Is Familiy Medicine Shelf Easy After Internal Medicine

Family medicine is the center of primary care, which makes family medicine physicians the generalists of generalists. As opposed to other specialties that only focus on one specific organ or disease, family physicians treat the broadest range of patients and illnesses. The family medicine clerkship provides medical students the opportunity to gain a wide range of knowledge and a better understanding of what it's like to be a family medicine physician.

"Cure sometimes, treat often, and comfort always." — Hippocrates

This post will cover the family medicine clerkship, including when to place this rotation, how to make the most of your rotation, family medicine clerkship resources, the Shelf exam, and the pros and cons of pursuing this specialty.

Intro to the Family Medicine Clerkship

Clinical clerkships, also called rotations, are when med students practice medicine under the supervision of an established doctor or health practitioner. They allow students to see what a specialty is really like so that they can determine what field of medicine they feel passionate about and want to pursue in their future career.

Most US medical schools require the following rotations:

• Family Medicine
• Internal Medicine
• Neurology
• OB-GYN
• Pediatrics
• Psychiatry
• Surgery

Additionally, some schools may also require other rotations, such as radiology, emergency medicine, anesthesiology, etc.

Family medicine is the specialty of choice for doctors who like the idea of primary care and want to treat people from young to old with a wide variety of diseases and ailments. Family medicine physicians represent people's gateway into the health system; it's the first line of defense for less urgent health concerns.

Family medicine physicians are responsible for applying preventive care measures by holistically viewing their patients and helping them navigate the care they need.

Most family physicians practice in an outpatient clinical setting, dealing primarily with pathologies like diabetes, hypertension, hyperlipidemia, preventative medicine, and health screenings—but there's a lot more to the specialty than that. You can focus on pregnancy and delivering babies, the elderly and geriatrics, focus on procedures like colposcopies, steroid injections, frenulectomies, and much more.

Family medicine physicians are generalists who know a little bit of everything, so you don't have the kind of organ-specific options for specialization as a physician in internal medicine, but you have several 1-year fellowship options, such as sports medicine, obstetrics, emergency medicine, and rural and international.

When to Place the Family Medicine Rotation

The family medicine rotation can be used in two ways. You can choose to pursue the family medicine rotation at the beginning of your third year or at the end of your third year. The decision is largely based on what purpose you want the rotation to serve.

The Beginning of Third Year

If your objective is a smooth transition into third year, and you're not that interested in pursuing family medicine, complete this rotation at the beginning of third year.

Family medicine is an easier rotation, so it's a great way to adapt to the clinical year. Plus, it's an excellent way to build your clinical reasoning framework. The cases will be lighter, allowing you to build your experience with acquiring a medical history, performing a physical exam, and creating a management plan.

Middle of Third Year

If you want to pursue family medicine, placing this rotation second or third allows you to accrue the kind of knowledge that will impress your attendings. Previous surgical rotations will also help you prove that you can carry out minor procedures in the clinic.

The second or third spot will allow you to feel out the experience while still leaving enough time to get letters of recommendation for pursuing a family medicine residency. Expectations often don't meet reality. You don't want to find out that the family medicine specialty isn't what you want to pursue too far into your year.

The End of the Third Year

If you do not want to pursue family medicine and are taking Step 2 CK at the end of your third year, it's a good idea to take this rotation at the end of your third year. Having a light rotation before Step 2 CK allows for more time to study. Additionally, there is a moderate degree of overlap between your family medicine Shelf and Step 2 CK, which improves the utility of each minute spent studying. With Step 1 transitioning to pass/fail, it's essential to perform your best on Step 2 CK, as this will become the primary metric in determining residency application competitiveness.

Making the Most of the Family Medicine Rotation

The family medicine rotation is usually an outpatient/ambulatory one. This third year rotation may also be your chance to experience rural medicine. At certain medical schools, you have the opportunity to opt-in for a rural family medicine cabinet.

To make the most of your rotation, ask for a physician practicing in a subspecialty you're interested in. For example, there are family medicine attendings that have OB/GYN training and help with deliveries. Other examples are practitioners with sports medicine experience who have a day focused exclusively on sports-related injuries, such as shoulder impingement or tennis elbow.

If you want to excel in your family medicine rotation, medical history taking and the clinical exam represent the ideal pathway to success. The most common pathologies seen in the outpatient setting are:

• Diabetes mellitus (DM)
• Hypertension (HTN)
• Dyslipidemia
• Pneumonia
• Anemia
• Depression/anxiety

Here are some strategies for the most common ones that will help you ace your first day of rotation.

