Requirements of Family Medicine Preceptorship

The bulk of your time (minimum 20 hours each week) will be spent seeing undifferentiated patients in order to practice a systematic clinical approach to common symptoms and management of medical conditions in primary care. Undifferentiated patients include those who are attending the primary care facility for the first time as well as those patients who come for follow up but are not already diagnosed with a particular disease or problem category. Undifferentiated patients make have previously diagnosed conditions (i.e. hypertension) but be presenting with a new complaint (i.e headache). Patients which chronic conditions that are being followed up are recorded elsewhere in this logbook. Good locations to find undifferentiated patients include OPD, casualty (A&E), new admission areas to hospital wards, and health centres. For each patient you see, you are required to conduct a full consultation, to make an appropriate assessment and to implement a management plan. This should be entered into the patient records used by the facility and discussed with the supervisor prior to doing further procedures (e.g. investigations, minor procedures) or sending the patient for whatever else is needed, such as collection of treatment, further management by other team members, or referral.

You are required to make 25 logbook entries though you will see a lot more patients than this during your preceptorship. Logbook entries should demonstrate familiarity with a wide variety of common symptoms and conditions. Try to record patients with different presenting complaints. A sample list, though not comprehensive, is below. Patients should also be a variety of ages, including paediatrics, geriatrics and adolescents.

• DYSURIA
• URETHRAL DISCHARGE IN MALES AND VAGINAL DISCHARGE IN FEMALES
• GENITAL ULCERS/SWELLING
• VAGINAL BLEEDING
• MCH ISSUES
• JOINT PAIN
• LOW BACK PAIN
• COUGH
• HEADACHE
• FEVER
• VOMITTING
• DIARRHOEA
• ABDOMINAL PAIN
• FATIGUE/WEIGHT LOSS
• EAR PROBLEMS
• EPISTAXIS
• DIZZINESS
• LEG SWELLING
• CHEST PAIN
• DYSPNOEA
• SKIN RASHES
• SORE THROAT
• DEPRESSION
• DEMENTIA

Each entry should include all the details of the assessment, the management, the follow up plan, and red flags. Examples of red flags are detailed fully in your textbook as well as sampled in Appendix D. Your assessment should include the three domains (bio, psycho and social) and your plan should have four parts (current complaint, chronic conditions, safety netting/follow up, and opportunistic health promotion. As you see the patients, make a note for yourself regarding issues about which you need to do further reading or that you wish to discuss with your colleagues.

Also note at least five patients that required admission or referral to a higher level of care and record these separately on the Emergency Care, Triage & Referral table. Follow up on them and record the outcome. Towards the end of the block, reflect on your observations related to referral and access to the health system and record your thoughts in the labelled section of the logbook.

You will be seeing patients with chronic illnesses on a regular basis in the clinic. Your facility may have designated chronic disease clinics, such as one for diabetes or hypertension, or you may find these patients in general OPD clinics. Record at least ten consultations with patients about their chronic conditions in your logbook. A variety of chronic conditions (i.e diabetes, asthma, epilepsy, HIV/AIDS, hypertension) should be included. Specifically describe how you used the five A’s (Assessment, Advising, Assisting, Agreeing, and Arranging) to provide comprehensive patient-centred care for each patient. During the Assessment portion of your consultation, make sure to complete all four tasks (4 C’s) of chronic care: Complaints/Concerns, Control, Compliance, and Complications. Appendix E gives some examples of targeted preventive therapies in patients with chronic illness. Then reflect on how well your facility demonstrates the seven principles of chronic disease management (7 C’s) and record your thoughts in the labelled section of the logbook.

You are required to see patients who present with complaints of sexually transmitted infections. Some facilities will have a specific STI clinic while in others patients may be found in the general outpatient clinic. Record at least five consultations in your logbook using the comprehensive A3P4 consultation model you have learned. The goal is to practice the syndromic approach to sexually transmitted infection management and to reflect on the rationale of drug choice, drug side effects and possible complications of illness. After you have seen at least five patients with STI complaints, reflect on how this type of consultations is handled at your facility and record your thoughts in the labelled section of the logbook.

