Family Medicine Clerkship Curriculum - Lake Erie College of Osteopathic Medicine

“The young physician starts life with 20 drugs for each disease, and the old physician ends life with one drug for 20 diseases.”
– Sir William Osler

Attention preceptors: In order to access the uploaded articles linked below in the required reading section, you must be logged into portal link here. Please email at travis.smith@lecom.edu for your username and password.

1. Table of Contents

Table of Contents
Description
Requirements
Materials
Evaluation
Objectives
1. Medical Knowledge
2. Patient Care
3. Interpersonal and Communication Skills
4. Practice-Based Learning and Improvement
5. Systems-Based Practice
6. Professionalism
7. Clinical Topics
8. Osteopathic Philosophy and Osteopathic Manipulative Medicine
Required Reading
Supplemental Learning Resources
Family Medicine Journals
Shelf Exam
Board Review Tips

2. Description

Family Medicine (MS3): 4 week rotation: During your 4 week rotation you are expected to meet and exceed the following requirements and challenge yourself, to be proactive learners and ask questions.

During this rotation there will be an emphasis on prevention of illness and caring for the patient in the context of family and community. When applicable, students are encouraged to participate in the care of hospitalized patients, those in skilled nursing or rehab facilities, home visits, and office-based procedures whenever possible. The majority of this rotation will be in the ambulatory setting but some students will participate in the care of the hospitalized patient. Students are expected to participate in morning report, noon conferences and other available educational offerings.

There is a lot of information that is tested on the Family Medicine Shelf exam and is very hard to accomplish all of the necessary reading in only 4 weeks. The other important reading topics that are not be included in this block will be found in the two Ambulatory Medicine blocks in your 4^th year, and various other topics in your third year OB/GYN, Pediatrics, and Psychiatry rotations. If there is a problem with one of the links to the readings or questions in your coursework section, please email me directly, travis.smith@lecom.edu

3. Requirements

Complete all reading requirements while on your respective Family Medicine Rotation including text book and online readings.
- Students are encouraged to supplement required readings with additional readings based on your specific rotation exposures.
- 10 hours per week of outside clinical reading.
Complete the Weekly Online Questions of the Day in the coursework section
Complete the online End of Rotation Quiz (Worth 20% of your final grade)
Health Care Management Series: This is a separate assignment and not part of your grade for this rotation. You must complete all 4 Units covering 5 chapters. You should complete one per week. This is required and to be completed during your first Family Medicine rotation. Please email Tim Novak if you have any questions. mhsa@lecom.edu
Students are expected to work at least 4 full work days and MUST adhere to the ACGME rules regarding the workweek, which include working no more than 80 hours per week, no more than 24 hours continuously, except an additional 6 hours may be added to the 24 to perform wrap-up duties, and have at least one of every 7 days completely off from educational activities.
Extended absences from the clerkship are not permitted. Any absence from the clerkship must be pre-approved by the regional campus dean prior to the beginning of the clerkship.

4. Materials: Required and Supplemental

Essentials of Family Medicine (Sloane) (Required)

American Osteopathic Association. (2011). Foundations for Osteopathic Medicine. Philadelphia: Chila, Anthony G. Lippincott Williams and Wilkins. (Required)

Savarese, Robert G.; Capobianco, John D.; Cox, James J. Jr. (2003). OMT Review; A Comprehensive Review in Osteopathic Medicine. S.I: Savarese (Required)

DiGiovanna, Eileen L.; Schiowitz, Stanley; Dowling, Dennis J. (Eds.). (2005). An Osteopathic Approach to Diagnosis and Treatment (3rd ed.). Philadelphia: Lippincott Williams & Wilkins.

