CoM Family Medicine MBBS Student Guide Version 3 - July 2018 - FINAL

UNIVERSITY OF MALAWI
COLLEGE OF MEDICINE
STUDENT GUIDE
for
FAMILY MEDICINE ROTATION
MBBS 402
Name of Student:……………………………Student Number:…………………….
Version 3 | Updated July 2018

TABLE OF CONTENTS
TABLE OF CONTENTS 2
WELCOME NOTE 4
CONTACT DETAILS: FAMILY MEDICINE TEAM 6
ADMINISTRATIVE ISSUES 7
STUDENT BEHAVIOUR AND DRESS CODE 7
ATTENDANCE AND ABSENCE 7
STUDENT HEALTH 8
I. INTRODUCTION TO STUDENT GUIDE 9

Overall Aim of the student Guide 9
Layout and Organization of the Rotation Guide 9
II. INTRODUCTION TO FAMILY MEDICINE 10

The Family Medicine PRECEPTORSHIP 10
Roles of the Different Teams 10
Expectations of Students at the District Site 11
III. OBJECTIVES OF THE FAMILY MEDICINE ROTATION 13

family medicine principles 13
Communication 13
Ethics in Family Medicine 13
Family Health 13
Adolescent Health 13
Clinical care 14
Health promotion and disease prevention 14
Broader biopsychosocial approach 14
Health care system 15
Palliative care 15
Pain and Symptom Control 15
Holistic Care: The Impact of Psychosocial and Spiritual Issues and the Family Situation 15
Dermatology 15
IV. STRUCTURE OF THE FAMILY MEDICINE ROTATION 16

WEEK 1: CLASSROOM BASED LEARNING 16
WEEK 2 – 5: PRECEPTORSHIP 17
Week 6: Assessment 17
V. EXPECTATIONS FOR THE FAMILY MEDICINE ROTATION 17

3. Chronic Illness CARE 18
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3. STI consultations 19
4. IMCI Consultations 19
5. Under 5 Clinic 19
6. Family Planning Consultations 20
7. visual inspection with acetic acid (VIA) 20
8. Antenatal Consultations 20
9. Management of Normal Labour 21
10. Management of TB Patients 21
11. Counselling 21
12. Patient Education 21
13. evidence based medicine 22
14. Home Visit 22
15. Palliative Care Patients 23
16. Role of Other Members of the Health Care Team 23
17. Significant Event Analysis 24
18. Health Facility Profile 24
19. Quality Improvement Project 26
20. Calls 27
21. Chart Review 27
22. Weekly Reflection 28
23. Observed Consultations 29
24. Reflection on Activities 29
25. Ethics 29
VI. STUDENT ASSESMENT AND PRECEPTORSHIP EVALUATION 34
APPENDIX A: HEALTH FACILITY AUDIT DATA COLLECTION TOOL 35
APPENDIX B: QUALITY IMPROVEMENT GUIDE 41
APPENDIX C: CONSULTATION MODEL: S.O.A.P. 45
APPENDIX D: RED FLAGS IN CONSULTATION 47
APPENDIX E: TARGETED PREVENTATIVE THERAPY 48
APPENDIX F: EFFECTIVE COMMUNICATION 49
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WELCOME NOTE
Dear Student,
We wholeheartedly welcome you to the Family Medicine

block, a six-week rotation, starting with lectures at the
main campus in Blantyre followed by four weeks spent at
a clinical preceptor site and a final week at campus. The
aim of the block is to expose you to the practice of family
medicine and primary care in the setting of a district or
rural site.
In this rotation, you will learn different models of Students learning ultrasound
during Family Medicine rotation
consultation, communication, principles of chronic care
and continuity of care, Integrated Management of Childhood Illness (IMCI), adolescent
health, family health, geriatric care, palliative care, and ethics in the context of primary care.
You will notice that this block will differ from others that you have already taken. The
patients you will see will often be those who may not have seen a health care worker before
―i.e., they are undifferentiated. They may have no diagnosis or may be presenting with new
symptoms, giving you an opportunity to make first impressions. Each of the patients you will
see should be considered as an integrated whole, and all of his/her problems will have to be
attended to within the context of his/her family and community.
Despite the presence of family medicine

practitioners, you will have to be self-
directed with the bulk of your learning a
result of the growth and development
that comes from managing and reflecting
on your patients. Take every patient
encounter as a learning opportunity.
You will diagnose and manage patients

Community health teaching on family yourself, and make decisions about them
planning during Family Medicine rotation.
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under supervision of your preceptor. Remember: ASK FOR HELP whenever you need it.
We hope that working in rural areas will be an important learning experience for you.
However, you also need to make a contribution to the sites where you are working, which
may not have as many resources. Become an asset to the site: work hard and willingly offer
support.
Make sure you have the latest MSTG book (2015), Paediatric Handbook for Malawi (Philips,
2008), The Clinical Book (Zijlstra, 2013), the IMCI guidelines (WHO, March 2014) and the
Handbook of Family Medicine (Mash 3rd Edition, 2011). At the preceptor sites, there are also
copies of reference books and textbooks of family medicine and general practice.
In the last week, you will return to the campus at Blantyre where you will have evaluations,
presentations, and end-of-block examinations.
We wish you the best of luck in this rewarding rotation.
We hope that you enjoy your time with us!
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CONTACT DETAILS: FAMILY MEDICINE TEAM
Department of Family Medicine Faculty
Dr. John Parks, Head of Department | jparks@medcol.mw | 09 96 609201
Dr. Prosper Lutala, Deputy HOD | plutala@medcol.mw | 09 99 637472
Dr. Martha Makwero, Clinical Lecturer | mmakwero@medcol.mw | 08 84 111312
Dr. Miriam van Goor, Clinical Lecturer | mvangoor@medcol.mw | 09 99 923112
Dr. Jane Bates, Clinical Lecturer | mjbates@medcol.mw | 09 99 208193
Honorary Department of Family Medicine Faculty
Dr. Barbara Swarthout | bswarthout@medcol.mw | 09 96 376520
Dr. Colin Pfaff | colinpfaff@yahoo.co.uk | 09 99 96 8762
Dr. Catherine Hodge | catcrawford@rocketmail.com | 08 85 422106
Dr. Briony Ackroyd | briony.ackroyd-parkin@nhs.net | 09 97 774225
Dr Ulrika Baker | Ulrika.Baker@ki.se | 09 93 087979
Dr. Annet Hofland | annethofland@gmail.com | 09 97 302063
Dr. Anna McDonald | acmcd5282@gmail.com | 09 98 185829
Dr. Jacob Nettleton | Jacob.nettleton@gmail.com | 09 92 703365
Primary Contact Person for Preceptor Sites (2018-2019)
Neno: Dr. Luckson Dullie, Country Director Partners in Health – Neno District Hospital
ldullie@pih.org | 08 84 024749 / 08 82 949488 or Dr George Talama, Medical Officer