You will be seeing many sick children during the block. For most, you should use the IMCI approach that was introduced in orientation. It is important that you become familiar with IMCI and be comfortable using it, whether or not it is being used as a standard approach in the clinic in which you are working because most primary care for children in Malawi will be delivered by this approach.

You should record information about five IMCI consultations. For three of the children, you should complete the only table in your logbook. For the remaining two children, full IMCI consultation formats should be completed (provided in the logbook). One of the detailed consults should be on a patient under 2 months of age and the other should be between 2 months and 5 years. After the detailed IMCI consultation format is completed, summarise your assessment (classification) for each child and the proposed management in the logbook as well as present each case to your preceptor. These two case write-ups will be scored out of 5 marks. If your facility does not have the most recent IMCI guide, the WHO international version is available at http://www.who.int/maternal_child_adolescent/documents/imci/en/.

Your facility will have Under 5 child health clinics for well babies. You should participate in the routine activities of such a clinic weighing babies, giving immunisations, and assessing developmental status. Record information about 10 children in your logbook. Specifically, comment on the following areas:

• Nutritional status. Review the Road to Health card and describe the child’s present weight-for-age percentile. Comment on the growth pattern to date.
• Immunization and Vitamin A status. Describe any immunizations the child is eligible for at the visit. Comment on the child’s HIV status and how this affects immunization. Comment on the child’s current immunization and Vitamin A status.
• Briefly describe what developmental milestones the child has achieved. Compare that to what is expected for his/her age. Developmental milestones include the domains of gross motor, fine motor, social and language. Also comment on the child’s vision and hearing screening.
• Record one to three key age- and patient-appropriate pieces of advice offered to the caregiver at the visit.

In addition, meet with the supervisor of the clinic and discuss how vaccines are stored, given correctly, safety mechanisms and other procedures related to the functioning of this service.

Consult and counsel at least six patients who present for family planning, either at the same time as they are presenting with other problems or at a visit solely about contraception. Your recorded patients should include two patients who received injectable methods, two who received oral methods and two who received implantable or permanent methods.

You should have opportunity to observe cervical cancer screening with VIA (visual inspection with acetic acid) services during the attachment. For one patient, record in your logbook the indications, the procedure, the results and arrangements that are made for further management depending on the outcome of the procedure.

You should observe normal vaginal deliveries during your family medicine block in order to understand the progression of normal labour. You are required to be involved in the labours and deliveries of at least five patients. Your involvement should be at least from the onset of active labour for learning purposes. You will also find you get better cooperation from midwives if you are actively involved. Each delivery must be recorded in your logbook; in addition you should write up one delivery in depth as a short case study. A detailed labour and delivery report, including a partograph, is provided for the case study.

You will be seeing many suspected and confirmed TB patients over the attachment. Record the details of three patients in your logbook. One patient should be a suspected TB case so that you reflect on the diagnostic process. The other two patients should be confirmed TB cases so that you can learn about the diagnostic and notification process.   Check with the TB office and record any contact tracing that has been done.

You have had education on counselling in lectures and some practical training sessions during your medical education. In this block you will have another chance to practice your skills. You should implement what you have learned on a regular basis with many of your undifferentiated patients, if not every patient you see. However, you are required specifically to record and reflect on five counselling sessions that you have with patients. Among the five sessions recorded, each of the following topics should be included: HIV pre-test, HIV post-test counselling session and breaking bad news. The latter may be done together with a supervisor if you are not comfortable to do this yourself or feel you do not have adequate training.  During at least some of the sessions you should be observed and obtain feedback from your supervisor. Additionally, after each documented counselling session, you should reflect and record on what you did well and where you can continue to improve.

