialty, common conditions seen in family medicine and practice settings.
Clerkship responsibilities in Family Medicine: How to get started in your orientation, what you’ll do in family medicine (expectations and responsibilities of clerks), opportunities for learning
What to Bring to Clinic: Dress code, essential medical equipment and optional items.
Documenting Patient Encounters: Tips, Types of medical documentation.
How to Study during your Family Medicine Rotation: How to review materials, background reading before the rotation, setting aside time to study, and reading around cases.
Favourite Family Medicine Clerkship: Recommended Apps, Books and Online Resources
I. What is Family Medicine?
Family Medicine is a vital specialty in the field of medicine that focuses on the comprehensive health care of individuals and families across their lifespan. When more specialized care is required, family medicine will facilitate referrals to specialists in surgical and non-surgical specialties. Primary care is not just focused on treatment of disease, but preventative health care which includes patient education (family planning), wellness tests, immunizations and screening (cancer).
As a PA, completing a clerkship in Family Medicine is a crucial step in your journey to becoming a PA.
What you’ll see in Family Medicine
Family medicine is a broad specialty and can cover quite a variety of common conditions including:
Acute conditions: You may learn about the assessment and management of acute conditions, such as cough, headaches, respiratory infections (influenza, pharyngitis, pneumonia, distinguishing between URTI’s and LRTI’s), gastroenteritis, pancreatitis, cholecystitis, constipation, diarrhea, dysuria/urinary tract infections, and ear infections.
Chronic conditions: Many patients in Family Medicine have chronic conditions, such as anemia, asthma, COPD, allergies, diabetes, dyslipidemia, hypertension, GERD, hemorrhoids, IBS, lactose intolerance, PUD, fatigue, migraines, hearing disorders, sleep disorders, weakness, chronic pain, and heart disease. You may learn about the management of these conditions and how to work with patients to improve their health and quality of life.
Mental health conditions: You may encounter patients with conditions such as Anxiety, depression, adjustment reaction (grief), depression, eating disorders, suicidal ideation, trauma and abuse (physical, emotional, sexual, child, spouse/domestic, elderly).
Musculoskeletal Conditions: Arthritis, acute/chronic low back pain, gout, osteoporosis, tendonitis, strain, joint separation, ligament injuries, carpal tunnel, trigger finger, sciatica and more.
Women's health: Conditions you may learn about you may encounter include pregnancy, infertility, menopause, and gynecological issues. Other conditions include breast mass/lump, mastitis, menstrual irregularities, female genital tract infections (e.g. bacterial vaginosis). From an obstetrical side you may be focusing on breastfeeding, first-trimester bleeding, post-partum depression and management of an uncomplicated pregnancy. Procedures you may perform may include IUD insertion and removal.
Pediatrics: You may encounter patients of all ages, including infants, children, and adolescents. You may learn about the care and management of common pediatric conditions, such as respiratory infections, growth and development, and behavioral issues.
Skin Conditions: Alopecia areata, acne vulgaris, bites (insect, reptile, animal or human), blisters, skin tags, lipomas, dermatitis, ulcers, moles/nevi, malignancies, nail conditions (onychomyocosis, paronychia, ingrown nails), rosacea and warts.
Geriatrics: You may learn about the care anad management of geriatric conditions, such as dementia, depression, delirium, cognitive dysfunction, vision/hearing evaluation, assessing falls risk, and frailty.
Practice Setting
Family Medicine can be delivered in a variety of different settings.
Outpatient Clinics:
Solo Family Physician Office/Independent Practice: a solo physician practice that may work with a PA or NP to see patients. Often this is a fee-for-service model (no rostering of patients).
Walk-In Clinic: providing episodic care for patients without the need for an appointment. They are designed to offer convenient and accessible care for patients who are suffering from minor illnesses or injuries, or who need medical attention but cannot wait for a scheduled appointment with their regular health care provider.
Family Medicine Organization/Group Practices. Here are a few examples of different group family health models in Ontario:
Community Health Centre (CHC): non-profit organizations that aim to promote the health and wellbeing of individuals, families, and communities by providing primary health care services and health promotion programs. CHCs are staffed by a team of HCPs including MDs, PAs, NPs, RNs, social work, health promotion specialists, and depending on resources may include dietitians, PTs and mental health works. The goal of the CHC is to provide comprehensive, integrated care to individuals, families, and communities, and to involve patients and communities in their own care.
Family Health Team (FHT): Primary care orgnizations compromised of MDs, PAs, NPs, RNs, social work, dietitians and other providers to provide primary care. Each FHT designed to cater to the needs of the local community they serve.