Family Medicine Principles and Practice Sixth Edition (Supplemental) 6th Ed. (2003) (Supplemental: Free text via Stat Ref)
Family Medicine: Blueprints (Supplemental)
CURRENT Diagnosis & Treatment in Family Medicine: 4^th Edition (Supplemental)
Other Web Resources
- ebscohost.com
- essentialevidenceplus.com- An evidence-based, point-of-care clinical decision support system that gives you access to over 13,000 topics, guidelines, abstracts, and summaries
- uspreventiveservicestaskforce.org
- fmCASES– Virtual patient cases
- OMM iOS app- DO OMT app

5. Evaluation: (Effective June 2017)

50% based on rotation evaluation
30% based on the shelf examination
20% based on completion of the end of rotation quiz (50 questions) and completion of the weekly quizzes (the weekly quiz grades will not factor into your end of rotation quiz grade).
- The end of rotation exam is due on the last Sunday of your rotation by 10PM eastern and will not be accepted late!
  - If you fail to complete the exam or fail turn it in on time (even 1 minute late), you are still required to take the make-up exam (while still receiving a 0% towards your grade)
  - If you then fail the makeup exam (<70%) or fail to take it completely by the end of your next rotation then you will be required to repeat the entire rotation during your elective month.

6. Goals and Objectives

The Family Medicine Clerkship is designed to enable students to establish competencies in the comprehensive approach to the practice of medicine by focusing on lasting and caring relationships with patients and their families. Students will learn to integrate the biological, clinical, and behavioral sciences to provide continuing and comprehensive health care that includes all age groups, each organ system, and every disease entity. During this rotation students should have the following goals:

6.1 Medical Knowledge

Demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

List the most common acute, chronic and psychological diagnoses that present to the family physician including their main presenting symptoms and physical examination findings
Describe the importance of commonly used laboratory modalities in family practice
Realize the effects (therapeutic and adverse) of commonly used medications, prescribed and over-the-counter, used for frequently seen diagnoses in family practice
Demonstrate the importance of longitudinal care including growth and development assessments, health screenings and management of commonly seen chronic problems
Demonstrate an understanding of health promotion and disease prevention
Generate a list of initial diagnostic hypotheses (differential diagnosis) from the clinical database, which takes account of the key points of the medical history, physical examination, as well as psychosocial, family, and community factors.

6.2 Patient Care

Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Interview a patient or patient’s surrogate, using appropriate interpersonal skills and maintaining professional demeanor, and obtain a comprehensive medical history which includes chief complaint, history of present illness, past medical history, family environment, psychosocial factors, and any applicable cultural issues.
Perform a systematic and technically correct physical examination on patients of various ages using appropriate interpersonal skills and professional demeanor emphasizing normal and abnormal findings on HEENT, heart, lungs, abdomen, skin, and musculoskeletal.
Perform any of the following including but not limited to reading growth charts, injections, rapid strep tests/throat culture, urinalysis, writing prescriptions, x-ray interpretation, laceration repair, sutures or staple removal, pap smear, KOH/skin, bimanual exam, gram stain/interpretations, referral, and foreign body removal.Be able to present a case of a patient encounter to a practitioner
Demonstrate an ability to develop rapport with patients through effective listening skills, empathy, sensitivity and respect for the patient
Recognize the importance of total patient management including preventive care, patient education, episodic illness care and chronic illness care
Recognize the impact of the disease process on the patient relative to family and other interpersonal relationships

6.3 Interpersonal and Communication Skills

Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates.

Communicate effectively with patients by explaining to a patient or patient’s surrogate, in a manner that the patient or surrogate can understand the assessment of the patient’s illness, the purpose of any diagnostic testing, what the patient can expect to experience during the diagnostic testing, treatment options available, and treatment recommendations.
List and demonstrate the principles of the art of interviewing
Present oneself in a professional manner to patients and their families
Demonstrate body language that places the patient at ease
Relate discussions and explanations in a manner that the patient can correctly interpret
Utilize touch when appropriate and within the boundaries of an appropriate doctor-patient relationship
Listen to what the patient is saying
Maintain confidentiality at all times

6.4 Practice-Based Learning and Improvement

Investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.