Partners in Health Neno District Hospital | gctalama@gmail.com | 09 99 119057
Mangochi: Dr. Prosper Lutala (see contact details in Faculty section, above)
Mulanje: Dr. Ruth Shakespeare, Medical Director - Mulanje Mission Hospital
shakespeareruth@gmail.com | 09 92 261569
Nkhoma: Dr. Catherine Hodge (see contact in Honorary Faculty Section, above)
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ADMINISTRATIVE ISSUES
STUDENT BEHAVIOUR AND DRESS CODE
As a student, you are expected to behave professionally during the 6 weeks. You represent
yourselves and the College of Medicine. As ambassadors for the College of Medicine
Department of Family Medicine we expect you to dress professionally and to conform to
the general code of the Faculty.
Improper attire: shorts, flip flops, tank tops or bare midriffs.
Proper attire:
Male students: Clean shirt, long pants.
Female students: Appropriate dress, long skirt or trousers.
All students: A white clinical coat should be worn always on hospital premises. Each
student should wear a name-tag. Appropriate, close-toed shoes should be worn
always for safety.
ATTENDANCE AND ABSENCE
The program requires your full attendance for all the six weeks, all days, including weekends
during the attachment. Absence from any part of the programme without prior approval
and arrangement with the department will result in failing the family medicine rotation and
exclusion from the end of block examination. All absences for sickness must be
substantiated with a “sick” note. If you are unable to attend a session for any reason, you
must inform the site preceptor and get permission. Since you will be travelling in the
community as part of the Department’s academic programme, it is important that you are
accounted for at all times.
You will be required to do home visits and community surveys within normal working hours,
while project work, reading and assignments are to be done after hours. Consulting time in
the facilities takes priority over personal study and work.
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STUDENT HEALTH
General Health
You are advised to practice universal precautions when in contact with patients. These
precautions include gloves, mask, protective eyewear or gowns as appropriate. If you have
an infectious condition, you should be issued a “sick” certificate and excused until non-
infectious. The preceptor at your site should ensure that you are not unduly exposed to
infectious patients.
As a College of Medicine student, you have health insurance under UNIMED which may be
used for hospitalisations. In case you fall sick while away from campus, inform your
preceptor. They will advise you on how to get urgent care and will inform the relevant
College authorities in a timely manner.
Needle Stick Injuries
In the unlikely event that you sustain a needle stick or other injury in which you may have
been exposed to HIV or other blood-borne pathogens, the preceptor/other clinical staff
should be notified immediately to advise on the next steps. The steps are:
➢ Follow the Malawi National Post Exposure Prophylaxis (PEP) protocol.
➢ Per protocol: Obtain the necessary starter pack of antiretrovirals.
➢ Ensure that a blood sample is taken from you.
➢ Inform the Department of Family Medicine as soon as possible.
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I. INTRODUCTION TO STUDENT GUIDE
OVERALL AIM OF THE STUDENT GUIDE
This guide was developed to help you (the student) through the family medicine rotation.
This document offers guidance on key areas for emphasis, specific skills to be learned, tasks
to be completed and, in general, and expected professional behaviour while at the
preceptor site.
LAYOUT AND ORGANIZATION OF THE ROTATION GUIDE
The student guide is organized into seven major sections:
Section I: Overview of the Student Guide covers the layout and suggestions for its use.
Section II: Introduction to Family Medicine describes the clinical teaching team, including the
preceptor and clinical staff at the facility. The section also covers roles and responsibilities
of the different team members, including students.
Section III: Goals of the Family Medicine Rotation provides a comprehensive list of
objectives for the Family Medicine rotation.
Section IV: Structure of the Family Medicine Rotation outlines the structure, prerequisites,
and schedule of the FM block.
Section V: Requirements of the Family Medicine Rotation outlines the major projects and
tasks of your rotation, including chart reviews, the health facility profile and the quality
improvement project.
Section VI: Student Assessment and Preceptorship Evaluation explains how your work is
assessed and evaluated.
Appendices constitute the last part of this guide. They include models, suggestions and
readings that can support this guide and your work throughout the rotation.
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II. INTRODUCTION TO FAMILY MEDICINE
The clerkship in family medicine aims to introduce you to a thinking process that puts the
family and context of a patient’s illness at the centre of his/her care. By letting the student
take history from the patient or guardian, perform a physical examination, writing the
findings and participating in the process of further investigations and treatment options
within the limits of his competence in the care of patients assigned to him/her, family
medicine allows you to learn the key principles and translate theoretical knowledge into
practical skills. The module also gives you an opportunity to experience and to practise
integrated primary care medicine that is responsive to patients, their families and
communities.
THE FAMILY MEDICINE PRECEPTORSHIP
The Family Medicine Preceptorship is offered the fourth year after attending the family
medicine block of lectures. It is offered in addition to the clinical experience that you
already have prior to your clinical clerkships and is one of the field experiences. It gives
students attached to any of our preceptor sites an opportunity to gain a greater
understanding of how district hospitals function away from the central hospitals and urban
centres.
ROLES OF THE DIFFERENT TEAMS
Figure 1 shows the role of the different teams.
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Blantyre Family Preceptors
Medicine Faculty
- Develop plan for clinical - Provide hands-on
practice and teaching training
- Organise teams
- Supervise students in
- Assess students
rotation and give feedback
- Assess students and give - Supervise students
feedback in rotation
-
Students
- Observe
- Clinical practice
- Self-guided learning
- Give feedback
- Complete
assignments
Figure 1. Roles and Responsibilities of Tutors, Clinical Staff/Instructors and Students
Specific cadres may play different roles, as shown below:

1. Medical Officers, Clinical officers, Medical Assistants: Where appropriate: Conduct
student teaching and supervise consultations. May lead teaching ward rounds,
demonstrate simple surgical procedures, etc.
2. Nurses: Demonstrate tasks that such as antenatal care consultation, dressing wounds
and conducting other procedures. See the Student Logbook for details of the required
tasks.
3. Counsellors: Supervise the counselling sessions that students must complete.
4. Home-based care workers and community health workers/volunteers: They help
organize and supervise the home visits, as well as the support group visits.
EXPECTATIONS OF STUDENTS AT THE DISTRICT SITE
Students are expected to:
▪ Apply the bio-psychosocial approach to primary care consultations.
▪ Appreciate the elements of primary care, and their place in the health service, including
disease prevention, health promotion, curative care, and palliation.
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▪ Integrate and apply skills from different disciplines.
▪ Observe common presenting problems in undifferentiated patients.
▪ Understand the roles and functions of different members of the health care team.
▪ Analyse the functioning of the health care system and the process of referral.
▪ Become familiar with and use national primary care protocols and guidelines.
▪ Conduct routine bedside procedures under supervision
▪ Present patient summaries, case studies, and other assignments to clinical staff or
preceptors.
▪ Complete assignments outlined in the student logbook
▪ Share clinical learning experiences through case presentations at clinical conferences.
▪ Receive feedback from preceptors and clinical staff on progress and discuss/ask questions.
▪ Provide feedback to Preceptors and COM coordinator on the clinical teaching and learning
process.
▪ As time allows, students may observe Preceptor consultations.
▪ Conduct consultations in the presence of Preceptors. (observed consultations in logbook)
▪ Accompany patients to other health services such as X-ray departments and

physiotherapists, to gain an understanding of the holistic health system and the
experience of patients utilizing such services.
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iii. OBJECTIVES OF THE FAMILY MEDICINE ROTATION
By the end of this 4-week rotation, students will be able to apply principles of family
medicine in clinical practice for patients of all ages.
FAMILY MEDICINE PRINCIPLES
1. Practice family medicine in the district health system.
2. Practice office-based general practice.
3. Use different models of consultation in family medicine.
COMMUNICATION
1. Observe and participate in the doctor-patient relationship.
2. Observe the counselling process.
3. Offer counselling to patients with different needs.
4. Communicate effectively in different languages and cultural settings.
5. Communicate effectively with a range of patients (ages, types of illness, socio-
economic background, etc.)
6. Give important information to patients in a non-judgemental and sensitive manner
(patient education).
7. Deliver bad news in an empathic and respectful way.
ETHICS IN FAMILY MEDICINE