Diabetes Mellitus

Diagnostic criteria:

• Fasting glycemia > 126 mg/dL
• OGTT (oral glucose tolerance test) > 200 mg/dL at two hours
• HbA1c > 6.5%

Pre-diabetes criteria includes:

• Fasting glycemia 100 – 125 mg/dL
• OGTT 140 – 200 mg/dL at two hours
• HbA1c between 5.7% and 6.5%

Follow-up on patients:

• HbA1c shows glucose control for the last three months
  • A fraction of the hemoglobin from RBC gets glycated, a monosaccharide (glucose) attaching spontaneously to hemoglobin. Since the lifespan of a RBC is 90-120 days, HbA1c approximates the level of glucose to which the RBC was exposed for this period. Therefore, HbA1c reflects the blood glucose level for approximately three months.
• Foot inspection in order to detect signs and symptoms of neuropathic foot ulcer (common complication)

Treatment:

• Lifestyle changes:
• Exercise (leads to lower levels of glycemia)
• Weight loss for the overweight patients (contributes to insulin resistance)
• First-line pharmacologic treatment:
  • Metformin (also, it promotes weight loss)
  • Avoid in patients with renal disease (risk of lactic acidosis)
• Other pharmacologic treatments:
  • Sulfonylureas (glipizide, glimepiride)
    • An important side effect of sulfonylureas is neuroglycopenic and adrenergic symptoms. As they stimulate the release of insulin from remnant beta cells, low glucose ensues. Patients will develop symptoms such as tremors, sweating, and confusion as the brain is deprived of glucose.
  • Insulin if the patient is in advanced type II DM or if the patient has type I DM.
    • Insulin is given for patients with type I diabetes because they lack pancreatic beta cells due to autoimmune destruction. Usually, they are given a rapid-acting insulin form (such as normal insulin) before each meal and a long-release insulin form (such as glargine.)
    • If a patient with type II DM requires insulin, this is a sign of severity. It means that the majority of their beta cells are depleted and can't compensate enough.

Essential Hypertension

Diagnostic criteria:

• Two readings at more than two occasions show BP levels of higher than 140/90 mmHg

Other secondary causes:

• Hyperaldosteronism
• Renovascular disease: renal stenosis/fibromuscular dysplasia

Usual therapeutics:

• Lifestyle modification (modifiable risk factors)
  • Weight loss, exercise, low sodium diet, Mediterranean diet for patients with dyslipidemia, and smoking cessation
• First-line drugs:
  • ACE inhibitors or ARBs, especially in patients with renal disorders or diabetes
  • Thiazide diuretics in African American patients

Dyslipidemia

Diagnostic criteria: LDL-C > 130 mg/dL or Cholesterol > 200 mg/dL

• Inquire about family history of dyslipidemia in order to screen for familial dyslipidemias.
• Start screening for it after the patient reaches 45 years of age if there are no risk factors associated. If there are risk factors, such as familial history of coronary artery disease at a young age or premature death, consider screening at an early age (>21 years.)

Treatment:

• Lifestyle modifications: exercise, diet
• Pharmacologic: statin (first-line of therapy), fibrates (if the patient has hypertriglyceridemia)

Anemia

Diagnostic criteria: Hemoglobin < 13 g/dL in males or <12 g/dL.

Diagnostic workup:

• MCH, MCHC, MCV are used for determining if there is a microcytic anemia (MCV < 80 fL), normocytic (80-100 fL), or macrocytic anemia (MCV>100 fL).
• If there is a microcytic anemia, then suspect:
  • Iron deficiency anemia: continue the workup with ferritin, TIBC, serum iron. In this case, the patient will have high TIBC, low serum iron, and low ferritin.
  • Anemia of chronic disease: the patient will have high ferritin, low transferrin saturation, and low serum iron.
  • Lead intoxication: basophilic stippling is seen on a blood smear.
• If there is a macrocytic anemia, then suspect:
  • Vitamin B12 deficiency: patients will have both neurologic signs such as paresthesias, alongside typical signs of anemia (pallor). Homocysteine and methylmalonic acid levels are high.
  • Folate deficiency: it lacks neurologic signs. Homocysteine levels are high, while methylmalonic acid levels are low.
• A normocytic anemia can be caused by various conditions. One might consider:
  • Hemolytic anemia: high reticulocyte count is associated with it
  • Anemia of chronic disease: in the first stages
  • Aplastic anemia: can be seen with a low reticulocyte count

Treatment:

• Iron deficiency anemia: iron supplementation
• Lead intoxication: one can administer succimer or dimercaprol for severe poisoning
• Anemia of chronic disease: treat the underlying condition
• Vitamin B12 deficiency and folate deficiency: administer vitamin B12, respectively folate. However, administering folate in a vitamin B12 deficiency is called the folate trap. Patients will no longer have anemia, but their neurologic signs will worsen.
• Aplastic anemia: treat the underlying condition. For example, if the patient is exposed to a radiation environment at work, suggest protective equipment. Also, in severe cases, they might receive packed red blood cells.

Screening

Knowledge of screening recommendations is an essential thing to master, as half of the daily patient population will require it. Some of the screenings to learn about are:

Pap smear + HPV:

• Screenings are performed every three years until the age of 30. After 30, every five years.

Breast cancer:

• Mammography is indicated on a biennial basis starting from 50 years old until 74 years old. However, if there is a family history of breast cancer, start the screening at 40 years old.

Colorectal cancer:

• Any population aged 50 to 64 years old is screened using a colonoscopy. For patients that have IBD, the screening is indicated at 10 years after the initial diagnosis. Then, continue them yearly.