Be cognizant of, and apply, evidence-based medicine as it pertains to outpatient/family practice
Collect and analyze patterns of medical practice and compare/contrast the individual patterns within the practice with established clinical guidelines and norms.
Select appropriate cost effective diagnostic tests that can be used to refute or confirm the initial diagnostic hypotheses, and which are acceptable to the patient in terms of cost, comfort and safety.

6.5 Systems-Based Practice

Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Integrate the importance of appropriate referral systems and their use in a family medicine practice
Identify health care issues involved in managed care with associated formulary, preventive care and referral pattern issues

6.6 Professionalism

Professionalism should imbue all aspects of your performance. Medicine as a whole will continue to evolve and change but this aspect of your character will stick with you forever. Each student should understand and be able to demonstrate these professional objectives:

Treat all patients, staff, and colleagues with respect.
Displaying good manners
A commitment to caring for all patients regardless of their medical diagnoses or social factors.
Displaying sensitivity to cultural differences
Avoiding confrontations
Demonstrate a positive attitude towards learning by showing intellectual curiosity, initiative, honesty, integrity, and dedication.
Showing discernment while avoiding deception when communicating with patients and their families
Effectively communicates empathy
Puts patients’ needs above own (altruism)
Showing intellectual curiosity
Accepting responsibility for your patients
Being prepared and on-time
Being dependable
Reliable attendance and participation
Strive for excellence
Not passing others’ work off as your own
Actively seek to broaden education and experience beyond clerkship requirements
Avoid complaining
Give feedback (including filling out course and teaching evaluations in a timely manner)
Convey humility

6.7 Clinical Topics Objectives

Each student must be able to demonstrate the ability to diagnose and manage selected patient presentations and clinical situations involving the following topics:

General Medical: Perform routine well visits, recommendations for screening, vaccinations, and preventive care, as well as health care delivery concerns.
Required Screenings: Please be familiar with the following screening recommendations from the AAFP (embedded links): Abdominal Aortic Aneurysm, Alcohol Misuse, Breast Cancer, Cancer Screening Controversies, Cervical Cancer, Colorectal Cancer, Dental Caries, Depression, Diabetes Mellitus, Fall Risk, Folic Acid Supplementation, Immunizations, Intimate Partner Violence, High Blood Pressure, Lipid Disorders Children/Adolescents, Lung Cancer, Obesity, Oral Cancer, Osteoporosis, Prostate Cancer, Sexually Transmitted Infection, Skin Cancer, Statin Use, Tobacco Cessation.
Cardiovascular System Disorders: Atherosclerosis, hypertension, arrhythmias, heart failure, valvular heart disease/murmurs, coronary artery disease, myocardial infarction, venous thromboembolism, and common pediatric cardiac conditions
Endocrine System Disorders: Diabetes, thyroid disorders, osteoporosis, dyslipidemia, obesity, metabolic syndrome, electrolyte imbalance, infertility, hypogonadism, adrenal disease, and pituitary disease
Gastrointestinal System Disorders: Abdominal pain, gallbladder disease, liver disease, pancreatitis, ulcer disease, gastrointestinal bleeding, gastroesophageal reflux disease, dysphagia, hernias, diarrhea, constipation, inflammatory bowel disease, anorectal conditions, nutritional considerations, and poisonings/ingestions
Genitourinary/Gynecologic/Reproductive System Disorders: Sexuality and developmental stages, men’s health issues, incontinence, common renal disorders, vulvovaginal disorders, vaginal discharge, urinary tract infections, sexually transmitted infections, abnormal vaginal bleeding/menstrual-related conditions, pelvic pain & masses, contraceptive management, common breast conditions, and pregnancy-related care
Hematology/Oncology & Immune System Disorders: Common forms of anemia, bleeding disorders, hypercoagulability disorders, blood dyscrasias, malignancies, immune deficiencies, autoimmune disorders, and common allergies
Integumentary Disorders: Common rashes, common skin cancers (benign and malignant), skin infections, nail disorders, bites/infestations, and dermatologic manifestations of systemic disease
Musculoskeletal Disorders: Sprains/strains/fractures, bursitis, somatic dysfunction, viscerosomatic relationships, osteopathic manipulative treatment, arthritis, chronic neck/back pain, overuse syndromes, ligament injuries,
Neurology System Disorders: Neuropathies, dementia, chronic pain, insomnia, headache, stroke/TIA, dizziness, tremors, and seizures
Psychiatry Disorders: Substance abuse, addiction, developmental and pediatric behavioral issues, anxiety, depression, schizophrenia, bipolar disorder.
Renal Disorders: Chronic Kidney Disease, end stage renal disease, nephropathies, hypertension.
Respiratory System Disorders: Common eye and ear complaints, respiratory infections, asthma, chronic obstructive pulmonary disease, pulmonary embolism, spontaneous pneumothorax, cough, and shortness of breath