In addition to individual counselling sessions, physicians are often asked to provide group teaching. As practice, at least once during the block you should give education to a group of patients at the health facility. This may be a group of similar patients (such as patients with diabetes or hypertension), a group of people attending for a specific purpose (such as women attending antenatal clinic or under 5 clinic), or simply patients sitting in the waiting area. The subject matter should be relevant to the group chosen and the talk should last 5-15 minutes. Two of your peers should observe your education session and give feedback. Document both your own reflections as well as the comments of your peers in your logbook. Both observers should sign their comments in your book.

You are required to visit a palliative or chronic care patient in his or her home. This should be arranged with a palliative care or home-based care health worker from the clinic or health centre. For safety purposes, a health worker or another student should accompany you to the home. If no formal system is functioning at your site to perform home visits, you may visit a patient that lives locally for whom you have cared. For example, you may wish to visit a patient that was discharged from the hospital that lives within walking distance of the facility.

Assess the patient using a bio-psychosocial approach. You should be able to explain the patient’s condition as it relates to their immediate home circumstances, describe the patient’s family support structure, and identify factors that affect the patient’s health. Be sure to set aside adequate time to make a thorough assessment during the home visit.

After you have completed your home visit, prepare a 15-minute oral presentation for your colleagues and supervisor. Topics that you should cover include the following:

• Aspects related to the environment
  • Community setting
  • Position of home in relation to community, health services, transport, shops and other amenities
• Description of home
  • Size, condition, number of occupants, facilities, kitchen, bathing and toilets facilities
• Aspects related to the patient & family
  • Description of the patient: personal, social and other demographic details
  • Genogram/ecogram of the patient
• Aspects related to the condition
  • Brief description of the condition using a systems approach
  • Patient’s explanatory model
  • Compliance and factors affecting it
  • Losses experienced and coping mechanisms
  • Health professionals utilised
  • Community resources available for patient’s condition
  • Self-help / support groups used / needed
• Effects of the condition
  • Impact on self
  • Impact on Family
  • Impact on community
  • Your personal relationship with the patient

In addition, summarize the main findings of your home visit in your logbook.

Record three palliative care consults in your logbook. Palliative care patients may be seen in any of setting (hospital, health centre, or home). The home visit is a separate case and should not be used as one of your three palliative care patients. Focus particularly on a detailed assessment of the patient’s pain, how it is managed, and whether this is effective. Remember holistic aspects of care and how these also contribute to pain in the context of the family and community. After you have seen several palliative care patients, reflect on the way palliative care is delivered in your facility as well as the accessibility and effectiveness of morphine to your patients. Record your thoughts in the logbook reflection.

Reflect on one incident in which you were involved or witnessed at your site where management of the patient was sub-optimal, an adverse event occurred, or a patient died. Record your analysis of the event and ways that poor outcomes could be avoided in the future in the logbook.

As a group, complete a profile of a health centre or the hospital within the first two weeks of the block. The goal is to give you an opportunity to fully understand the settings under which primary health care is provided. By the end of the assessment, you should be able to describe the basic facilities in the site, report on the access, quality of care, equipment and the infrastructure status of the facility, identify resource challenges faced by the facility as it fulfils its role in the delivery of primary health care, and list required resources to address any identified gaps. In addition, you should be able to critically discuss the strengths and weakness of primary health care and make recommendations for improving its delivery.

You should assess the following areas of your facility:

• Clinic location
• Structure and size of buildings
• Staff numbers by cadre
• Facility capacity and number of patients served
• Description of the catchment area (population, demographic, population, economic, activities, administrative area)
• Facility governance/leadership
• Services offered by the facility: Home based care, outpatient, in-patient
• Organisation of the clinic
• Equipment available
• Drug supply system
• Description of patient consulting rooms
• Privacy for patients
• Infection control status of the facility (ventilation, disposal of medical waste)
• Availability of water and electricity
• Communication systems (phones, road network)
• Referral networks (ambulance)
• Toilet facilities

For each category listed, there should be a thorough assessment including (if applicable) whether the item exists and is functional. Collect data through observation of the clinic environment and activities, interviews with key clinical personnel (facility manager/in-charge or other designee, nurses and other staff), and review of existing information (hospital reports, census data, and district office records). Appendix A contains a detailed checklist that outlines areas to be assessed. It is in the format of a questionnaire which may be adapted to suit the local facility conditions and may be used if you so desire.