Family Health Organization (FHO) or Family Health Network (FHN): a group of family physicians (of at least 3) who work together to provide primary care to patients and their families including extended hours on evenings and weekends, with availability of same day walk-in appointments. Patients are enrolled in a blended capitation model
Inpatient or Hospital Settings
In northern, rural or remote family medicine practices, it is not uncommon for family physicians to have extended scope to work in obstetrics or Emergency Medicine settings.
II. Clinical Clerk Expectations
As a clinical clerk in Family Medicine, you will have several responsibilities to fulfill during your rotation.
Getting Started on Your Rotation
On your family medicine rotation, you should receive some kind of orientation on the first day. This can include receiving a tour, getting an overview of the schedule including start and end times, times for lunch, and timing of any teaching rounds (if applicable).
A few other tips to get oriented:
Introduce yourself to the team: Be polite, respectful and professional to all the staff. Learn people’s names and their role in the clinic.
Understand the flow and expectations of the clinic: Will you be seeing patients first, case presenting to your preceptor and then going back? Will the preceptor be observing your encounter for every patient interaction?
Get familiar with the Electronic Medical Records System (EMR) such as AccuroHealth, PS Telus Suite EMR, or OSCAR.
What you’ll do in Family medicine
These responsibilities will vary depending on the specific setting and the physician/PA preceptor you are working with, but here are some of the most common tasks you can expect:
Medical Knowledge: As a medical learner, you are not expected to know everything about family medicine. However, the expectation will be to “learn as you go”. Take advantage of your academic half day each week to read around cases, review common presentations in family medicine. This will be helpful for your preparation for the End of Rotation Exam (EOR exam) that you will write at the end of your clinical rotation (UofT only).
See and assess patients: Clerkship is not an ‘observership’ where you primarily shadow and watch other providers providing care (although you may do this in the first few days just to orient to the practice). You should be seeing and assessing patients daily with hands-on experience.
Patient History Taking: Taking a comprehensive or focused history with patients is key. Often clerks start with a “checklist’ like approach to asking questions, but as you develop your skills in clinical reasoning history taking will start to feel more conversational where you ask pertinent positives and pertinent negatives.
Physical Examinations: You may learn how to perform comprehensive physical exams, including head-to-toe assessments and targeted exams for specific conditions (peripheral vascular assessment in a diabetic patient, cardiac exam, respiratory exam, etc.).
Order and interpret investigations: this includes labs (blood work - CBC, electrolytes, clotting/coagulation studies liver function tests, basic metabolic panel, lipid panel, liver tests, thyroid tests, pancreatic test, blood culture), imaging (urine tests, x-ray, ultrasound, bone scan, bone mineral density), and ECGs.
Diagnosis: formulate a diagnosis, and differential diagnoses based on your assessment.
Management of medical conditions:
Prescriptions for medications, physiotherapy, or medical devices include instructing patients on use (e.g. different types of puffers for asthma, indications of use, side effects and demonstrating how to use them).
You may also facilitate referrals to specialists, clinics or resources within the community. Get familiar with the local resources around the family medicine clinic you’ll be completing your placement!
A large part is also patient education around preventative health, and making healthy lifestyle changes.
Case Presentations: A case presentation is where the clinical clerk provides a brief summary (less than 3 minutes) of the patient’s history, physical exam, diagnostic results, provisional diagnosis and treatment plan for the purpose of feedback, review and guidance. It’s a great way for the preceptor to assess the clerk’s clinical reasoning, and decision-making process.
Tip: Even if you aren’t sure of the diagnosis and plan, take a guess “I think this may be [X diagnosis], and treatment could include [X treatment options].”
Medical Documentation: Writing progress notes on your patient encounters, usually following the SOAP note method. Ask your supervising PA or MD what format is preferred notes, or view previous notes to see what format was used and model that. See “Section IV. Documenting Encounters in Family Medicine” below to learn more.
Don’t forget to track your patient encounters! Canadian PA programs require clinical clerks to record every patient encounter through an app like e*Value. Rather than wait until the end of the rotation, try logging at the end of each day or each week.
Medication review/reconciliation: Reviewing patients’ medications comparing past and current regimens, ensuring correct doses and ruling out potential interactions that can cause adverse side effects.
Wellness Exams:
Well-baby and well-child exams: Assessing child growth and development. Immunization schedules, development milestones, physical exams. The Rourke Baby Record is used in Canada to perform wellness visits from children aged 1 week to 5 years.
Adult Well-Woman Exams are also known as gynecological exams. This is a routine check-up for adult women that focuses on reproductive and sexual health as well as a Review of Systems (ROS). Be sure to get proficient with breast and pelvic exams (bimanual exam), as well as how to perform pap smears. Recommendations for mammograms and STI testing can also be done.
Adult Well-Male Exams are comprehensive physical examination for adult males to monitor overall health and identify potential health issues early on. In addition to a general Review of Systems, prostate cancer screening, ruling out other chronic conditions such as HTN, DM and DLP.