1. Identify common ethical principles and dilemmas in the health facilities and family
practice.
FAMILY HEALTH
1. Demonstrate Family-oriented primary care to every day patients.
2. Demonstrate and apply principles of NCDs to everyday patient care.
ADOLESCENT HEALTH
1. Manage common adolescent health problems.
2. Provide HIV and sex education to adolescents.
3. Provide family planning services to eligible adolescents.
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CLINICAL CARE
1. Recognise common presenting problems in primary care for both adults and children
2. Manage adults and children with common illnesses, e.g.:
1. Common emergencies
2. Acute illnesses, such as diarrhoea, abdominal pain, rashes, respiratory
infections, etc.
3. TB, including participation in DOTS (Directly Observed Therapy, Short course)
4. Common non-urgent surgical conditions
5. Mental health problems in patients presenting with or without physical
illness
3. Care for patients with chronic conditions.
a. Screen patients for chronic illnesses.
b. Assess risk factors.
c. Identify complications.
d. Provide on-going care.
e. Apply standard management approaches.
4. Apply the IMCI approach in consultations involving children.
5. Conduct family planning consultations.
6. Conduct antenatal consultations.
7. Fill the antenatal clinic record card.
8. Request relevant investigations.
9. Interpret investigation results.
10. Pharmacology: considerations for special groups like elderly.
HEALTH PROMOTION AND DISEASE PREVENTION

1. Perform assessment of risk in patients with acute, chronic and mental health
conditions.
2. Practice essential skills for maintenance of child health, including immunisation,
growth monitoring, developmental assessment, etc.
3. Promote antenatal health.
4. Promote sexual reproductive health (STI prevention, VIA, HIV counselling)
BROADER BIOPSYCHOSOCIAL APPROACH

1. Explain the impact of disease on individuals, families and communities.
2. Appreciate the health-seeking and help-seeking behaviours.
3. Explain the reasons behind these behaviours.
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HEALTH CARE SYSTEM
1. Explain the structure and organisation of primary care in the context of health care.
2. Apply a range of skills required to provide primary health care.
3. Refer patients as indicated/appropriate.
4. Record patient information.
5. Use the record systems and information systems.
6. Deliver health care in rural areas.
PALLIATIVE CARE
1. Be familiar with basic principles of providing palliative care
2. Describe how to provide end-of-life care, e.g., for mouth care, poor appetite,
breathlessness, skin care (including malodour), incontinence, oedema, and
restlessness in final days of life.
3. Identify and address ethical dilemmas at end of life.
PAIN AND SYMPTOM CONTROL

1. Conduct pain and symptom assessment.
2. Manage common symptoms.
3. Appropriately manage pain. (WHO Analgesic ladder)
HOLISTIC CARE: THE IMPACT OF PSYCHOSOCIAL AND SPIRITUAL ISSUES AND THE FAMILY
SITUATION
1. Provide holistic care to families.
2. Consider psychological and spiritual responses to illness.
DERMATOLOGY
1. Identify and understand basic management principles for common skin conditions,
e.g., Eczema, infections: bacterial, fungal, viral, parasitic, etc.
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IV. STRUCTURE OF THE FAMILY MEDICINE ROTATION
WEEK 1: CLASSROOM BASED LEARNING
Before the preceptorship, you should have completed 36 contact hours in relevant family
medicine concepts to acquire the necessary theoretical preparation. During week 1 of the
FM block you will complete sessions on topics that include the following:
Table 1. SAMPLE OF Family Medicine Teaching Schedule: Week 1 on Campus

(Sample Below from the August 2016 Teaching Week)
Monday Tuesday Wednesday Thursday Friday

8:00 – 9:00 Introduction to 8.00-9.30 IMCI 8.00-10.00 Approach to Ethics
(1hr) Family Medicine Evidence Based common primary
9.30-10.30 Medicine (EBM) care symptoms 2
9:00-10:30 Family Health Expectation Ethical case
(1.5 hrs) guided reading Setting: studies in family
intro 1# Sites and medicine
Logbooks
10:30-10:45 Break 10.00-10.15

10:45-12:30 Consultation Family 10.15-12.30 Adolescent health Paediatric cases
(1:45 hrs) models medicine as a Chronic care with
career. with reference questions/IMCI
to logbook review
activities &
Geriatrics
12:30-2:00 Lunch break

2:00-3:30 Approach to 1.30 Qualities Palliative care Significant event
(1.5 hrs) Common Primary required in a analysis/Reflective
care symptoms 1 medical leader learning/Stress
at district level management
2.30 Change
management at
district level
3:30-3:45 Break
3:45-5:00 Approach to Introduction to Palliative care 3.45-4.15
(1:15 hrs) Common Primary QI project Site Assignment
care symptoms 1 4.15-5.15
Family Medicine in
Kenya Video
Drinks/snacks
2# Family Health 3# Palliative 4# The Diabetic 6# Ethical
care Adolescent dilemmas in Family
Guided
emergencies 5# Approaching Medicine
Reading
burnout 7# Case to read
and discuss in class
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WEEK 2 – 5: PRECEPTORSHIP
During the four-week preceptorship, students will be placed in groups at different hospitals.
A logbook will guide the desired tasks and activities to be carried out. Details are in Section
V of this guide.
WEEK 6: ASSESSMENT
The last week of the block will include multiple forms of assessment. Logbooks will be
submitted to faculty for review and COM faculty may request that groups present again
their quality improvement projects. In addition, student will take a written (multiple choice
and short answer) exam and an OSCE. Section VI outlines the evaluation process in more
detail.
V. EXPECTATIONS FOR THE FAMILY MEDICINE ROTATION
1. UNDIFFERENTIATED PATIENT CONSULTATIONS
The bulk of your time will be spent seeing undifferentiated patients 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 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 the logbook. Good locations to find undifferentiated patients include OPD,
casualty (A&E), and new admission areas to hospital wards. For each patient you see, you
are required to conduct a focused consultation, similar to how you were taught during the
teaching week. You are expected to make an appropriate assessment and to advise on 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. Logbook entries should demonstrate
familiarity with a wide variety of common symptoms and conditions. One (1) should be a
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patient with a skin condition and one with a musculoskeletal condition. 10 randomly
chosen over the 4-weeks will be marked for a mark of 1 – 10 per patient case. Note, you will
see more patients than this during your rotation. 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 Headache Chest Pain