The analysis should discuss the adequacy of resources at the facility. Although some of the measures are subjective, students should look at each category and decide if the situation is good, acceptable or poor. This is a subjective judgment and may need to be adapted to suit the clinic.

Good is a situation where all facilities are in good working order and in no way interfere with the delivery of services.

Acceptable is a situation in which the minimum requirements are available but existing conditions may interfere with the provision of services, hence adjustments need to be made so that services may be rendered unhindered.

Poor describes a situation where the facilities or equipment are such that services cannot be provided at an acceptable level.

For each category, generate a description of criteria that meet good, acceptable or poor levels. Comparisons may be made across categories and represented in tables and graphs in the group report.

In putting together the final oral report, the group should work through data collected in the different categories of the audit, identifying problems or issues in each category, the implications of these issues/problems for service delivery in the clinic and the possible solutions proposed. For example:

Although the checklist serves as a guide to carrying out the health facility assessment, the main component of the presentation will be around the analysis and recommendations for addressing the identified gaps to service delivery. Each group will be expected to suggest at least 3 key proposals or recommendations for enhancing service delivery. One of the proposals may become a foundation for the Quality Improvement Project.

Present your findings in a group oral presentation. It should not exceed 15-20 minutes. Audio-visual aids, where available, may be used for the presentation. This is a group activity and group marks will be allocated. Students may divide the various aspects of the study among group members, but the final report must be integrated and will be assessed as such. Each group will receive a single mark. If you chose to audit to audit a health centre other than your primary site, the group should elect a group leader who will work with the preceptor to arrange the visit.

The health facility profile should be carried out within the first 2 weeks of your block and presented to an assessor (College of Medicine staff or local block supervisor) in an oral presentation. A representative of health facility management should be represented at this final oral presentation.

After you have completed your health facility audit and discussed its findings with the staff, review the areas that need improvement.  Select ONE focused area and develop a quality improvement plan. The goal of this assignment is for you to develop an appreciation for the process of quality improvement as well as potentially leave something useful at your site. You should be able to identify a shortcoming of the health service, investigate the issue thoroughly, make a plan to overcome the issue, and discuss how to implement the plan. Because you are at sites for only four weeks, it may not be possible to fully carry out your proposed project.

There are many options for topics of investigation. It could be improving the management of a particular condition, helping to clear an administrative bottleneck, or implementing a practical strategy to improve aspects of ward or clinic functioning. You may continue with a project that was started up by a previous group that they did not have the time to complete. Note, however, that this is not a research project. Try to avoid the temptation to do surveys of staff or patients. Focus on service issues you can measure.

Appendix B outlines in detail an approach to quality improvement projects. Briefly, steps to consider include the following:

1. First, evaluate critically the project that was undertaken by a preceding group. How far did they get? What were its strengths and weaknesses? Has it been sustainable? Should it be continued?
2. After you have conducted the health facility audit, meet with local staff and your site coordinator/supervisors to discuss the project. Together make the decision regarding whether to continue the previous group’s project (if there has been one done at that facility) or to start a new one.
3. Define the problem and describe it briefly. Which part of the health service is affected? Focus on a specific problem.
4. Set standards. What is the quality of service you would like to see in the problem area? Are there standards against which you can measure this? What criteria will you use to for measurement? What targets are you aiming to achieve? Discuss this with the local staff and with your supervisor.
5. Determine and collect the information you need to help you understand the situation fully. How is the service falling short of the standards you have set and why? What resources are available to rectify the situation? From which sources (people, documents, observations) do you need to collect this information? Are there instruments that you need to prepare to collect data? How will you analyse the information so that it clarifies the problem?
6. Draw up a plan of action. How can you bring the service up to the standard that you have set? Who must do what and by when?
7. Share your plan with the local staff and with your supervisor so that they can make inputs before you start implementing it. It is important that this plan be feasible; you should be able to implement it in the couple of weeks available to you.
8. Start implementing the plan that you have made in close cooperation with the staff.
9. Write a report for the health facility to assist them in continuing the project and for the group that follows so that they understand clearly what you have done and how much you accomplished.
10. Present your project to the facility management at the site.

An oral presentation of the project should be made to the site coordinator during your last week at site. In most cases, the site coordinator or academic supervisor marks the presentation. The academic coordinators of the Family Medicine Department may request that the presentations be repeated during the examination week. The department faculty will moderate the final grade as necessary.

In addition to the oral report that you make for your facility, you should submit a written report for marking. It should be 8-12 pages long, single-spaced and computer printed. Make two copies of your report: one for the facility site supervisor and one for the academic supervisor. Your report is due prior to the written exam at the end of the block.

The written report should include the following elements:

1. Title/cover page: title of the project, site and hospital/ward/section where the QI project was carried out, student names, the rotation, the month and the year.
2. Your names and with whom you worked (staff members who were particularly involved).
3. A one-page summary of the project.
4. Your evaluation of the previous group’s project, if applicable.
5. The problem you decided to deal with, and why.
6. The methods you used including the criteria you agreed upon and standards set.
7. The data you collected about the present situation.
8. Your detailed plan for achieving improvement (either with a new plan, or for one that is already partly implemented and that you are improving).
9. The process of implementing your plan.
10. The results of your plan:
    1. What was achieved (in terms of the standards you set)
    2. What was not achieved
    3. How patient care was affected
    4. Reasons for successes and failures
11. Comments how the group functioned as a team, internally and with staff.
12. Comments from the health service staff about the project and what it achieved.
13. Details about what role each group member played and the contribution of each to the report.
14. Names and signatures of each member of your group.

Reports will be marked based on the following criteria:

1. Choice of topic, and review of previous group’s project. Was the review balanced, appropriate and insightful? Was your topic SMART (specific, measurable, achievable, relevant and time-bound)?
2. Definition of problem. Was the problem clearly defined and described? Was the problem clearly understood?
3. Methods, including standards and criteria. Was the methodology clear? Were the right tools used? Were the standards and criteria appropriate?
4. Intervention plan, including effort, logic, and practicality. Was the plan really suitable for rectifying the gaps you have discovered? Was your evaluation of the plan based on the degree to which standards were achieved? Does the project show understanding of the problems in the facility? Are the ideas applied? Is there too much focus on the theory of quality improvement?
5. The process of the QIP and teamwork. Has a clear process been followed? Does the project show an understanding of the principles of quality improvement? Is there evidence of teamwork within the group and with other members of staff?
6. Reflection on the project, including successes and failures. Is there evidence of understanding of the strengths and weaknesses of the project, of the group dynamics and of the teamwork? Is there an honest evaluation of the process?
7. Presentation of project. What efforts, creativity, and logic are evident in the way the project is presented? How well does the final report showcase the project?

The QI study is a group project; all members of the group are awarded the same mark unless group members can make a case for why individuals should score differently.

Call is required at the hospital during the block in order to provide opportunities to learn skills such as triage, emergency procedures, referral, and deliveries. Each student is required to do one night per week (minimum of four weeknights during the block) and two full weekend days (i.e. a 24-hour day from 8H00 to 8H00 the next day). In most circumstances it is expected that you will get some hours sleep during your call and work normally the following day. You should make a schedule as a group, together with your site supervisor, for call.