Preventative Care:
Immunizations: HPV, Pneumococcal, Herpes Zoster. See Canadian Immunization Guidelines, Ontario Immunization Schedules, and Manitoba Immunization Schedules.
Sexual Health and Family Planning: Methods of contraception, family planning, infertility
Screening Tests: Hypertension, Pap smears, mammographic, cancer screening (colorectal breast, cervical, prostate), bone mineral density/osteoporosis, diabetes and hyperlipidemia screening, AAA (men age > 65), HCV, STIs, and cognitive impairment. Know how to manage abnormal results.
Lifestyle: smoking cessation, poverty (important social determinant of health), obesity, exercise, diet, substance use, vitamin D/calcium supplementation. Be sure to review motivational interviewing
Assist and/or perform procedures:
Skin procedures: You may learn about common skin procedures, such as wound care (debridement, dressing changes), abscess incision and drainage, cautery, cryotherapy, skin biopsies, and the removal of moles or skin lesions.
Minor procedures: You may learn about minor surgical procedures, such as removing sutures and repairing simple lacerations with suturing. You may also do PICCC line removals, foreign body removal, nail removal, ear irrigation and manual cerum disimpaction, and nasal packing.
Injections: You may learn how to perform injections. This can include IM, intradermal, SC or intra-articular injections. Injections include immunizations, injecting local freezing prior to procedures, joint injections, and tendon injections.
For a more comprehensive list of procedures, see CFPC’s List of Procedural Skills in Family Medicine.
Opportunities for Learning in Family Medicine
You'll be expected to act professionally, communicate effectively, and demonstrate a strong understanding of patient confidentiality.
Sit down at the beginning and share your objectives with your preceptor: If this is not formally done, this is highly recommended! Be sure to share:
Where you are in your training (e.g. at the beginning of clerkship? in the middle? towards the end?)
What areas of interest you have (do you hope to work in primary care? emergency medicine?). It’s okay to say that you’re “interested in Dermatology”, even if you’re completing a rotation in Family Medicine
What do you hope to get out of the rotation (develop clinical reasoning? performing more hands-on procedures? develop confidence of your cardio and resp exam?).
Observe a variety of procedures: Make sure to observe as many procedures as possible during your clerkship, including physical exams, injections, skin procedures, and minor surgical procedures.
Shadow a variety of health care providers inside the family practice! Spend time shadowing different health care providers and allied health. Whether that’s a half day, or 1-2 patient encounters to see how other providers approach care with patients.
Anne’s Tip: When I did my 12 week family medicine rotation at a Community Health Centre (CHC), I had the opportunity to shadow (for half day or 1-2 patient encounters, 1-2 times per week) a family physician specializing in LGBTQ2S+ with a focus on transgender health, nurse practitioner, physician assistant, social work, dietitian, physiotherapist, nurses, and the dermatologist who came to the CHC once a month! All of these providers were already working within the CHC. This exposure was in addition to seeing patients with my primary physician preceptor.
Attend teaching rounds and patient conferences: Attend teaching rounds, patient education classes offered by the family medicine clinic and patient conferences, and actively participate in discussions (some of these patient conferences are free!). Classes can include: parenting education, weight/body image issue, peer relationships, healthy sexuality, programs for teen mothers, domestic violence prevention and treatment, addictions and more! This will give you a deeper understanding of how care is planned and managed for patients in a primary care setting.
III. What to Bring to Clinic
When starting your Family Medicine clerkship, it's important to come dressed professionally and prepared with the right materials.
Dress Code for Family Medicine
Dress code can vary depending on the specific family medicine setting. You can ask your preceptor or other students who have done the rotation beforehand what is typically allowed or what the office usually wears on a regular basis.
A few guidelines to follow for dressing professionally:
Professional business or business casual attire: clean shirt or blouse, dress pants or skirt that follows below the knee.
Scrubs: It may be office issued or you may have your own scrubs.
Personal Hygiene: no scented products, hair well kept. Avoid jewellery to prevent contamination.
Closed-toe, comfortable shoes: No crocs with holes in them. These help decrease your risk of exposure to bodily fluids, infectious disease, dropping of objects onto the foot or when tripping.
White coat (optional): The PA school issued white coat is sufficient, and helpful because of its pockets.
Compression Stockings (optional): Great for days when you are on your feet for prolonged periods!
Below is a list of items that you should bring with you on a daily basis:
Essential Items
Physician Assistant ID/Name Tag
Stethoscope
Pen and notepad: You'll need to take notes. Although many students use their phone or tablets to take notes, it may come across as distracting and disrespectful during patient encounters.
SmartPhone with helpful point-of-care apps (e.g. Medscape, MdCalc)
Optional Items
Reflex hammer
Snellen Chart
Measuring Tape
Tuning Fork
Penlight
Pocket References: A small reference book
IV. Documentation in Family medicine
One of the key responsibilities of a PA student in Family Medicine clerkship is to document patient encounters accurately and effectively.
