ACGME's proposed changes to FM

[Splenda88]

My third year of FM residency consisted of 4 months of inpatient medicine and 8 months split amongst required and elective outpatient rotations.

Had I gone straight into independent practice after PGY2, I do think I could have competently practiced what I had already learned.

I fail to see how I could have similarly learned the nuances I picked up on a month rotation of Derm, ENT, Ophtho, Ortho, Urology, etc by just going straight into practice.

The answer should never be less training in my opinion. I’d be more likely to advocate for a PGY4 year in FM than I would dropping the third year.

I am sure you would advocate for even a PGY5 and a 5th yr undergrad and med school. Hey, the more training the better...

---

Members don't see this ad.

 

[Lurts]

You’re right, I would.

 

[deleted941485]

You’re right, I would.

So what is a sufficient amount of training in your view?

 

[VA Hopeful Dr]

Programs can be restructured. Requirements can be changed. During the peaked of covid, a lot of these requirements were changed.

I wonder if the AAFP has data about % of FM docs who truly see peds/Obgyn patients. Not talking about treating otitis media, PIH, and doing PAP etc..., which even most IM docs also do.

Some of that has been surveyed: Table 11: Clinical Services Performed by Physicians

 

[Lurts]

So what is a sufficient amount of training in your view?

Training as it currently stands is sufficient.

But I would take an FM PGY4 year before I dropped it down to 2 years.

 

[MedicineZ0Z]

My third year of FM residency consisted of 4 months of inpatient medicine and 8 months split amongst required and elective outpatient rotations.

Had I gone straight into independent practice after PGY2, I do think I could have competently practiced what I had already learned.

I fail to see how I could have similarly learned the nuances I picked up on a month rotation of Derm, ENT, Ophtho, Ortho, Urology, etc by just going straight into practice.

The answer should never be less training in my opinion. I’d be more likely to advocate for a PGY4 year in FM than I would dropping the third year.

You need to draw the line somewhere.

You can also learn as an attending too and go to conferences/courses to fill in some missing blanks. It's not the same as doing something under supervision in residency, but you can absolutely learn on the fly. This is especially true for medical management and workups. I learned a lot by reading and applying it to patients and doing as much as I can on my own. Eventually if a specialist got involved, I was able to see some indirect feedback on my work too and fine tuned my approach.

My biggest concern is programs where they do 3 years but half of it is useless scut work. If you're shadowing on a rotation or doing nothing more than write notes, that's useless. At least there were some rotations where I did a lot of scut work but was hands on for procedures and what not. But this doesn't apply at every program.

 

[NewYorkDoctors]

This is deeply concerning to me as someone who has spent the last 5 years working towards going to med school because I wanted to do full scope primary care to serve rural and underserved communities. I have zero interest in being a referral monkey with a scope of practice equal to an NP or PA but with 4x the debt and double the time spent in training.

I am honestly having to now drastically re-think my career goals right on the cusp of going to med school. I have literally just a month or so to decide where I want to attend to have the best chance at being the sort of physician I want to be. The proposal leaves me with no idea of how to move forward. Because I do not want this brand of "family medicine" at all.

Do internal medicine and do nephrology /hypertension afterward . You can be a super PCP for adults

 

[thatonegrrl]

Do internal medicine and do nephrology /hypertension afterward . You can be a super PCP for adults

For me at least, I don't want to be just an adult doctor. I know for sure I want to see peds patients, so for me I think I'd be more apt to go for Med-Peds or Gen Peds if not able to do true full scope Family Med. And I like the possible fellowship options a little better if I wanted to get more specialized. (I'm also interested in PedsPscyh triple board or Peds Bridge programs).

 

[NewYorkDoctors]

For me at least, I don't want to be just an adult doctor. I know for sure I want to see peds patients, so for me I think I'd be more apt to go for Med-Peds or Gen Peds if not able to do true full scope Family Med. And I like the possible fellowship options a little better if I wanted to get more specialized. (I'm also interested in PedsPscyh triple board or Peds Bridge programs).

