Marathon

Introduction for Family Practice Residents and Medical Students

Welcome to Marathon and to Marathon Family Practice. We have prepared this package to help orient you to the practice, the hospital and the town.

Marathon

Marathon has a population of approximately 5000. We also serve the neighbouring community of Heron Bay and the two First Nation Reserves at Pic River and Mobert. It is a resource-based community with its biggest employer being the gold mines (Williams Operating Corporation, Teck-Corona/David Bell). The local pulp mill closed in February 2009 and this has had a significant impact on the community. Please see the following websites for more information about the town: http://www.marathon.ca/ and http://www.ournorth.com/portal/marathon/marathon.

Marathon Family Health Team:
This group practice evolved in August of 1996 and became a Family Health Team in December 2005. Please see our website www.mfht.org for more information about MFHT. Please also see the following article to learn more about our practice: http://www.cfpc.ca/cfp/2005/Sep/vol51-sep-cme-1.asp. The family physicians currently in the practice (and their home phone numbers) are: Peter Cunniffe (229-8662), Nancy Fitch (229-8275), Sarah Newbery (229-1777), Eliseo Orrantia (229-1777), Scott Wilson (229-8359), Mary Wilson (229-8359) and Barb Zelek, (229-1402). We all prefer first names be used. Hopefully you will have a chance to meet each of them and discuss their particular interests and roles. As well, let the group know your specific interests and objectives so that if a case of interest arises they will contact you.

Joanne Berube (229-8216) is the Family Health Team Director and is working in collaboration with the Board of Directors for the Family Health Team and the Ministry of Health to develop the five-year Business Plan and Budget for the Family Health Team. One Social Worker, two Registered Nurses, two Registered Practical Nurses, one part-time epidemiologist, one Registered Dietitian and 1 Nurse Practitioner and several Administrative Support staff have been hired, and they are currently working actively on their respective programs. These individuals are listed in the MFHT Staff section under the Learner/Locum area of the website.

Other Services and Providers at MFHT (Details of the programs are listed separately on our website)

NURSING

NURSE PRACTITIONER AT MFHT
Currently, the Nurse Practitioner is doing some acute care clinics, high school clinics and general appointment clinics. She is also working on some chronic care program development including diabetes management.

PROGRAMS PROVIDED BY RNS AT MFHT

• Travel Medicine and Travel Vaccines
• Smoking Cessation
• Reproductive Health Care including pregnancy tests and counseling, prenatal counseling (first visit with RN then sees MD at 10 to 12 weeks gestation), well woman exams, emergency contraception counseling and administration, abortion counseling, hormonal contraception counseling and follow-up
• Asthma Education and Spirometry
• INR Monitoring and Warfarin Therapy Program
• Hypertension Program medication adjustment

SERVICES PROVIDED BY RNS AT MFHT

• Compression stocking measurements for fitting for Rx. (for those patients unable to travel to Thunder Bay only)
• Injections: vaccines, TB skin testing, B12, DepoProvera, Lupron, Zoladex
• Teaching self administration of injections
• Allergy serum injections. (emergency epinephrine available on site, & anaphylaxis policy in place)
• Telephone triage of more complicated patients requesting appointments
• Telephone patients with more complicated results

PROGRAMS PROVIDED BY RPNS AT MFHT

• Hypertension including monitoring, home monitor verification, counseling and healthy life style counseling
• Wound Care including staple and suture removal
• Foot care and wart treatments

SERVICES PROVIDED BY RPNs AT MFHT

1. Injections: Vaccines (all except travel vaccines), TB skin tests, Depo Provera, B12
2. Ear Syringing
3. Calling patients with normal results and uncomplicated abnormal results.

There are Nursing Medical Directives in place for the following:

• Td vaccine booster
• MMR vaccine
• Pneumococcal Polysaccharide Vaccine
• Influenza Vaccine
• Hepatitis A and B vaccines
• Typhoid vaccine
• 2 – 18 mo. routine vaccines – Pediacel, Prevnar, MMR, Meningitis C, Varicella
• School age vaccines – Quadracel, Adacel (dTaP), Hepatitis B, Meningitis C
• PAP testing
• Screening swabs for STDs
• Management for anaphylaxis
• Warfarin dose adjustment
• Glucagon/Dextrose for Hypoglycemia
• Emergency Contraception
• TB skin testing for screening
• Wart and skin treatments
• Spirometry and Salbutamol administration for post spirometry

Please feel free to review the RN /RPN policy and procedure manual for specifics regarding these duties.
Please note that wart treatments, other than feet and genitals, skin tags and non-medically necessary skin treatments are not covered by OHIP and patients will be charged $20 per visit. Also travel consults ($30 single and $60 family) and travel vaccine administration ($15) are not covered by OHIP.