Vaginal Discharge Fever Dyspnoea
Vaginal Bleeding Vomiting Skin rashes
Joint Pain Diarrhoea Sore Throat
Ear Pain Abdominal Pain Low Back pain
Dizziness Cough
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 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.
2. EMERGENCY CARE, TRIAGE & REFERRAL
You are required to see at least 5 cases in casualty that require triaging, emergency
management and referral. Referral can be from the OPD to the ward, from the Health
centre to the District Hospital, or from the District Hospital to other hospitals (example:
Central Hospital). Assessment should cover the history and physical examination, working
diagnosis, immediate management and the reason for the need for referral. Where
possible: it is encouraged that students can accompany the patient through the referral
process to gain insight in the whole referral system.
At the end of this task students are expected to reflect on the main reasons for referral and
the functionality of the whole system.
3. CHRONIC ILLNESS CARE
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 10 consultations with
patients about their chronic conditions in your logbook. Four (4) of these randomly chosen
over the 4-weeks will be marked 1-10. A variety of chronic conditions (i.e diabetes, asthma,
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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.
3. STI CONSULTATIONS
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 four (4) consultations in your logbook
which will be marked 1-10. Use the comprehensive A3 P4 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 relevant section of the logbook.
4. IMCI CONSULTATIONS
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 which will be marked 1-
10. 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 marked 1-10. 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/.
5. UNDER 5 CLINIC
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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.
• Neurodevelopment. 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.
• Counselling. 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.
6. FAMILY PLANNING CONSULTATIONS
Consult and counsel at least six (6) patients who present for family planning, either at the
same time as they are presenting with other problems or at a visit that is only about
contraception. Your recorded patients should include two (2) patients who received
injectable methods, two (2) who received oral methods and two (2) who received
implantable or permanent methods.
7. VISUAL INSPECTION WITH ACETIC ACID (VIA)
You should have the opportunity to observe cervical cancer screening with VIA (visual
inspection with acetic acid) services during the attachment. For one (1) 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.
8. ANTENATAL CONSULTATIONS
During this block you should observe antenatal consultations with patients attending the
routine antenatal clinic at your health facility. This usually takes place in the mornings but
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will vary from site to site, and is run by a midwife, to whom you should report. The main
goal is for you to become familiar with the concept of risk assessment and the referral
system. You should record ten (10) antenatal patients that you have seen in your logbook.
Nine of these patients may be recorded briefly in the table provided. One should be clerked
with an in-depth report that follows the format provided.
9. MANAGEMENT OF NORMAL LABOUR
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 (5) 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.
10. MANAGEMENT OF TB PATIENTS
You will be seeing many suspected and confirmed TB patients over the attachment. Record
the details of three (3) patients in your logbook. One (1) patient should be a suspected TB
case so that you reflect on the diagnostic process. The other two (2) 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.
11. COUNSELLING
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 (5) 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 colleagues. Additionally, after each documented counselling
session, you should reflect and record on what you did well and where you can continue to
improve.
12. PATIENT EDUCATION
In addition to individual counselling sessions, physicians are often asked to provide group
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teaching. As practice, at least once (1) 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.
13. EVIDENCE BASED MEDICINE
You are expected to describe a clinical situation at the inpatient bedside or OPD that gave
rise to a clinical question. This should be a real clinical question that you faced – where you
were uncertain about the best course of action for the patient. You should formulate this
clinical question into the PICO format. Use at least three different databases, point-of-care
tools or websites to find an evidence-based answer to this question. (If possible, do this at
the bedside or in OPD. If not possible, this can be done later.) You should then describe the
evidence found in each search and evaluate the strength of the evidence according to the
hierarchy of evidence pyramid. Lastly, based on this evidence, you should describe how you
decided to manage the patient.
14. HOME VISIT
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

o Community setting
o Position of home in relation to community, health services, transport, shops
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and other amenities
• Description of home
o Size, condition, number of occupants, facilities, kitchen, bathing and toilets
facilities
• Aspects related to the patient & family
o Description of the patient: personal, social and other demographic details
o Genogram/ecogram of the patient
• Aspects related to the condition
o Brief description of the condition using a systems approach
o Patient’s explanatory model
o Compliance and factors affecting it
o Losses experienced and coping mechanisms
o Health professionals utilised
o Community resources available for patient’s condition
o Self-help / support groups used / needed
• Effects of the condition
o Impact on self
o Impact on Family
o Impact on community
o Your personal relationship with the patient
In addition, summarize the main findings of your home visit in your logbook.
15. PALLIATIVE CARE PATIENTS
Record three (3) palliative care consults in your logbook which will be marked 1-10.
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.
16. ROLE OF OTHER MEMBERS OF THE HEALTH CARE TEAM
The aim of this task is for you to engage with another member of the health care team to
understand more about how they work and their respective roles in the health care team.
Interview a member of one of the following departments: Administration, Accounting,
Human Resources, Maintenance, HMIS/Data collection, Pharmacy, Transport, Laboratory, or
Heath Surveillance. Reflect on their role within the health system and ways to improve
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teamwork, then record your thoughts in the logbook. This task will be marked 1-10.
17. SIGNIFICANT EVENT ANALYSIS
Reflect on one (1) 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. This task will be marked 1-10.
18. HEALTH FACILITY PROFILE
As a group, complete a profile of a health centre 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 • Equipment available
• Structure and size of buildings • Drug supply system
• Staff numbers by cadre • Description of patient consulting
• Facility capacity and number of rooms
patients served • Privacy for patients
• Description of the catchment area • Infection control status of the
(population, demographic, facility (ventilation, disposal of
population, economic, activities, medical waste)
administrative area) • Availability of water and electricity
• Facility governance/leadership • Communication systems (phones,
• Services offered by the facility: road network)
Home based care, outpatient, in- • Referral networks (ambulance)
patient • Toilet facilities
• Organisation of the clinic
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
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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:
Categories Issues Implications Proposals or

solutions
Infrastructure Poor electricity - Low immunization - Advocacy directed
supply coverage in the at the local council
Equipment Non-functional community or provincial
refrigerator for cold- - Outbreaks of government to link
chain storage measles the clinic to the
Access: Child health Poor immunization national power grid
services -Alternate source of
electricity (e.g. a
generator)
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. 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
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report must be integrated and will be assessed as such. Each group will receive a single
mark.
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 site preceptor) in an oral
presentation. If possible, attempt to include a representative of the health facility at the
final oral presentation.
19. QUALITY IMPROVEMENT PROJECT
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
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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. Present your project to the facility management at the site.
An oral presentation of the project should be made to the site preceptor and local staff
during your last week at site. The Site Preceptor will provide a mark for the QI process. The
presentation will be given a second time in Blantyre during exam week in the presence of
Blantyre Faculty and fellow students. The Blantyre-based Faculty of Family Medicine will
provide a mark for the QI presentation.
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.
20. CALLS
Call is required at the hospital during the block to provide opportunities to learn skills such
as triage, emergency procedures, referral, and deliveries. Call is required once each week
and one full weekend during the block (totaling 4 weeknights and 2 full weekend days). In
most cases you should expect to get some sleep during your call and work normally the
following day. You will receive a schedule as a group, together with your site supervisor, for
call. Please note: ** If you want to swap/exchange calls with other students at your site you
must seek permission to do this from your local site Preceptor **
21. CHART REVIEW
On a weekly basis there should be a group chart review session with your Preceptor. You
will be requested to present for discussion one chart (patient record) of a patient that you
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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
a.S.O.A.P. usage and methodology
b. Notes made including clear reference to instructions / advice given

to patient
c. 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.
22. WEEKLY REFLECTION
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
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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 reflection sessions, but most should be
present.
23. OBSERVED CONSULTATIONS
Three times in your block you will be do an observed consultation of an unprepared

undifferentiated patient who is waiting in the queue. The marks from the last two
consultations will count towards the final assessment. The mark of the first observed
consultation will not count towards the final grade. The first consultation should take place
in the first week of the rotation. 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. The
district site preceptor, Blantyre Family Medicine Faculty, or supervisor designated by the
Preceptor will observe and mark the consultations.
24. REFLECTION ON ACTIVITIES
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 to help with ongoing improvement of the block. Your ratings of activities are
not considered 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.
25. ETHICS
Discussions on ethical issues arising in the routine care of patients should be reflected on as
part of the daily reflection and 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.
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Time requirements of activities (estimates provided, actual times will vary by student):
EXPECTED HOW MANY/WHAT SUPERVISION/