Fair enough since you plan on serving a rural community and you should be able to provide as many services for people as possible . Perhaps Med Peds 5 year residency ? Fellowship can follow that I believe

 

[NewYorkDoctors]

The reason why most FM physicians do not “do everything “ has to do with the requirement of purchasing malpractice insurance for surgery, medicine , obgyn , peds . Anything surgical or medical has higher malpractice premiums and that can erode into revenue quite quickly. Hence hospitals are loathe to pay that much and the individual private physician cannot afford that much without working for peanuts .

Hence why at most it’s adult and children primary care. Usually .

Maybe some truly rural physicians have arrangements with the hospital systems

 

[VA Hopeful Dr]

The reason why most FM physicians do not “do everything “ has to do with the requirement of purchasing malpractice insurance for surgery, medicine , obgyn , peds . Anything surgical or medical has higher malpractice premiums and that can erode into revenue quite quickly. Hence hospitals are loathe to pay that much and the individual private physician cannot afford that much without working for peanuts .

Hence why at most it’s adult and children primary care. Usually .

Maybe some truly rural physicians have arrangements with the hospital systems

That has not been my experience. Most of us don't do traditional practice because the hours suck and doing both doesn't pay as well as just clinic. Peds is included in FM malpractice insurance, I've never been asked on any malpractice form whether or not I plan to see children. OB was historically a lifestyle thing now its that and liability/cost as you described.

Family doctors doing any OR procedures has always been exceptionally rare. In-office procedures are likely done more commonly than you realize.

 

[InternistDO]

While you always have to draw the line somewhere (you're not going to do PCI or infuse chemotherapy as a PCP no matter where you are), there are plenty of pretty broad scope FM or IM jobs in both cities and rural areas, as someone who is looking right now.

I'm IM, but just in Philly and New York City I've seen FM jobs that span from adults only outpatient, to complete prenatal (but no deliveries)/peds/adults outpatient in urban FQHCs, to all ages outpatient/inpatient/OB with deliveries in a large academic hospital. Just on the IM side I have offers for places that want outpatient procedures, places that want or allow inpatient rounding, places that want you to completely manage HIV and Hep C treatment, etc. And regardless of where you are, 50-80% of mental health care is delivered by PCPs, not psychiatrists, so I wouldn't worry about missing out on that. It takes 6 months for my patients to see a psychiatrist in my hospital that has a psychiatry residency one floor above our clinic.

There are also plenty of referral monkey jobs in big cities if you aren't too careful, but the payment models seem to be shifting away from that model and towards encouraging even very urban PCPs with lots of specialist backup to manage more and more things themselves. NYC in particular used to be famous for patients having a cardiologist, a nephrologist, a psychiatrist, and no PCP, but even here the tide is shifting.

I would be extremely cautious about listening to what anyone in a subspecialty tells you about what it's like to be a PCP, which you will experience quite a lot of in medical school and in residency (especially if you do internal medicine).

 

[MedicineZ0Z]

While you always have to draw the line somewhere (you're not going to do PCI or infuse chemotherapy as a PCP no matter where you are), there are plenty of pretty broad scope FM or IM jobs in both cities and rural areas, as someone who is looking right now.

I'm IM, but just in Philly and New York City I've seen FM jobs that span from adults only outpatient, to complete prenatal (but no deliveries)/peds/adults outpatient in urban FQHCs, to all ages outpatient/inpatient/OB with deliveries in a large academic hospital. Just on the IM side I have offers for places that want outpatient procedures, places that want or allow inpatient rounding, places that want you to completely manage HIV and Hep C treatment, etc. And regardless of where you are, 50-80% of mental health care is delivered by PCPs, not psychiatrists, so I wouldn't worry about missing out on that. It takes 6 months for my patients to see a psychiatrist in my hospital that has a psychiatry residency one floor above our clinic.

There are also plenty of referral monkey jobs in big cities if you aren't too careful, but the payment models seem to be shifting away from that model and towards encouraging even very urban PCPs with lots of specialist backup to manage more and more things themselves. NYC in particular used to be famous for patients having a cardiologist, a nephrologist, a psychiatrist, and no PCP, but even here the tide is shifting.