SOCIAL WORKER AT MFHT

PROGRAMS OFFERED BY THE SOCIAL WORKER

• Reproductive Health Care
• Smoking Cessation Group Therapy
• General Social Work including access and referral to all community social service programs
• CBT for Mood Disorders
• Urgent Care Program for urgent same day referrals – booked daily 2-3pm
• Hospital visitation
• Geriatric programming including performing the MMSE
• Coordination of telepsychiatry referrals, sitting in on appts and follow ups

You can refer by using the EMR. Please ask patients to book their appointment before before they leave the clinic.

DIETITIAN AT MFHT

The Registered Dietitian’s role is to provide nutrition assessments, counseling and care plans in collaboration with individuals and families referred for dietitian services. Referrals to the Registered Dietitian are made by all health care providers for a variety of conditions and diseases, including but not limited to:

• Diabetes (includes management and prevention strategy)
• Cardiovascular Disease (includes heart disease and stroke)
• Hypertension
• Anemia
• Celiac Disease
• IBS (Irritable Bowel Syndrome)
• High Risk Pregnancy
• Eating Disorders
• Weight Management

The Registered Dietitian collaborates with the physicians and all other health providers on already established programs such as:

• Hypertension
• Diabetes
• Smoking Cessation
• INR
• COPD
• Geriatrics

Some phone numbers:

Main Clinic Line: #229-3243
Clinic Fax: #229-2672
Clinic Line for Hospital use: #229-1246
Clinic Line for Personal use: #229-1541, plus your extension number.
Wilson Memorial General Hospital:
This hospital recently finished a complete renovation in 2003.

Some phone numbers for the Hospital:

Main Phone Line: #229-1740
Administration Office Fax: #229-1721
Medical Records Fax: #229-3242

See the following page for a checklist for your hospital orientation. Please review it and sign it with your preceptor. There is a separate information package for the hospital.

Learner Issues Locally

Barb Zelek is coordinating the teaching locally. Each learner will have one or two “major” preceptors for their entire rotation that will, in addition to doing part (or all, in some cases) of the teaching/supervision, will be responsible for seeing that evaluations, paperwork, etc. are done. In addition you may have a “minor” preceptor: someone who accepts the teaching/supervision responsibility for part of the time you are here.

Clinical issues should be discussed with the preceptor who is currently taking responsibility for teaching/supervision. Concerns/issues relating to your rotation in a non-clinical area should be taken first to your “major” preceptor or, if for some reason you feel this is not possible to do, to Barb.
You are invited to join our group at our CME functions (we are taking part in a Practice-Based Small Group Program as well as others) and our MAC and medical staff meetings. Other meetings are just business meetings for the Associates and would not be appropriate for you to attend. You should note that every Wednesday morning we will either have a meeting or a CME event (see schedule).

Teaching Plan and Expectations
In order to make your session here a positive one we will outline our plan for the structure of your stay here and our expectations.

First, some “golden rules”:

1. Patient care comes first, teaching/learning comes second. Especially for medical students and first year residents this may be a bit of change–this is a practice-based learning opportunity with on-going and continual patient care responsibility. This is not to say that the emphasis here will be on “service” rather than “learning”. Rather, your and our primary responsibility will be to providing high quality patient care, and from that learning opportunities will follow.
2. There will always be someone easily accessible to you to ask for help. Always ask for help when you need it and never do anything that you feel uncomfortable doing. If your need is urgent or if you are kept waiting a long time while your preceptor is seeing a patient of their own, feel free to interrupt. If your preceptor is away for any reason you will have a specifically designated substitute preceptor.
3. Communicate. Let your preceptor, other physicians and staff know if things are going well or if they aren’t. We will provide you with lots of opportunities to do this–avail yourself of them.