Osteoporosis:

• At least one DEXA scan in postmenopausal women (>65 years)

Abdominal aortic aneurysm:

• Ultrasound exam at least once in men who smoked (65 – 75 years)

Diabetes:

• Screen patients aged between 35 – 70 years who are either obese or overweight

Lung cancer:

• Annual screening in patients 50 – 85 years old with a 20-year history of smoking who are currently smoking or who smoked in the last 15 years. The screening ceases if it's been more than 15 years since the last time the patient smoked.

Regarding the skills with the highest return during the family medicine rotation, ultrasound skills are the ones you will benefit the most from. Before the rotation, you can attend ultrasound workshops. Another way to develop these skills is during the internal medicine or emergency medicine rotations. During these rotations, there is a high chance of finding conditions that require such a diagnostic modality, so you can use this opportunity to further your expertise.

However, even if ultrasound skills are not part of the toolset yet, showing interest in developing them will be sufficient enough for family medicine attendings to teach it.

Family Medicine Clerkship Resources

UWorld is the best resource for your family medicine clerkship. A lot of internal medicine questions will have a high return on investment in family medicine, as diseases overlap. Also, add some random question blocks, including gynecology, neurology, and psychiatry. Some ambulatory medicine questions will use knowledge from these areas. Utilize UWorld in two modes:

• If you're exhausted at the end of the day, focus on tutor mode and learning from the questions.
• During weekends and days when you finish early, time yourself in order to build the test-taking skills you need for Step 2 CK.

Another high-yield resource is the AAFP Question Bank. This is essential for the Shelf exam since the questions are very similar. Make sure to apply for free membership on the site.

Complementary resources to consider include review books. This entails Case Files/Blueprints or PreTest: Family Medicine. Among them, Case Files for Family Medicine is the most recommended among medical school students. Another solid option is Step-Up to Medicine, which many students argue is on the same level as Case Files.

• While Case Files might be useful as a comprehensive study guide, Step-Up to Medicine is more compressed.
• If you are looking into primary care medicine as a residency option, there are benefits to studying Case Files. Not only that, but you will also have a better understanding of the conditions seen in medical practice and the knowledge required to impress on your core rotation.
• If you feel crunched for time before the Shelf, Step-Up to Medicine is a good alternative for the last rapid review.

Family Medicine Shelf Exam

The family medicine Shelf exam will require less intense studying if you have already passed the internal medicine exam with honors. If not, this is the chance to work out what went wrong during the internal medicine exam and improve your test taking strategies.

Tips for the Family Medicine Shelf Exam:

• Take a first pass through the questions to build momentum. Answer the easy questions, mark the ones you are unsure of so that you can review them during the mini-breaks, and leave any questions you don't know the answer to.
• Take some mental breaks within the exam to avoid making errors caused by going through the questions too fast.
• For the questions you don't know the answer to, choose either the most probable choice or what the test makers would want you to choose.
  • For example, if you do not know the diagnosis but know that the most frequent cause of peripheral neuropathy in the population the patient represents is diabetic nephropathy, choose that answer.
  • Also, if the answers on management seem to refer to a TB diagnosis, it can be a sign that the test makers wanted to see if you know that the tuberculin test is used and its values for a positive test result.
• For Shelf exam preparation, take a Clinical Mastery Self-Assessment one week prior to the exam to familiarize yourself with the test conditions. Another useful technique is to block three hours during the weekends to simulate the conditions on UWorld with the IM questions.

Residency Choices: Pursuing the Family Medicine Specialty

If you want to pursue family medicine, this specialty comes with some perks. First, it has a good work-life balance. Usually, the schedule is similar to a 9 to 5 job. Calls are rarely seen in the specialty, unless your practice includes delivering babies.

There is a low threshold for entering the family medicine residency. With an average 238 Step 2 CK score, family medicine is ranked at the bottom of our MSI Competitiveness Index ranking. It ranks 22nd of 22 analyzed specialties.

View our comprehensive Specialty Competitiveness Index, which assesses specialties based on USMLE Step 1, Step 2CK, Top 40 NIH, publications, and more.

The major downside of family medicine is the lower compensation in comparison with other specialties. The Medscape annual compensation report from 2021 reports an annual compensation of $236,000 for family medicine physicians. Only pediatrics has a lower compensation.

Learn more about whether or not the family medicine specialty is right for you: So You Want to Be a Family Medicine Doctor (video and article).

Final Thoughts on Family Medicine Clerkships

The family medicine rotation will be an opportunity to explore rural medicine, as well as to grow your previously-developed internal medicine skills and knowledge. Master the most common diseases, and you will impress your attendings and dominate the Shelf.

Family medicine is a great specialty for physicians who have a wide range of medical knowledge. It is meant for people who want to master a broad (though shallow) knowledge of medicine as opposed to a deep and narrow one. It also represents one of the choices for medical students who envision a good work-life balance throughout their career.

Get the Advice and the Resources You Need

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View our library of resources, including guides on the entire residency application process, how to choose a specialty, how The Match algorithm works, and more.

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