I would be extremely cautious about listening to what anyone in a subspecialty tells you about what it's like to be a PCP, which you will experience quite a lot of in medical school and in residency (especially if you do internal medicine).

Such a waste of time, resources and money. If you did a 3 year residency and can't manage a lot of that stuff, you literally wasted 3 years.

 

[VA Hopeful Dr]

Such a waste of time, resources and money. If you did a 3 year residency and can't manage a lot of that stuff, you literally wasted 3 years.

I always thought it was a patient preference issue. We've all had patients that demand an ENT for their first ever nosebleed or an orthopedist for their knee pain that started yesterday.

 

[InternistDO]

Such a waste of time, resources and money. If you did a 3 year residency and can't manage a lot of that stuff, you literally wasted 3 years.

It's a huge waste of absolutely everyone's time and energy (not to mention the insane polypharmacy and conflicting recommendations), but the issue wasn't that PCPs were referring, it was more the cultural idea that everything needed to be managed by "a specialist" and so patients would bypass PCPs completely and self refer. Though I guess historically a lot of urban PCPs who wanted to make money realized the only way to do that was churning 30-40 PPD in clinic and referring everything that moved.

Thankfully things seem to be changing even in the northeast, I'm guessing it's due to the increased money flowing into primary care, the value based and risk based care models, and the push for cost savings at a systems level--the big NY systems are opening up primary care offices left and right when 10 years ago they couldn't be bothered and were trying to shut down FM programs in the city.

 

[MedicineZ0Z]

I always thought it was a patient preference issue. We've all had patients that demand an ENT for their first ever nosebleed or an orthopedist for their knee pain that started yesterday.

Heavily location dependent, but this thing is also more prevalent inside some urban centers. The occasional time I get these requests, I explain why it's not necessary and what my plan will be (aka same plan as the specialist) + the very long wait time to see one. I also do emphasize when relevant that often they will not see a specialist and will see their NP/PA only. After all that is done, it becomes very rare to have people who still want it.

 

[hallowmann]

Heavily location dependent, but this thing is also more prevalent inside some urban centers. The occasional time I get these requests, I explain why it's not necessary and what my plan will be (aka same plan as the specialist) + the very long wait time to see one. I also do emphasize when relevant that often they will not see a specialist and will see their NP/PA only. After all that is done, it becomes very rare to have people who still want it.

Honestly, its a lot of time/effort to try to convince someone they don't need a specialist when they insist on it.

I counsel them, prescribe what I know the specialist will, and write the referral for "within 3 mos" (the longest default interval in our EMR). 50% of the time, they are better and cancel their specialist appointment because no one has time for that, 25% of the time they see the specialist, are told the same thing, and don't see the point going again in the future (i.e. have renewed faith in their PCP), and the last 25% of the time they especially push to have the specialty visit as soon as possible (i.e. calling in repeatedly to scheduling), and the specialist can deal with them. I figure that last group would have been the ones I couldn't convince even if I spent the whole visit on it.

 

[Trousseau]

Honestly, its a lot of time/effort to try to convince someone they don't need a specialist when they insist on it.

I counsel them, prescribe what I know the specialist will, and write the referral for "within 3 mos" (the longest default interval in our EMR). 50% of the time, they are better and cancel their specialist appointment because no one has time for that, 25% of the time they see the specialist, are told the same thing, and don't see the point going again in the future (i.e. have renewed faith in their PCP), and the last 25% of the time they especially push to have the specialty visit as soon as possible (i.e. calling in repeatedly to scheduling), and the specialist can deal with them. I figure that last group would have been the ones I couldn't convince even if I spent the whole visit on it.

It's the same thing in hospital medicine tbh...I get lots of families who demand that (for example) their pulmonologist be called for a bog-standard COPD Exacerbation. I'm tired of fighting with people so I do call him...of course he doesn't actually see the patient, he has his NP see it, she doesn't add anything (and there's nothing to add in a bog-standard case anyways), and two days later he writes "Agree with APP's Assessment and Plan."