ACTIVITY WHERE FORMAT
AMOUNT OF TIME MUST BE RECORDED RESPONSIBLE PERSON
Consultation of General OPD/
At least 20 hours 25 undifferentiated
undifferentiated casualty/ PRECEPTOR (MARKING
weekly cases, 5 referral cases, Logbook entries
patients, referral cases, hospital ward/ OF LOGBOOK)
(80 hrs/ block) and reflection
and reflections health centre
Part of general
Chronic illness General OPD
consults; Aim for 3 10 patients and PRECEPTOR (MARKING
consultations and clinic/ chronic Logbook entries
hours per week reflection OF LOGBOOK)
reflections illness clinic
(15hrs/block)
General OPD
STI consultations and 4 patients and PRECEPTOR (MARKING
clinic / STI 1 hour Logbook entries
reflections reflection OF LOGBOOK)
clinic
Part of general Logbook entries Supervisor
General OPD
consults; Aim for 3 5 patients: 3 entries and (Logbook entries)
IMCI consultations Clinic/Under 5
hours per week plus 2 detailed cases. Presentation of Preceptor (Mark of
clinic/casualty
(12 hrs/block) detailed cases Detailed record)
Under 5 Clinic Under 5 Clinic 3 hours/block 10 patients Logbook entries Supervisor or Preceptor
General OPD
Family Planning
clinic/Family 3 hours/block 6 patients Logbook entries Supervisor or Preceptor
consultations
planning clinic
VIA VIA clinic 3 hours/block 1 patient Logbook entries Supervisor or Preceptor
Supervisor or Preceptor
10 patients: 9 entries
Antenatal consultations Antenatal clinic 6 hours/block Logbook entries (Preceptor for case
plus 1 case study
study)
5 total patients: 4 Supervisor or Preceptor
Hospital/
Deliveries As long as needed entries plus 1 short Logbook entries (Preceptor for L&D short
Health centre
case case)
Clinic/hospital 1 suspected and 2
TB management 3 hours per block Logbook entries Supervisor or Preceptor
ward diagnosed TB patients
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EXPECTED HOW MANY/WHAT SUPERVISION/
ACTIVITY WHERE FORMAT
AMOUNT OF TIME MUST BE RECORDED RESPONSIBLE PERSON
with contact tracing
Counselling Clinic 2.5 hours/block 5 patients Logbook reports Supervisor or Preceptor
20 mins/block,
Patient education Clinic/
plus two colleague 3 sessions Logbook report Peer assessment
sessions community
observations
Evidence-Based
Hospital/clinic 2 hours / block 1 EBM case Logbook report Preceptor
Medicine
Logbook report
Home visit Community 5 hours/block 1 patient Preceptor
Presentation
Palliative care patients Hospital/ 3 patients and
2 hours/block Logbook entries Preceptor
and reflection health centre reflection
Role of Other Members
Clinic/ hospital 3 hours/block 1 interview Logbook report Preceptor
of Health Team
Significant Event
Clinic/hospital 1 hour/block Reflection Logbook report Preceptor
Analysis
Clinic/ Group
Health Facility Audit 4 hours 1 audit Preceptor (for marking)
Community presentation
Site Preceptor ( marking
Quality Improvement 3 hrs weekly
Clinic/hospital 1 project Presentation QI process) Blantyre
Project (12 hrs per block)
Faculty (presentation)
1 weeknight per week
Weekly
Calls Hospital (4 nights) and 2 full Logbook entries Preceptor
weekend days
1 hour weekly as Each student presents
Chart review Clinic Logbook entries Preceptor
group 1 chart/week (4/block)
Weekly Learning
Any meeting
Journal (Reflection 1 hour per week 4 sessions Logbook entries Preceptor
venue
meeting)
3 hours (1hour
Observed consultations Clinic 3 patients Logbook entry Preceptor
each)
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As you can see, your days will be very busy completing all the tasks of the logbook. It may be helpful to divide up the tasks by week. A sample
schedule is below. Please use your time wisely.
By the end of week 1, you will be able to:

• Utilise principles of family medicine in patient management.
• Apply basic clinical and diagnostic laboratory procedures in management of patients.
Week • Apply basic communication principles with patients.
1 Tasks to be completed by preceptor/clinical staff Tasks to be completed by students Clinical Areas
Orientation to clinical areas Take patients history All clinical areas
Demonstrate clinical care Conduct physical exam
Brief teaching as necessary Perform simple procedures
Start Health Facility Audit
• Apply basic principles of clinical examination and diagnostic procedures to reach proper diagnosis.
• Use principles of family medicine to manage patients.
• Apply principles of clinical medicine and pathology in management of patients.
• Apply basic principles of immunization, health education and nutrition to promote health.
Week Tasks to be completed by preceptor/clinical staff Tasks to be completed by students Clinical Area
2 Demonstrate signs and symptoms and general Take history independently Outpatient clinic
clinical skills Present cases to preceptor and other staff Specialized clinics
Model professional behaviour Continue with tasks and learning Inpatient male and
competencies in family medicine. female wards
Paediatric clinics
Antenatal care
Community
See next page for Week 3 & 4 Suggetions
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• Conduct clinical procedures and laboratory findings to arrive at a proper diagnosis.
• Manage patients with simple medical and surgical conditions.
• Employ effective health promotion and counselling techniques to patients, clients and families at the facility
Week
and in hospital.
3
Tasks to be completed by preceptor/clinical staff Tasks to be completed by students Clinical Area
Teach skills Record histories accurately All Areas, including
Communicate with patients Community
Fill patient files
Prescribe under supervision
Tasks to be completed by preceptor/clinical staff Tasks to be completed by students Clinical Area

Week
Provide guidance home visit Health Facility audit and Quality All areas, including
4
Provide guidance on facility assessment improvement projects community
Conduct home visit
Conduct facility assessment
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VI. STUDENT ASSESMENT AND PRECEPTORSHIP EVALUATION
Attendance to all 6 weeks is compulsory (including ALL lectures). Attendance of the lectures will be
documented and is part of the professionalism mark in the logbook.
Your logbook accounts for 40% of your total mark. The site supervisor will mark your logbook, and
the academic staff will moderate that mark if needed. To pass the Family Medicine block, the
Logbook must receive a mark of at least 50%. The logbook must be passed to sit for the
examination.
The written exam will make up 30% of your total mark for the Family Medicine block. Objective
Structured Clinical Examination (OSCE’s) also makes up 30% of your total mark for the Family
Medicine block. To past the examinations, a mark of at least 50% must be achieved.
Student must pass each of the three components separately and in sequence (Logbook, Written,
OSCE) to pass the entire Family Medicine rotation.
Weight in Minimum
Component
Final Mark Passing Mark
Logbook 40 50
Written Exams 30 50
OSCE 30 50
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APPENDIX A: HEALTH FACILITY AUDIT Data Collection Tool
Name of Health Facility _____________________________________ Date _________________
This project is done as a group exercise in a rural health center; each individual student is thus not expected
necessarily to complete this checklist him or herself. You may decide to use it for your part of the process
and even to complete it on the basis of the information collected by your colleagues. However, a separate
group presentation is required. Use only those parts of the tool that are relevant to your facility or element
of the faculty you are evaluating. If the facility/area was previously evaluated, focus on changes since the
last evaluation.
CATEGORY 1: INFRASTRUCTURE
1. Clean running water
a. Daily problems with supply
b. Weekly supply problems
c. Monthly supply problems (6-12 times per year) or in the dry season only
d. Fully reliable supply
2. Electricity
a. None
b. Power outage with load shedding and no backup system exists
c. Power outage in excess of load-shedding and no backup system exists
d. Reliable power supply or automatic backup system
e. Solar power
3. Structure of the building

a. Major repairs required
b. Minor repairs required
c. Sound structure and no immediate repairs required
4. Toilets
a. Simple pit latrine
b. Other (e.g. chemical mobile unit)
c. Ventilated pit toilets (VIP)
d. Separate flush toilets for patients and staff
5. Communication
a. None
b. Functioning two-way radio with no spare battery
c. Functioning two-way radio with spare batteries
d. Functioning telephone 24 hours per day within 100 metres of the clinic
e. Functioning telephone in clinic, but with frequent breakdowns
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f. Functioning telephone on site
g. Cell phone network
6. Hand basin for washing hands

a. None
b. Available outside consultation room
c. Available inside consultation room
7. Functioning refrigerator
a. None
b. Other fuel supply (e.g. paraffin or gas), no spare cylinder
c. Other fuel supply with spare cylinder
d. Electric (functional)
8. Emergency kit or trolley (equipment and drugs)