This helps to ensure that the patient's medical record is up-to-date and provides a clear picture of their presenting complaint and overall health status.
Familiarize yourself with EMR: Most practices use an electronic medical record system (EMR), learn how to navigate it to access patient notes and document your patient encounters.
Model how the PA/MD preceptor documents their patient encounters: Although we are taught SOAP notes and medical documentation in PA school, it’s good to see how the preceptor takes notes and incorporate that model into your own documentation. It may be more brief or detailed.
Tip - Take notes in real time: When you are sitting in front of a patient, you can document in real-time (as patient is speaking) rather than make notes after the fact and try to recall everything that the patient said. This helps ensure information is accurate and complete.
Proof-read your notes: Your note on the patient encounter is now apart of the official medical-legal documentation for the patient. Ensure that the content of the information is accurate and clear, and that there are no typos or grammatical mistakes.
Request feedback on your notes: It’s not common to get feedback on every single patient note you write, but it would be helpful to get some feedback or advice.
Types of documentation and paperwork in Family Medicine
Return to Work or School Letters
WSIB/Worker’s compensation forms
Disability forms
Referral requests to Specialists (surgical or non-surgical specialties)
Imaging and Lab Requisitions
Perinatal Records: Ontario Perinatal Record, Manitoba Prenatal Record Form
Immunization schedules
V. How to Study during your Family Medicine Rotation
Studying during your Family Medicine clerkship is important to ensure that you are retaining and applying the knowledge you are gaining through patient encounters and other learning opportunities.
Set Learning Objectives: Identify what you need to know and what you would like to know about family medicine. What do you hope to get out of the rotation? What do you want to learn and do? What would you like to be more comfortable with? Do this at the start of your rotation, and check in each week to ensure you are meeting each of your goals.
Do background reading before your rotation: Review your notes from first year PA school on physical examination and common conditions that present in family medicine (e.g. Hypertension, Diabetes, Asthma, etc.)
Set aside dedicated study time: Schedule regular study time each week to review your notes and reading materials. This can help you to stay on track and avoid feeling overwhelmed.
Read around cases:
Review cases from family medicine clinic: Pick 1-2 interesting patient cases you saw that day, and do a deep dive into medical literature, textbooks or online resources (e.g. UpToDate, AccessMedicine).
Use a clerkship prep source like Case Files: Family Medicine to review 1-2 cases a day.
Ask Questions: Ask questions relevant to the patient cases that you see and present with your preceptor. You do not have to ask a question for every single case, or ones that are easily looked up with a quick google search (e.g. what is the anatomy of X?).
VI. Favourite Family Medicine Clerkship Resources
Apps
UptoDate: If your school or institution has access, see if you can get this set up on your phone!
MDCalc (free): Over 275 calculators for health care providers to calculate algorithms, scores and risk.
Books
Case Files: Family Medicine: A great problem-based approach to learning key cases in Family Medicine! This book includes high-yield cases to excel on your clerkship rotation, and practice cases that you can later use to practice for the PA certification exam. Aim for 1-2 cases per day. Each case includes a complete discussion, clinical pearls, clinical approach, tables, definition of key terms and review questions to test your comprehension.
OSCE and Clinical Skills Handbook: Includes physical exam checklists that will help provide flow and organization to your physical exams in family medicine.
MUM’s Health Orange Books on Canadian Practice Guidelines
Pocket Primary Care: High yield clinical pearl on common conditions seen in clinic and ambulatory settings. A reference that fits into your white coat pocket.
RxFiles.ca Drug Comparison Flipbook Chart: This is a handy flip chart that organizes medications by category. The drugs are presented in tables to make it easier to compare drugs side by side. It contains Canadian names and prices. This one is super handy for Family Medicine rotations.
Online Sources:
American Academy of Family Physician (AAFP) papers on common conditions in family medicine that are commonly covered.
Calgary Cards: flashcards to review common concepts during clerkship!
College of Family Physicians of Canada (CFPC) List of Procedural Skills in Family Medicine
Learn FM: Canadian Family Medicine Clinical Cards: From the Canadian Undergraduate Family Medicine directors, these summary cards provide common diagnoses, initial approach, key elements on history, physical examinations,investigations, red flags, and general treatment measures
McMaster PA Family Medicine Clerkship Guide PDF: This has useful tips and a checklist of different topics to cover!
Final Notes
Completing a clerkship in Family Medicine can be a valuable and rewarding experience for PA students. By learning about the responsibilities of clinical clerks in Family Medicine, preparing for your rotation, documenting patient encounters, and setting your own learning objectives, you can make the most of this opportunity to gain hands-on experience and develop the skills you need to become a confident and competent Physician Assistant!