Hope the family got what they were looking for.

---

I think a lot of people don't really get what generalist physicians do. It's kind of sad.

 

[bltzybltz]

So, speaking as an MS1, are there any updates to when these proposed changes would take effect? If the changes go through, it seems like a no brainer to do IM instead of FM if you're interested in outpatient

 

[Cranjis McBasketball]

If the changes go through, it seems like a no brainer to do IM instead of FM if you're interested in outpatient

Its not. Good programs wont suddenly weaken their programs just because of these changes. All itll do is allow already weak programs to continue receiving accreditation and not make changes. Strong programs will stay strong.

 

[thatonegrrl]

Its not. Good programs wont suddenly weaken their programs just because of these changes. All itll do is allow already weak programs to continue receiving accreditation and not make changes. Strong programs will stay strong.

I think the hard part/area of concern is the hiring market. Do those doing the hiring know which are the strong programs and which aren't? Are they going to grant you admission and/or OB privileges because you went to a strong program, or are they going to push you into the limited scope of the lowest common denominator? Also, are patients as likely to choose an FM doc over an internal medicine doc if the specialty is diluted by crappy programs? (Similar things already happening to an even worse extent with NPs, where degree mill crappy programs are pumping out FNPs and damaging the reputation of all NPs, even those with years of experience in nursing pre-NP and who attended high-quality graduate programs). I dunno that it is as easy as saying "strong programs will stay strong" unless you can take that strong training and earn a living still practicing to the full scope under which you were trained.

 

[smq123]

I think the hard part/area of concern is the hiring market. Do those doing the hiring know which are the strong programs and which aren't? Are they going to grant you admission and/or OB privileges because you went to a strong program, or are they going to push you into the limited scope of the lowest common denominator? Also, are patients as likely to choose an FM doc over an internal medicine doc if the specialty is diluted by crappy programs? (Similar things already happening to an even worse extent with NPs, where degree mill crappy programs are pumping out FNPs and damaging the reputation of all NPs, even those with years of experience in nursing pre-NP and who attended high-quality graduate programs). I dunno that it is as easy as saying "strong programs will stay strong" unless you can take that strong training and earn a living still practicing to the full scope under which you were trained.

So what you're describing is not how the hiring/credentialing process usually goes.

People who are responsible for hiring generally don't know if you went to a strong program or not. This is particularly true in IM/FM/peds, where there are soooooooo many programs. They may only know about the programs in their immediate geographic area, but I wouldn't even bet on that.

Hiring usually happens by word of mouth. "Dr. Smith, who has worked here for 10 years, said that his buddy was looking for a job and suggested that we look at his CV." "Dr. Jones is from Generic Hospital Residency Program; we've hired 12 of their grads over the past several years and they've all been good, so she's probably fine too." "Dr. Doe said that the applicant was her intern when she was chief; she vouched for this person." "His current CEO called our CEO, and asked if we would hire him." But the "strength" of your program is almost never a factor.

Credentialing, or the process by which the hospital/clinic approves you to perform certain procedures, also has nothing to do with the reputation of your residency program. For a minor office procedure, they may watch you as you perform a few of them. Once they're satisfied that you know what you're doing, they'll sign off on it.

For anything more significant (like intubation or vaginal delivery), they will require case logs from your residency experience, as well as directly observing you. So it's up to you to keep good records from your residency experience, if you think that that procedure is something that you will want to do as an attending.

Also, are patients as likely to choose an FM doc over an internal medicine doc if the specialty is diluted by crappy programs?

VERY very very few patients know, or care, what the difference is between FM and IM.

98% of patients will choose you for reasons that have absolutely nothing to do with your educational background. "My roommate said that you were nice." "My wife saw you and said that I should come see you too." "My cardiologist said that you were good." "Your office was two blocks from my job and you happened to have an opening during my lunch break." "I liked the tie that you were wearing in your website photo."