On a weekly basis there should be a group chart review session with your supervisor. You will be requested to present for discussion one chart (patient record) of a patient that you have seen during the week. You should select patients that you believe will provide useful discussion topics and present those to the group. Each student should present a minimum of four chart reviews during the block. One of the patients you present should be a child under five years of age that was seen using an IMCI approach.

During this exercise, the preceptor will guide you on how to systematically review a patient’s clinical record. They will evaluate the quality and content of patient care and record keeping after a consultation by you or one of your fellow students. This exercise will be an opportunity to receive constructive criticism. By the end of the chart review, you will be able to demonstrate your problem-solving skills in the consultation based on the patient’s presentation and the clinical findings and justify your clinical decisions and interventions including the process and content of examinations, investigations and management. In addition, you should be able to describe the quality of clinical record-keeping including the comprehensive 3-stage assessment and outline the tasks completed in the consultation.

The preceptor will discuss with you all of the decision points, including the following:

1. Key symptoms and signs
2. Interventions done, including side-room procedures
3. Clinical management
4. Appropriate execution of Davis and Stott’s tasks of consultation
5. Quality and adequacy of record
   1. O.A.P. usage and methodology
   2. Notes made including clear reference to instructions / advice given to patient
   3. Accuracy of prescriptions and interventions

The preceptor will also critique you what was done well in the chart and what could have been done better. In addition, your attention to family and community issues will be addressed.

Every week, each of the students in the group will be involved in different activities and/or will see different patients. In order to learn from each other and grow from the collective experiences, once a week you are required to spend about an hour with your colleagues discussing the patients you have seen. Use this as a chance to reflect critically on the practices you have observed (good and bad). Consider what you have done well during your day and where you still need to learn. Bring up questions that you may have had, decide together what you need to learn and discuss how you are going to share that knowledge. You may arrange these meetings as fits best in terms of the location, whether it is in the clinic, hospital, or residence. These are student directed sessions but you must record each reflection session in your logbook. The amount of writing is less important than the issues recorded. A student who is on call may be busy and not able to attend, so it is recognised that not everyone in the group will be at every these reflection sessions, but most of the group should be present.

Three times in your block you will be do an observed consultation of an unprepared undifferentiated patient who is waiting in the queue. The scores from the last two consultations will count towards the final assessment, but the scores of the first observed consultation will not. The first consultation should take place in the first week of the block . The second consultation in the second or third week of the block. The last consultation should take place in the third to fourth week of the block. An academic supervisor or the site leader should observe at least one of your consultations.

You should reflect on the activities you have completed in the block in terms of their usefulness to you and to the health service/community. This is a way of taking stock of your learning process for yourself and seeing what you have learned in the block. The free comments are an important reflection of your ability to self assess your learning needs and guide your studying as you fill gaps in your knowledge and skills. These will be reviewed as part of your logbook assessment. You may wish to justify your comments.

We also request that you rate the activities in terms of their value and enjoyment respectively in order to help with ongoing improvement of the block. Your ratings of activities are not taken into account in any way in assessing your logbook or finalising your marks. They will be recorded separately and anonymously in a database. We would thus appreciate honest ratings of these activities. Please rate the value of each activity from your perspective and from the community’s perspective.

Near the end of your family medicine block you should assess yourself in terms of what you have achieved in the block. Your rating will not influence the mark given to your logbook, but your ability to assess yourself is considered as self-knowledge and an understanding of strengths and weaknesses are critical in the safe practice of primary care. This work serves also as a checklist for you to make sure you have completed all the activities. There is space for any additional activities you may feel are important to review. It is unlikely that you will have the same rating for all areas as all learners have strengths and weaknesses.

Discussions on ethical issues arising in the routine care of patients should be reflected on as part of the daily reflection and also included in the chart reviews. Practice of ethics will be evaluated as part of the Professionalism assessment. Your attendance and professionalism during the first week of the block is also considered by faculty.