6.8 Osteopathic Philosophy and Osteopathic Manipulative Medicine

Integrate Osteopathic Concepts and OMT into the medical care provided to patients as appropriate. Understand and integrate Osteopathic Principles and Philosophy into all clinical and patient care activities.
The OMM objectives for this Family Medicine rotation are taken from two chapters from the text; American Osteopathic Association, and Anthony Chila. Foundations of Osteopathic Medicine, 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins.

Each student must be familiar with the following learning objectives pertaining to the patient presenting with Acute Low Back and Neck Pain.

Chapter 69: Acute Low Back Pain. Foundations of Osteopathic Medicine, 3rd ed. 1006-1018.
- How to effectively evaluate, diagnose, demonstrate a constructive clinical approach, and apply OMT in the treatment of the patient with the following:
  - Low Back Pain: Acute, Subacute, Chronic
  - Piriformis Syndrome
  - Sacroiliac Joint Pain
  - Coccydynia
  - Psoas Syndrome
  - Short Leg Syndrome

Define acute, subacute, and chronic low back pain.
Be familiar with and know the major elements of lumbar back anatomy and physiology, shared muscles and fascia and venous and lymphatic drainage.
Discuss the function of the anterior and posterior muscles of the lumbar spine, including the different layers of the posterior musculature (ie superficial, intermediate, and deep layers).
Discuss and be familiar with the muscles, fascia, and ligaments (soft tissues) commonly associated with lumbosacral somatic dysfunctions in patients with lower back pain.
Describe and use the structure-function model of differential diagnosis of LBP and approach in determining whether the pain is due to local pathology, spinal or pelvic muscular somatic dysfunction of the lumbar region, localized manifestation of a systemic pathophysiological process, or referred pain from internal organ disease.
Perform a thorough history (especially searching for potential urgent etiologies) and physical exam including an osteopathic palpatory exam in those presenting with acute lower back pain.
Describe the general categories of etiology for low back pain and be able to describe the presentation of lumbar radiculopathies, differentiate possible mechanical etiologies including psoas, piriformis, and sacroiliac joint pain, the circumstances that cause and trigger them, and be able to demonstrate how to diagnose and treat the above structural issues.
Differentiate between mechanical and non-mechanical etiologies of lower back pain, characteristics, and how their diagnostic evaluation may differ.
Be familiar with and describe the three common somatic dysfunctions associated with lower back pain.
Describe the pathophysiology, physical exam, manipulation, and exercises/activities of daily living issues that pertain to:
Discogenic low back and cervical spine pain
Musculoskeletal components of cervical, lumbar, thoracic and rib pain
Spondylolisthesis, Spondylolysis, Spondylosis
Viscero-somatic etiologies of lumbar pain
Viscero-somatic etiologies of thoracic and chest wall pain
Discuss the recommended indications for radiological imaging in patients presenting with low back pain based on the American College of Physicians and the American Pain Society.
Perform appropriate differential diagnostic techniques of patients presenting with lower back pain in order to assign the patient to one of the following general categories:
Biomechanical
Medical
Metastatic
Surgical
Traumatic
Each student should be able to apply the five pathophysiologic models for musculoskeletal medicine for the patient presenting with low back pain:
- Biomechanical model:
- Respiratory-circulatory model:
- Neurological model:
- Metabolic-energy model:
- Behavior model:

Identify approaches that integrate the entire postural mechanism within the biomechanical model considered for a patient complaining of back pain.
Understand that most causes of lower back pain are musculoskeletal and amenable to OMT as there is evidenced-based literature and expert consensus guidelines that support the utilization of OMT for patients with acute, subacute, and chronic back pain.
Discuss the indications for referral to a spine or pain specialist for further evaluation and surgical management.
Describe and identify self-care recommendations, patient specific exercises, and physical therapy options to patients presenting with low back pain.
Know the evidence based literature and expert consensus guidelines that support the utilization of OMT for patients with acute, subacute, and chronic back pain.
Know and summarize the AOA recommended parameters for frequency of the application of OMM for patients with acute low back pain.
Effectively apply Osteopathic Manipulative Treatment and Osteopathic theory in the diagnosis and treatment of patients with acute lower back pain.
Identify that most cases of low back pain are musculoskeletal and amenable to OMT and be able to describe and perform key Osteopathic Manipulative Treatment techniques used in the treatment of common low back problems:
- Articulatory
- Counterstrain Techniques
- Direct – HVLA
- Direct – Muscle Energy
- Exercise Therapies
- Facilitated Positional Release
- Muscle Energy Techniques
- Myofascial Techniques
- Osteopathy in the Cranial Field
- PINS Techniques for the cervical spine
- Soft tissue
- Still Techniques
- Strain/Counterstrain
- Thrusting Techniques

Chapter 66: Acute Neck Pain</5h>. Foundations of Osteopathic Medicine, 979-989. Each student must be familiar with the following learning objectives in the treatment of Acute Neck Pain:

How to effectively evaluate, diagnose, demonstrate a constructive clinical approach, and apply OMT in the treatment of the patient with acute neck pain.
Understand and discuss neck pain due to whiplash-associated disorder (WAD) in adults as well as its proposed mechanisms, understand the “how the body is a unit mechanism”, associated somatic dysfunctions, and adjunct therapies.
Be familiar with and know the major elements of cervical spine anatomy and physiology, including all possible local neck pain generators.
Describe the general categories of etiology for neck pain and be able to describe the presentation of cervical radiculopathies, the circumstances that cause and trigger them, and be able to demonstrate how to diagnose and treat the above structural issues.
Recognize and describe and use the structure-function model of differential diagnosis of acute neck pain and approach in determining whether the pain is due to local pathology, spinal somatic dysfunction of the cervical spine, localized manifestation of a systemic pathophysiological process, or referred pain from intern organ disease.
Describe a broad differential diagnosis of neck pain from local pathology including supporting characteristics and diagnostic modalities.
Perform a thorough history and physical exam including an osteopathic palpatory exam of the neuromusculoskeletal system in those presenting with acute neck pain.
Be familiar with and describe the common comorbid conditions that are found associated most commonly in patients with neck pain.
Be familiar with and describe the work-related and non-work-related risk factors for neck pain.
Identify and discuss the characteristics of patients with radicular neck pain.
Each student should be able to apply the five pathophysiologic models for musculoskeletal medicine for each of the above different types of back pain:
- Biomechanical model:
- Respiratory-circulatory model:
- Neurological model:
- Metabolic-energy model:
- Behavior model:
Discuss the recommended indications for radiological imaging in patients presenting with neck pain.
Discuss the indications for referral to a spine or pain specialist for further evaluation and surgical management in the management of patients with acute neck pain.
Describe and identify self-care recommendations, patient specific exercises, alternative therapies, and physical therapy options to patients presenting with acute neck pain.
Describe the other somatic dysfunctions typically affected in patients with mechanical neck pain and effectively apply Osteopathic Manipulative Treatment and Osteopathic theory in the diagnosis and treatment.
Identify approaches that integrate the psychological, behavioral, and social responses to acute neck pain and somatic dysfunction using the behavioral model.
Identify and understand the contraindications and cautions regarding OMT for somatic dysfunction in patients with acute neck pain.
For patients with neck pain, be familiar with the osteopathic approach of treating the whole patient and not just the symptoms as it will help maximize the patient’s restorative health potential.
Describe and perform the key Osteopathic Manipulative Treatment techniques used in the treatment of neck pain:
- Counterstrain Techniques
- Cranial Techniques
- Myofascial Techniques
- Muscle Energy Techniques
- Facilitated Positional Release
- Still Techniques
- PINS Techniques for the cervical spine
- Thrusting Techniques
- Exercise Therapies