The other 2% will choose you for reasons related to your educational background but not the reasons that you would assume. "I saw that you went to Michigan for undergrad. I did too!!! GO BLUE!!!!!" "You went to college in Georgia; I'm from there so I decided to see you." I live in Florida; a patient once told me that he decided to see me because he felt that anyone who had gone to school in Florida "has to be an idi**" and I had gone to medical school in Pennsylvania. I didn't agree with that assessment, but whatever.

What will probably happen with the new requirements is that programs that weren't strong in those areas will just continue to be weak in those areas, and applicants who are interested in those areas won't apply. That's all.

 

[VA Hopeful Dr]

So what you're describing is not how the hiring/credentialing process usually goes.

People who are responsible for hiring generally don't know if you went to a strong program or not. This is particularly true in IM/FM/peds, where there are soooooooo many programs. They may only know about the programs in their immediate geographic area, but I wouldn't even bet on that.

Hiring usually happens by word of mouth. "Dr. Smith, who has worked here for 10 years, said that his buddy was looking for a job and suggested that we look at his CV." "Dr. Jones is from Generic Hospital Residency Program; we've hired 12 of their grads over the past several years and they've all been good, so she's probably fine too." "Dr. Doe said that the applicant was her intern when she was chief; she vouched for this person." "His current CEO called our CEO, and asked if we would hire him." But the "strength" of your program is almost never a factor.

Credentialing, or the process by which the hospital/clinic approves you to perform certain procedures, also has nothing to do with the reputation of your residency program. For a minor office procedure, they may watch you as you perform a few of them. Once they're satisfied that you know what you're doing, they'll sign off on it.

For anything more significant (like intubation or vaginal delivery), they will require case logs from your residency experience, as well as directly observing you. So it's up to you to keep good records from your residency experience, if you think that that procedure is something that you will want to do as an attending.



VERY very very few patients know, or care, what the difference is between FM and IM.

98% of patients will choose you for reasons that have absolutely nothing to do with your educational background. "My roommate said that you were nice." "My wife saw you and said that I should come see you too." "My cardiologist said that you were good." "Your office was two blocks from my job and you happened to have an opening during my lunch break." "I liked the tie that you were wearing in your website photo."

The other 2% will choose you for reasons related to your educational background but not the reasons that you would assume. "I saw that you went to Michigan for undergrad. I did too!!! GO BLUE!!!!!" "You went to college in Georgia; I'm from there so I decided to see you." I live in Florida; a patient once told me that he decided to see me because he felt that anyone who had gone to school in Florida "has to be an idi**" and I had gone to medical school in Pennsylvania. I didn't agree with that assessment, but whatever.

What will probably happen with the new requirements is that programs that weren't strong in those areas will just continue to be weak in those areas, and applicants who are interested in those areas won't apply. That's all.

You must be in a high supply area, every job I've ever gotten I just called up the recruiter and said "hey, I'm looking for a job in your area. Are y'all hiring FPs". The answer is always yes.

 

[hallowmann]

So what you're describing is not how the hiring/credentialing process usually goes.

People who are responsible for hiring generally don't know if you went to a strong program or not. This is particularly true in IM/FM/peds, where there are soooooooo many programs. They may only know about the programs in their immediate geographic area, but I wouldn't even bet on that.

Hiring usually happens by word of mouth. "Dr. Smith, who has worked here for 10 years, said that his buddy was looking for a job and suggested that we look at his CV." "Dr. Jones is from Generic Hospital Residency Program; we've hired 12 of their grads over the past several years and they've all been good, so she's probably fine too." "Dr. Doe said that the applicant was her intern when she was chief; she vouched for this person." "His current CEO called our CEO, and asked if we would hire him." But the "strength" of your program is almost never a factor.

Credentialing, or the process by which the hospital/clinic approves you to perform certain procedures, also has nothing to do with the reputation of your residency program. For a minor office procedure, they may watch you as you perform a few of them. Once they're satisfied that you know what you're doing, they'll sign off on it.

For anything more significant (like intubation or vaginal delivery), they will require case logs from your residency experience, as well as directly observing you. So it's up to you to keep good records from your residency experience, if you think that that procedure is something that you will want to do as an attending.



VERY very very few patients know, or care, what the difference is between FM and IM.