In Marathon

Before your arrival

• If all goes as planned you are reading this before you arrive in town. If so, we would like you to spend some time thinking about and listing any specific learning objectives you may have during your stay. Examples include practice management or group practice issues, procedural or obstetric experience, specific exposure to First Nations clinics and any special topics you may have a particular interest in.
• Let us know ahead of time if there will be any vacations or special leaves during your stay here.
• Try and familiarize yourself with this package.

Your first day

• You and your preceptor will meet and do an orientation tour of the town, the hospital and the clinic.
• You and your preceptor will discuss and plan how to meet any specific objectives you may have.
• You and your preceptor will review your schedule.
• You and your preceptor will draft an educational plan/learning contract.

Your weekly schedule
You and your preceptor will be following a weekly schedule pattern that should have some or all of the following elements:

1. You and your preceptor will be seeing patients in the office a variable number of shifts per week.
2. The last 20 minutes of every day is scheduled for review of the patients you have seen that day.
3. At the end of every week there will be an opportunity for feedback and review of how your objectives are being met.
4. Each morning will usually begin with hospital rounds.
5. On-call will be with your preceptor and the frequency will vary depending on your schedule. Should you, for some masochistic reason, want to do extra call shifts that can be arranged.
6. At the end of each day when you and your preceptor are not on call you must contact the on-call physician and inform him or her about any active inpatients.
7. Outpatient procedures (lumps and bumps, cast rechecks, joint injections) will be booked for the morning of call days.
8. The day after on call will be booked off except for a morning hospital round and review of any cases from the call shift.
9. Residents will be seeing their own booked patients. They will be scheduled at 20-40 minute intervals depending on the complexity of the presenting problem. This booking frequency will be reviewed after your first couple of weeks. On occasion, your preceptor will be sitting in with you to enable direct observation of your patient contact and clinical skills.
10. Medical students will, at least initially, be seeing patients with the preceptor. The degree of independence will be decided upon individually.

Feedback and Evaluation

Your evaluations will be in four parts:

1. daily sessions after the end of seeing patients: an unstructured evaluation and opportunity for reflection
2. weekly sessions on the last day of the week: an unstructured evaluation with review of the week and specific reference to objectives and your progress in meeting them
3. interim evaluation: approximately halfway through your rotation you will have a structured review of all objectives and completion of evaluation forms
4. final evaluation: a structured review of your success in meeting objectives and completion of evaluation forms.

Expectations of Residents & Medical Students

Finally, I would like to tell you what expectations we have of you.

1. Respect the golden rules.
2. Take an active part in CME, group meetings etc. We believe that observing and participating in the group process is one of the most valuable components of the learning experience that we offer in Marathon. In addition, you will be expected to present one CME topic to the physicians at the Wednesday morning session during your stay.
3. Be “first line” when on-call (residents only): You will be called first for any patients presenting during your on call days. You will be expected to make your assessment and management plan and then contact your preceptor. If you (or the nurses) are uncomfortable with this approach in a particular case please contact your preceptor as soon as possible. Once we have experience with each other you may not need to contact your preceptor with simpler cases but will always be expected to review the case the following morning.
4. Within your comfort level try and make your own decisions first. It is our belief and experience that the learning from a particular event is only crystallized when you have to reach your own conclusions and decisions first before seeking help or feedback. With this in mind we would like you to think a particular situation through before discussing it with your preceptor. If you are at all uncertain please do seek help or feedback–it’s the decision we want, not necessarily the action.
5. Try and develop as much continuity as possible with patients. Try and follow-up, when appropriate, patients you see in the office and in outpatients. The clinic staff are aware of the importance of this to your learning experience and will be assisting you in this.
6. Remember to do billings. While we are no longer, for the majority of our patient contacts, a fee for service practice, we are still required to “shadow bill”. In addition, the “ins and outs” of billing are one very useful practical skill you can work on during your stay. Please complete the office day sheets, outpatient sheets and hospital in-patient sheets with diagnostic and billing codes to facilitate this.
7. Be prompt. You will be expected to show up on time and if delayed (e.g. held up at the hospital when you’re due at the office) to notify staff of your delay and anticipated arrival time.
8. Be organized.

One final comment. As a medical community we are always looking to our future needs. To avoid conflicts of interest, however, your preceptor will not be talking to you about any future recruitment possibility or locum interest.
Enjoy your stay!!!!!
Barb Zelek, M.D., CCFP
Learner Coordinator