7. Required Reading

During your rotation these articles below should help improve your knowledge base of common conditions. They are broken down into 4 sections for each week of your rotation. These articles are required in addition to reading the required core text book, Essentials of Family Medicine (Sloane). The linked articles can only be viewed when you are logged into the Portal. The order of the articles will correlate the topics you will be quizzed on during your weekly quizzes that are located in the coursework section under Family Medicine. In addition to the reading articles there are chapters and objectives attached from your OMM text.

Family Medicine Rotation 1 Required Reading: Read the following articles on your Family Medicine Rotation in addition to your required textbook readings. You are also required to complete the weekly questions located in your coursework section that is located under my courses. Those questions correlate with the below reading topics.

Required Screenings: Please be familiar with the following screening recommendations from the AAFP: Abdominal Aortic Aneurysm, Alcohol Misuse, Breast Cancer, Cancer Screening Controversies, Cervical Cancer, Colorectal Cancer, Dental Caries, Depression, Diabetes Mellitus, Fall Risk, Folic Acid Supplementation, Immunizations, Intimate Partner Violence, High Blood Pressure, Lipid Disorders Children/Adolescents, Lung Cancer, Obesity, Oral Cancer, Osteoporosis, Prostate Cancer, Sexually Transmitted Infection, Skin Cancer, Statin Use, Tobacco Cessation.

Week 1 Readings

Week 2 Readings

Knee Pain in Adults: Nonsurgical Management: AAFP
Evaluation of the Patient with Hip Pain: AAFP
Nonoperative Management of Cervical Radiculopathy
1. American Osteopathic Association, and Anthony Chila. Chapter 66: Acute Neck Pain. Foundations of Osteopathic Medicine, 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins, 2011, pp. 979-989.
Diagnosis and Treatment of Acute Low Back Pain: AAFP
1. American Osteopathic Association, and Anthony Chila. Chapter 69: Acute Low Back Pain. Foundations of Osteopathic Medicine, 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins, 2011, pp. 1006-1018.
Diagnosing Common Benign Skin Tumors: AAFP
Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinoma: AAFP
Cancer Screening in Older Patients: AAFP
USPSTF Screening Recommendations at a Glance
Immunizations: Routine Childhood and Adolescent Immunizations: AAFP
Immunizations: ACIP Releases 2016 Adult Immunization Recommendations: AAFP
Substance Use Disorders: In the Clinic

Week 3 Readings

Week 4 Readings

If there is a problem with an article or link please email and let me know, travis.smith@lecom.edu

8. Supplemental Learning Resources

In addition to the required textbooks and readings there is a plethora of step-by-step demonstrations of 122 OMT procedures online through a free educational resource for all osteopathic medical residents and students. This site was developed by the ACOFP’s Subcommittee on OMM/OPP Publications & Educational Resources. To access the videos, simply click on the link below, accept the licensing agreement and then select the videos you would like to see, sorting by anatomic area to be treated, type of OMT, or chapter in the ACOFP publication Somatic Dysfunction in Osteopathic Family Medicine.