98% of patients will choose you for reasons that have absolutely nothing to do with your educational background. "My roommate said that you were nice." "My wife saw you and said that I should come see you too." "My cardiologist said that you were good." "Your office was two blocks from my job and you happened to have an opening during my lunch break." "I liked the tie that you were wearing in your website photo."

The other 2% will choose you for reasons related to your educational background but not the reasons that you would assume. "I saw that you went to Michigan for undergrad. I did too!!! GO BLUE!!!!!" "You went to college in Georgia; I'm from there so I decided to see you." I live in Florida; a patient once told me that he decided to see me because he felt that anyone who had gone to school in Florida "has to be an idi**" and I had gone to medical school in Pennsylvania. I didn't agree with that assessment, but whatever.

What will probably happen with the new requirements is that programs that weren't strong in those areas will just continue to be weak in those areas, and applicants who are interested in those areas won't apply. That's all.

Good post, but I think at least a third to half of patients end up choosing you because "you're the only one accepting new patients" and "you're the first PCP I could get into because most others are booked 30+ days out".

 

[VA Hopeful Dr]

Good post, but I think at least a third to half of patients end up choosing you because "you're the only one accepting new patients" and "you're the first PCP I could get into because most others are booked 30+ days out".

You're not booked out 30+ days?

 

[smq123]

Good post, but I think at least a third to half of patients end up choosing you because "you're the only one accepting new patients" and "you're the first PCP I could get into because most others are booked 30+ days out".

Very true.

Or my other favorite: "My insurance card had your name on it/my insurance assigned me to you."

 

[VA Hopeful Dr]

Very true.

Or my other favorite: "My insurance card had your name on it/my insurance assigned me to you."

Also a great sign of how much of a pain in the rear dealing with their insurance will be.

 

[VA Hopeful Dr]

Yup. My criteria was: 1- Actual physician; 2- Could see me within the next few weeks/ taking new patients; 3- Looked nice in their photo (maybe this one is odd but something about a nice photo is comforting when you’re finding a new physician).

The hard part was #2 because almost every “doctor” who was taking new patients really was pawning then off to the np (very sad).

This was my lame criteria and I’m a bloody physician. I think people are really living in a fantasy world when they think any significant amount of people care about the stuff being discussed here.

#2 is the biggest issue around here. Vast majority of us who are even taking new patients are booked out around 6+ weeks.

 

[smq123]

I think people are really living in a fantasy world when they think any significant amount of people care about the stuff being discussed here.

Well, to be fair, the person posting that is pre-med, based on their other posts. And that's really the narrative that everyone advises online - you work hard in high school to get into the best undergrad that you can afford, so that you can get into the best med school that you can get into, in order to get your top residency choice, which will help you land that perfect job. Because REPUTATION MATTERS.

It's only AFTER you finish the trajectory that you realize that almost no one cares where you did residency, and that few people care about where you went to med school. And that for >90% of physicians, pedigree/prestige doesn't really matter all that much. It only matters if you want to be, like, chair of derm at Yale, but otherwise....meh.

Also, no one tells you that the more prestigious the job name, then the more likely it is that the salary, benefits, and hours will suck - because apparently the Ivy League places believe that the joy of working at a place with such a good reputation will be more than enough to make up for the >$75K salary cut.

 

[NITRAS]

#2 is the biggest issue around here. Vast majority of us who are even taking new patients are booked out around 6+ weeks.

My PCP died last year. Getting signed up for a new one has been irritating. My old boss’s husband is IMED clinic. His first appointment for new pts is in 2024, one of the other ones I know has appointments in June. . 2023.

Odd I can’t have one of the residents be my PCP because of some BS. Honestly I don’t need much.

 

[VA Hopeful Dr]

My PCP died last year. Getting signed up for a new one has been irritating. My old boss’s husband is IMED clinic. His first appointment for new pts is in 2024, one of the other ones I know has appointments in June. . 2023.

Odd I can’t have one of the residents be my PCP because of some BS. Honestly I don’t need much.

IM PCPs are somewhat rare. Find an FP, we're much more common.