a. None available
b. Emergency kit on site but incomplete
c. Complete emerge kit available and accessible
CATEGORY 2: SERVICE ACCESS AND AVAILABILITY
1. Size of building compared with patient load

a. Overcrowded every day
b. Overcrowded on certain days only
c. Facility never overcrowded
2. Waiting time
a. Less than 1 hour
b. 1 – 3 hours
c. More than 3 hours
3. Range of routine services
Not Not
Daily
daily Available
Child Health
TB and HIV
Family Planning
Antenatal Care
Acute Care
Chronic Disease Care
Deliveries
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4. Mobile clinic or Outreach services
a. No mobile/outreach service attached to the clinic
b. Mobile facility offers less than 3 scheduled services/wk
c. 4 – 6 scheduled services offered per week
d. More than 6 scheduled services offered per week
5. Frequency of mobile/outreach services

a. None available
b. Once a month or less frequent
c. At least every 2 weeks
d. Once a week
6. Home visits
a. Not done
b. 3 or less scheduled services (child health, TB/HIV, ANC, chronic disease care, etc.)
offered during home visits
c. 4 – 6 scheduled services offered
7. Position of a clinic in relation to community served (‘easily” defined below*)

a. Only 40% of population served can reach the clinic easily
b. 40 – 80% of the population can reach the clinic easily
c. 80% or more of the population can reach the clinic easily
*Community members can easily walk to the clinic, or need only one bicycle taxi to get to the clinic.
CATEGORY 3: MANAGEMENT OF RESOURCES
1. Drugs and supplies

a. Secure place for all stocks, under appropriate conditions
b. Stock cards used and up to date
c. Orders placed regularly and on time
d. Drugs received are verified against order placed
e. Monthly stockpots recorded and discussed with clinic supervisor
f. Organisation of stock: FEFO (first expiry, first out) followed, no expired stock
g. Essential Drugs List (EDL) followed
h. Lab test supplies in stock (for sputa, blood, etc.)
2. Clinic Supervisor visits

a. No supervisor visits in previous 3 months
b. Irregular supervisor visits
c. Monthly visits by clinic supervisor
d. Written record of monthly supervisor visits left with clinic
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CATEGORY 4: PATIENT AND CLINIC ENVIRONMENT
1. Waiting area
a. Some patients have to wait outside with no shelter from sun or rain, no seating
available
b. Some patients wait outside with shelter and seating available
c. Patients are all accommodated inside but some have to stand
d. Patients are all seated inside on most days
2. Patient privacy (in consulting room)

a. No auditory (consultation) or visual (examination) privacy
b. Consulting rooms have visual privacy but no auditory privacy
c. Consulting rooms have auditory and visual privacy
3. Patient consideration
a. Clear list of services available (with times) posted
b. Patient charter posted (in local language)
c. Each patient is greeted in a friendly manner
d. Facilities and service accessible to disabled patients
e. Complaint mechanism in place (For example: suggestion box)
4. Staff Privacy
a. No privacy for taking tea or lunch breaks
b. Separate area for taking staff breaks but conditions are unsatisfactory
c. Separate area for exclusive staff use; satisfactory conditions.
5. Health education materials (on display and for taking home)

a. None available on display or to take home
b. Materials available for display only
c. Materials on display and some available to take home
6. Community statistics on display at the clinic

a. None on display
b. At least one statistic on display
c. Appropriate statistics on display
CATEGORY 5: COMMUNITY INVOLVEMENT
1. Community participation
a. There is no participation in the health facility activities by the community within the
catchment area
b. There is some evidence of community participation
Page 38 of 49
c. There is a functional advisory committee that met last month.
d. Community fully involved in developing clinic priorities and support service
programmes.
2. Health facility involvement in community development

a. The facility does not participate in any community development activities
b. The facility participates in an ad hoc way in community development activities
c. The facility is involved in a structured way in community development
CATEGORY 6: EQUIPMENT CHECKLIST FOR PRIMARY CARE SERVICES
1. Equipment Considerations
a. Inventory of clinic equipment up-to-date?
b. Broken equipment labelled and listed, with problem stated?
c. Equipment due for routine maintenance identified?
d. Refrigerator – temperature recorded daily?
2. Equipment Available: Create a list of expected equipment for each area and tick the
appropriate boxes. Only examples given below.
Good
Not Non-
1. Maternal Health Service working
available functional
condition
Sphygmomanometer
Urine test strips
Weight scale
Haemoglobin meter
Fetoscope
Measuring tape
Specimen bottles for VDRL,
blood group, Rh test
Oral contraceptives
Injectable contraceptives
Intrauterine device (IUD)
Condoms
Speculum
Health education materials
Access to sterilisation of
equipment
Delivery packs
Standing spot lamp
Good
Not Non-
2. Acute Care Service working
condition
Oxygen concentrator and face
masks
Thermometers
Page 39 of 49
Glucometers
Urine analysis strips
Diagnostic set
Good
Not Non-
3. Child Health Service working
condition
Weighing scale
Refrigerator
Diagnostic set
Good
Not Non-
4. TB and HIV Services working
condition
HIV rapid test kits
TB notification forms
Sputum bottles
Good
Not Non-
5. Chronic Disease Care working
condition
Good
Not Non-
6. Accident and Emergency working
condition
Category 7: Human Resources
Availability of staff
Category of health Number of posts Number of posts Number of people Reasons for absence
worker available filled currently on duty of staff
Nurses
Medical officers
Administration clerks
Medical assistants
Clinical Officers
Pharmacy technician
Pharmacy aid
Patient attendant
Ward attendant
HAS
It is important that data collection on this issue be handled with tact and sensitivity to facility staff.
1. Reflect and review the adequacy of staffing in relation to

a. Range of health workers available d. Services provided
b. Catchment population and needs e. Skills and competencies required
c. Demographic profile of users f. Working hours/Opening times/Shift
Page 40 of 49
APPENDIX B: QUALITY IMPROVEMENT GUIDE
THE ISSUE
Improving the quality of health care in districts and hospitals is something everyone, in
management at least, is, or should be, striving for. No one will deny the need to look at this
as a priority, and quality of care is listed as a pillar in the development of the district health
system. Many programmes have been introduced to improve the quality of health care at all
levels. However, these have often been externally driven processes which do not provide an
understanding of quality and the process of improving quality. It is essential that there is an
understanding of this within districts and hospitals so that management teams and units
within these structures can be fully involved with any quality improvement process, and,
more importantly, initiate their own quality improvement activities.
DEFINITION
What is quality? The dictionary defines quality as “degree of goodness or worth”. It is about
meeting standards, conforming to requirements, or performing at acceptable levels.
Another way to describe quality is that it is “doing the right thing right”.
In terms of health care, quality improvement is a process of developing and improving
quality, through making necessary changes to health care systems (clinics, hospitals,
programmes) in such a way that a different level of performance is reached, and better
results are achieved. i.e. it is not simply about doing new things or doing old things
differently, but rather about doing things that bring about changes in the system as it
operates at present.
PHILOSOPHY OF QUALITY IMPROVEMENT (QI)

Most health care teams are already busy with quality issues in some ways, but by quality
improvement we imply a systematic, structured and focussed attempt to develop quality of
health care through identifying areas of difficulty and adjusting deal with these. Put another
way, quality improvement seeks to identify the gaps between the services currently
provided on the one hand and what is expected, needed or desired on the other hand, and
then to find ways to reduce the gaps.
Underlying this definition is an understanding of elements of quality improvement:

1. The delivery of health services should be focussed on the needs and expectations of
the community (patients, clients, customers)
2. Health care workers must understand the system they work in, to improve it.
3. Any changes need to be tested to assess whether they bring about improvements.
This means that information needs to be collected and reviewed to assess whether
quality is improving.
4. Quality improvement is a team effort. Health care teams working together to solve
problems and bring about necessary changes can achieve them.
Improvement implies better outcomes and reduced costs of health care delivery. It looks at
how activities can be changed so that people function better, without necessarily any
increase in resources. The challenge in resource poor situations particularly is to strive for
excellence within the context of lack of resources, rather than to accept poor quality as an
inevitable result.
Page 41 of 49
The process of quality improvement looks at both what is done (i.e. the content of care) as
well as how it is done (the process of care).
THE QI PROCESS
There are many processes for quality improvement. The following steps are suggested as a
useful and reliable process for QI in the district health context, for managers, leaders, or any
health workers wishing to improve the quality of care in their domains.
1. Identify the issue

What is the problem? What needs to be improved? There are always many things that need
to be improved, but it is helpful to choose one issue to focus on, at least initially. Success
breeds success – if you improve the quality of care in one area you will be encouraged to
continue and work towards further improvement.
It is useful to start with something manageable, and particularly something within the scope
of the unit you are working in. Tackling something too big may lead to discouragement.
For example, the issue identified may be the problem of patient waiting times in the clinic or
the hospital OPD.
2. Form a Team
It has already been noted that teamwork is essential for quality improvement, because
many people are involved and work interdependently in health care delivery, because
problems are more easily analysed and tackled by a group. A team needs to be formed to
deal with the issue identified – though sometimes the team is already formed and decided
together on the issue to be tackled. Even then the team needs to see if others need to be
included. Different issues will involve different people – all the stakeholders in the issue
should be involved.
In looking at patient waiting time, in the OPD, one would probably involve the PHC nurses
and doctors who work in OPD, the outpatient clerks, the pharmacy staff, possibly
representative from lab and x-ray departments, etc. The broader consultative group could
include the nursing services manager, the clinical manager, the administrator, etc. It would
be helpful to include patient representatives in the broader group as well.
3. Understand the Problem

The next step is to look at the problem more detail.
This firstly involves collecting information, or data, about the problem. Information about
the problem allows the team to be sure the problem exists and there is a need for
improvement, to measure the present practice for later comparison, and to assist with the
identification of the elements which need change.
It secondly requires analysing the problem to establish issue such as who is involved; where,
when and why the problem occurs; and what happens because of the problem.
Various tools can be used to seek to understand the process clearly and identify where the
main difficulties are, to establish where changes are needed. These include flow charts,
cause-and-effect diagrams, brainstorming, etc, and require teamwork to be effective. It
essentially is a process of reflecting on current practice, or ways of doing things, to
understand them better.
Page 42 of 49
By the end of this step the team should be aware of what changes are needed.
In our example, one may collect information on actual waiting times in every part of the
OPD, from the time a patient enters the hospital until they leave. Analysing this may then
show that the biggest hold-ups are at the clerks’ office and waiting for laboratory results, or
due to doctors not being available at certain key times in OPD.
4. Plan Changes
On the basis of the analysis, the team can now plan changes that need to be made.
Sometimes where a lot of changes are needed it is helpful to prioritise one or two to start
with, in order to be more focussed.
This step includes deciding how the changes will be made, who will be responsible, and
when they will occur. It is essential to get agreement from the team on these changes,
otherwise nothing will be achieved. It also will require selling the changes to other
colleagues who are in the unit or section.
In our example, it may be decided that two clerks are needed for the early morning rush
when there are too many patients, that one doctor should be in OPD first thing in the
morning and do his ward rounds later, and that more side-room tests (e.g. glucose and
haemoglobin estimations) should be done rather than laboratory tests. The front desk
clerks, the senior OPD doctor and the clinicians will take responsibility respectively.
5. Implement Changes
The changes now need to be implemented, and time needs to be given for them to take
effect. The team should agree on the time frame.
At the same time monitoring needs to happen. Information needs to be collected to ensure
the changes are bringing about improvements – if they do not, they are a waste of time and
energy. This involves either a continuous monitoring exercise, or a repeat data collection
process at an agreed upon point in time.
6. Review Changes
The process needs to be reflected upon and reviewed by the team. This is in order to see:
If the changes were in fact implemented
If the changes did lead to improvement in the problem
Whether further changes are needed
7. Repeat the Cycle

On the basis of this review, the team can decide to
Continue with the same changes
Implement new changes
Choose another issue to address.
Form a new team
Whichever is decided, it involves entering a new cycle of quality improvement. This is called
continuous QI and allows the quality to continue improving all the time, rather than just
reaching a certain level and stopping there. This can be referred to as a quality spiral.
Page 43 of 49
STANDARDS
As part of the definition of quality, the issue of standards was seen to be an essential
ingredient. During the process of QI, the team needs to develop a set of standards against
which the current practice can be measured, and so that any changes made can be in the
direction of these. These standards may be internal or external or a combination. That is,
the team can together develop its own set of standards based on the local situation and the
needs of the health service. Alternatively, it can decide to adopt a readymade set of
standards derived from the literature (books, articles, etc), or from documents put out by
the Department of Health (such as the Primary Health Care Package: Norms and Standards);
these often provide a very useful and appropriate set of standards to use. Often it is most
useful to take the external standards and then to adapt and apply these to the local
situation in order to develop an appropriate set of standards that everyone in the team can
agree to.
CONCLUSION
It is only by doing quality improvement that one can learn. Do not be afraid of mistakes –
give it a try. And share your experiences with others.
Page 44 of 49
APPENDIX C: Consultation Model: S.O.A.P.
This section provides guidance for consultations and presenting patients. The recommended
model is represented by S.O.A.P. (Subjective, Objective, Assessment, and Plan). Use the
S.O.A.P. leaflet provided by the Department as a guide.
Subjective information gathering (or taking the history):

▪ Obtain the patient’s history
▪ You should start with open-ended questions before following with focused questions
▪ RICE: Reason for coming / Ideas about the illness / Concerns / Expectations
Objective information gathering (or doing the examination):

▪ Conduct an appropriate focused physical examination (suggested by history)
Assessment (or 3-stage assessment)

▪ Make an informed assessment using elements of the history and physical exam. Make
provisional diagnoses with Biological, Psychological, and Social assessments.
▪ Use the A3 assessment model
o Biological
o Psychological:
o Social : Context
Plan (or 4-task plan)