Access the OMT Procedures Videos Online

Dr. John Weston, DO C-NMM/OMM guides you through common cases seen in the both outpatient, acute care settings, and Step II PE. Clinical pearls and pitfalls are reviewed during the evaluation, management and osteopathic approaches to such cases. The link to the Google Drive can be found here. Below is list of the topics covered:

The 5 Keys to Success
This is Typing Test
The Six Squares of Success
Before Going into the Room
Greeting the Patient
Sanitizing Hands
Draping
How to Ask
The Two Minute Warning
Case Distractors Overview
Case Distractor-Tobacco
Case Distractor-Alcohol
Case distractor-Grief
Case Distractor-Fear of Dying
Distractors-Elevated BP and BMI
Heart and Lung Exam
CN2-12 exam
Cervical Nerve Root Testing
MSK-OMT Universals
Differential-Low Back Pain
Evaluation of Low Back Pain
OMT for Piriformis
OMT for Piriformis II
OMT for Psoas
OMT Quadratus Lumborum
Evaluation of Elbow Pain
OMT for Lateral Epicondylalgia
Jaw Pain Evaluation
Jaw Pain Treatment
Shoulder evaluation
Spencer for Shoulder
OMT for Bicipital Tendinitis

9. Family Medicine Journals

American Family Physician
Annals of Family Medicine
Archives of Family Medicine (no longer in publication)
Australian Family Physician
Family Practice
Family Medicine Journal
Family Practice Management
Journal of the American Osteopathic Association
The D.O. Magazine
Osteopathic Medicine and Primary Care

10. Shelf Exam

Students will take a web-based NBME examination in Family Medicine at the end of the clerkship. This will include the core 80-question exam with an additional module on chronic care. The family medicine subject examination is like a mini USMLE Step 2 exam. The Shelf Exam is 100 multiple-choice questions. One must be proficient at medicine, pediatrics, surgery, Ob/GYN, and psychiatry to do well on this exam. For this reason, a passing score is set at the 4^th percentile. Below is a breakdown of the topics that are seen on the COMAT Family Medicine examination and can be used as an example of the breakdown on the shelf exam.

DIMENSION 1 – PATIENT PRESENTATION
TOPIC	%
General	1-10%
Cardiovascular	9-20%
Endocrine	5-15%
Gastrointestinal	7-17%
Genitourinary/Renal & Gynecologic/Reproductive	7-17%
Hematology/Oncology & Immune Disorders	5-15%
Musculoskeletal/Dermatology	7-17%
Psychiatry/Neurology	7-17%
Respiratory	9-20%

DIMENSION 2 – PHYSICIAN TASKS
TOPIC	%
Health Promotion/Disease Prevention/ Health Care Delivery	5-20%
History/Physical/Diagnostic Technologies	40-60%
Management	20-40%
Scientific Understanding of Mechanisms	5-15%

11. Board Review Tips

If this is one of the last subject exams of 3rd year, less studying is needed. If this is one of the first subject exams of 3rd year, more studying will be needed. Do USMLE world questions throughout the rotation. It is very important to plan your studying as you will be busy considering this is a quick rotation. Devise a study plan that allows for reading time often. You can either base your reading on what you are seeing day in and day out, or you can simply read a book cover to cover. One could possible start with general medical illnesses and treatments, then move on to pediatric illnesses followed by gender specific health issues, and finish up with elderly care issues.

Several books are available, as are questions books. The point is to USE a textbook, and PRACTICE with questions books. DO NOT THINK YOU WILL PASS THE SHELF EXAM WITH A QUESTION BOOK or QUESTION BANK AS YOUR MAIN SOURCE OF INFORMATION!!!!

Family Medicine covers way too much ground, and clinic will be very challenging if you are not reading.

Board Review Resources: I recommend using Blueprints along with Case files.

USMLE Step 2 Secrets: USMLE Secrets Short and to the point, but contains quite a bit of information. Question and Answer format. Chapters separated by medical specialty. Contains a few black and white photos. Not a comprehensive resource. The subject examination could easily be passed if using only this resource.
Boards and Wards: Boards and Wards Offers succinct summary of all major topics covered on the subject exam. Outline format, similar to the notes distributed during 2nd year of medical school. Contains many full color photos of dermatologic conditions and other photos. Breadth of information is great, but contains little depth. May need to reference a larger textbook at times. Excellent resource for the subject examination and USMLE Step 2. Easily reviewed the week before the shelf exam.
Case Files: Family Medicine: To properly prepare for the family medicine subject exam, you would need to study from all case file books. This book contains a smattering of subjects not covered in the other case files, such as prevention. Not comprehensive enough to be used as a sole resource for the subject exam.
Current Diagnosis and Treatment in Family Medicine: Very useful for the in-house family medicine exam. Not as useful for the subject exam. Very long, but contains good information. Would be helpful with the shelf exam only if you started reading it at the beginning of the rotation but cannot be easily reviewed the week before the subject exam.
First Aid for Medicine: This doesn’t cover all the bases, however, and you will need to use some pediatric and OBGYN references as well (like Blueprints for both).
A text that is more comprehensive and directed at Family Med specifically is Swanson’s Family Practice Review. It has questions, but is divided into topics which make a cohesive unit for studying. If you read one or two topics on your patients each night, you will find that you have very little to review before the shelf exam. It is, however, pretty long, so don’t wait until the week before to begin studying if you want to use this book.

These tests are notorious for throwing some curveballs, and often test your ability to take a test as much as your knowledge related to the clerkship. Do plenty of practice questions for this test. While reading is paramount and necessary for back ground info, the questions prepare you for the variety of topics and depth of knowledge needed for the test.

The following list is merely a recommendation of what to know well, but does not exclude other material. However, rest assured that learning by doing is the most efficient way of covering ground. Seek out the opportunities to practice skills and be involved in patient care.

Clinical Portion: As mentioned earlier, you will see everything from prenatal care, infancy, childhood, adolescence, adulthood, and beyond.
Recognize the MOST COMMON conditions and illnesses in each of those age groups. As always, your most important goal is to learn and perform a thorough History and Physical.
Memorize high yield info such as developmental stages, immunizations, diagnostic process for diabetes and HTN.
Understanding medication usage is important, although memorizing prescribing information is not necessary.
Prenatal care: Understand importance of pre-conception visits and family counseling, as well as week-to-week and month-to-month prenatal care. Know the value of immunizations; risks of infections passed from mother to child, mom’s health risks, etc. Know how to examine a pregnant woman.
Infancy/Childhood: Know stages of development (Freud, Piaget, and Erickson) and be able to correlate normal and abnormal findings. Learn how to use growth and weigh charts. Know immunizations. Be familiar with common complaints of earaches, coughs, colds, and flu. Be familiar with childhood rashes and their causes. Counsel parents on what to expect behaviorally at certain ages, know safety precautions around the home.
Adolescent: Understand awkwardness of period in patient’s life. Be confident in your exam; learn to modify questions and approach to specific population. Always be aware of signs of depression, alcohol and drug use, physical or emotional stress and abuse, family dynamics, school performance, etc….Understand sexual development, identify abnormal development. Counsel on sex-related matters including abstinence, birth control, rape, and peer pressure. The Delta 8 vapes from OCN is said to be helpful to reduce stress.
Adulthood: Important aspects are those commonly seen in the general population. Know symptoms, evaluation, diagnosis, and treatment of DM, HTN, CAD, hypercholesterolemia, common infections, mental health, genitourinary illness in both sexes (from menstrual abnormalities to benign prostatic hyperplasia), outside stressors, and job performance.
Elderly: Much of the same as adulthood but be aware of mental health, nutritional health, everyday activities, etc…
Emergency/Orthopedics/Social Work: Invariably, you will see cases that require a trip to the ER for immediate attention, a specialist for further evaluation, or social work to make sure patients are receiving proper care and fair living circumstances. Be prepared to deal with all of these. Know and identify emergency cases (usually obvious), know basic orthopedic exams and understand what type of imaging to order, and be patient when trying to contact family member, nursing homes, etc…