▪ Use the ‘P4 assessment’.
▪ Demonstrate the use of this step to complete the 4 tasks of the consultation:
– Managing the presenting problem.
– Managing ongoing/ chronic problems.
– Carrying out appropriate health promotion.
– Planning future health care to ensure continuity of care.
▪ Summarise and show how this leads to a plan for further investigations, observation,
therapy/ medication, counselling, and referral/ follow-up.
Page 45 of 49
Example model SOAP note:
S
45-year old man; complains about pain in his stomach, increasing over the last six
months, worse on eating.
Used to be relieved by drinking milk now persistent.
No change in his bowel habits.
Can’t sleep at night. Works as a store manager, where there have been increasing
complaints of stock losses.
Has been divorced for a year. Struggling with maintenance payments.
O
Appears anxious.
BP= 140/100. Pulse 82/minute. Moderately overweight.
Slightly tender in the epigastrium.
Include available investigation results
A
Peptic ulcer disease, GORD
Anxiety: work, money
Social: disrupted family, lonely
P
Mag. trisilicate 500mg tabs 1 h. before and 3 h. after meals
Reviewed diet, advised to avoid irritating foods.
Booked for gastroscopy at GIT unit in 2 weeks.
Discussed his situation, counselled on stress relieving activities.
Prescribed an exercise routine for weight loss.
Will need after gastroscopy in 2 weeks.
Page 46 of 49
APPENDIX D: RED FLAGS IN CONSULTATION
The list below is of “red flags” to consider when doing primary care consultations with
adults. These are critical warning signs of possible serious illnesses that should be
considered when consulting adult patients. You should indicate if any of these are present,
as a way of reminding you to look out for them and to get into the habit of checking for
them, where appropriate. Other symptom specific “red flags” may be found in the
Handbook of Family Medicine.
Alterations in weight (WA)
Pain that does not improve / Unresolving pain (UP)
Chronic cough (CC)
Chronic thirst/polyuria (TP)
Exertional chest pain (CP)
Alterations in bowel habits (BH)
Persistent fever (F)
Change in mood (M)
Change in activity level/lethargy (AL)
Swelling of feet, face or body (O)
Urinary abnormalities on urine dip stick (haematuria and/or proteinuria) (UD)
Loss of appetite (LOA)
Dysphagia (DP)
Page 47 of 49
APPENDIX E: TARGETED PREVENTATIVE THERAPY
Record the extent to which patients with chronic illnesses are achieving the appropriate
targets when doing chronic illness consultations.
Cessation of smoking
Alcohol consumption in moderation
o Male: < 14 units per week
o Female: < 10 units per week
o Pregnant Women: nil
Blood pressure
o Hypertension patients: <140/90 mmHg
o Diabetes mellitus patients < 130/80 mmHg
Diabetes
o Random blood glucose < 11mmol/l (200 mg/dl)
o Fasting blood glucose < 7 mmol/l (126 mg/dl)
Hba1c (if available) < 7 % ideally (< 8 % reasonable)
Obesity – Body mass index (weight [kg]/ height2 [m2]) < 25
Lipids (if available)
o Total cholesterol < 5 mmol/l
o LDL cholesterol < 3 mmol/l.
Asthma – Aim for best PEFR (or at least 80 % of predicted for age and gender)
Page 48 of 49
APPENDIX F: EFFECTIVE COMMUNICATION
COMMUNICATION SKILLS
People often remember more about how a subject is communicated than the speaker’s
knowledge of the subject. Techniques for effective communication include active listening,
reflecting, and summarizing.
Often, instead of truly listening to what the other person is saying, we’re thinking about
what our response will be, or what we want to say next, or something else entirely. Active
listening involves making eye contact, facing the speaker, concentrating on the speaker and
what he/she is saying, paying attention, and demonstrating interest in what is being said. It
is also important to avoid distractions, like phone calls, other people, or paperwork.
Reflective listening is the process of verbally “reflecting” back what someone has said. It
helps you check your understanding of the student and helps them feel understood and
respected. It is important to confirm that you have understood your student by using
statements such as: “it sounds like you’re concerned about this patient’s ability to adhere to
treatment;” or “you’re wondering if this patient should be started on an ART regimen.”
Note that the sample statements include the word “you,” which emphasizes that the
preceptor is actively listening and reflecting back what the student has said.
Summarizing is the process of synthesizing and stating what a student has said to capture
key concerns and issues. One can use summarizing to check that you have understood the
student’s story or issue; when changing topics, closing discussion, or clarifying something; to
collect your thoughts; and/or to show the student that you have heard them.
BARRIERS TO COMMUNICATION
Barriers to communication could include having a disorganised office, interruptions and
distractions, such as looking out the window, speaking to someone else, and shuffling
papers can also impede communication. It is important to have a private space to ensure a
confidential and safe space. In addition, talking too much, not giving the student time to
express him or herself; being critical and/or judgmental; laughing at or humiliating the
student; contradicting or arguing with a student; or being disrespectful can pose serious
threats to effective communication.
Page 49 of 49

CoM Family Medicine MBBS Student Guide Version 3 - July 2018 - FINAL

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UNIVERSITY OF MALAWI

FAMILY MEDICINE ROTATION

Name of Student:……………………………Student Number:…………………….

Version 3 | Updated July 2018

I. INTRODUCTION TO STUDENT GUIDE 9

II. INTRODUCTION TO FAMILY MEDICINE 10

III. OBJECTIVES OF THE FAMILY MEDICINE ROTATION 13

IV. STRUCTURE OF THE FAMILY MEDICINE ROTATION 16

V. EXPECTATIONS FOR THE FAMILY MEDICINE ROTATION 17

We wholeheartedly welcome you to the Family Medicine

Despite the presence of family medicine

You will diagnose and manage patients

We wish you the best of luck in this rewarding rotation.

We hope that you enjoy your time with us!

Department of Family Medicine Faculty

Dr. John Parks, Head of Department | jparks@medcol.mw | 09 96 609201

Dr. Prosper Lutala, Deputy HOD | plutala@medcol.mw | 09 99 637472

Dr. Martha Makwero, Clinical Lecturer | mmakwero@medcol.mw | 08 84 111312

Dr. Miriam van Goor, Clinical Lecturer | mvangoor@medcol.mw | 09 99 923112

Dr. Jane Bates, Clinical Lecturer | mjbates@medcol.mw | 09 99 208193

Honorary Department of Family Medicine Faculty

Dr. Barbara Swarthout | bswarthout@medcol.mw | 09 96 376520

Dr. Colin Pfaff | colinpfaff@yahoo.co.uk | 09 99 96 8762

Dr. Catherine Hodge | catcrawford@rocketmail.com | 08 85 422106

Dr. Briony Ackroyd | briony.ackroyd-parkin@nhs.net | 09 97 774225

Dr Ulrika Baker | Ulrika.Baker@ki.se | 09 93 087979

Dr. Annet Hofland | annethofland@gmail.com | 09 97 302063

Dr. Anna McDonald | acmcd5282@gmail.com | 09 98 185829

Dr. Jacob Nettleton | Jacob.nettleton@gmail.com | 09 92 703365

Primary Contact Person for Preceptor Sites (2018-2019)

ldullie@pih.org | 08 84 024749 / 08 82 949488 or Dr George Talama, Medical Officer

Mulanje: Dr. Ruth Shakespeare, Medical Director - Mulanje Mission Hospital

STUDENT BEHAVIOUR AND DRESS CODE

Improper attire: shorts, flip flops, tank tops or bare midriffs.

Male students: Clean shirt, long pants.

Female students: Appropriate dress, long skirt or trousers.

ATTENDANCE AND ABSENCE

Needle Stick Injuries

➢ Follow the Malawi National Post Exposure Prophylaxis (PEP) protocol.

➢ Per protocol: Obtain the necessary starter pack of antiretrovirals.

➢ Ensure that a blood sample is taken from you.

➢ Inform the Department of Family Medicine as soon as possible.

OVERALL AIM OF THE STUDENT GUIDE

LAYOUT AND ORGANIZATION OF THE ROTATION GUIDE

The student guide is organized into seven major sections:

THE FAMILY MEDICINE PRECEPTORSHIP

ROLES OF THE DIFFERENT TEAMS

Figure 1 shows the role of the different teams.

Figure 1. Roles and Responsibilities of Tutors, Clinical Staff/Instructors and Students

Specific cadres may play different roles, as shown below:

EXPECTATIONS OF STUDENTS AT THE DISTRICT SITE

Students are expected to:

▪ Apply the bio-psychosocial approach to primary care consultations.

▪ Observe common presenting problems in undifferentiated patients.

▪ Conduct routine bedside procedures under supervision

▪ Complete assignments outlined in the student logbook

▪ Share clinical learning experiences through case presentations at clinical conferences.

▪ As time allows, students may observe Preceptor consultations.

▪ Conduct consultations in the presence of Preceptors. (observed consultations in logbook)

▪ Accompany patients to other health services such as X-ray departments and

FAMILY MEDICINE PRINCIPLES

1. Practice family medicine in the district health system.

2. Practice office-based general practice.

Name of Health Facility _____________________ Date _