Difference between rural FP and in cities with specialist

[803]

what all procedures and extra stuff do those FP get to do working in small towns that do not have any specialist.

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[cabinbuilder]

It's not about what you "get" to do, it's about what you are "trained" to do and are safely comfortable doing.

What I have seen rural FP's do in various states. Not everyone does all of these.

C-Sections
Colonoscopy
EGD
Appendectomy (Montana)
T&A (Montana)
Paracentesis
Cardiac Stress Test
Thoracentesis
Setting bones under conscious sedation
Central lines
ICU
Vent management
Bronchoscopy

Then all the usual stuff that I do
casting, joint injections, nail removal, skin biopsy, suturing wounds, taking off lesions, OMT, I&D, etc.

 

[septoplasty]

It's not about what you "get" to do, it's about what you are "trained" to do and are safely comfortable doing.

What I have seen rural FP's do in various states. Not everyone does all of these.

C-Sections
Colonoscopy
EGD
Appendectomy (Montana)
T&A (Montana)
Paracentesis
Cardiac Stress Test
Thoracentesis
Setting bones under conscious sedation
Central lines
ICU
Vent management
Bronchoscopy

Then all the usual stuff that I do
casting, joint injections, nail removal, skin biopsy, suturing wounds, taking off lesions, OMT, I&D, etc.

Wholy smokes.

Would they even encounter legal implications (even if done properly) because its something outside of "their" specialty?

 

[Dharma]

Wholy smokes.

Would they even encounter legal implications (even if done properly) because its something outside of "their" specialty?

If done properly, technically speaking, any licensed physician can perform these procedures without legal backlash. (Correct me if I'm wrong). I'm wondering how this holds up when it comes to reimbursement though.

 

[375RGRRGT]

It's not about what you "get" to do, it's about what you are "trained" to do and are safely comfortable doing.

What I have seen rural FP's do in various states. Not everyone does all of these.

C-Sections
Colonoscopy
EGD
Appendectomy (Montana)
T&A (Montana)
Paracentesis
Cardiac Stress Test
Thoracentesis
Setting bones under conscious sedation
Central lines
ICU
Vent management
Bronchoscopy

Then all the usual stuff that I do
casting, joint injections, nail removal, skin biopsy, suturing wounds, taking off lesions, OMT, I&D, etc.

During my rural FM rotation I regularly went to the OR with the FP doc to do appy's EGD, colonoscopy, laproscopic procedures, ulnar nerve transposition, median nerve release, etc.

Sometimes in certain rural locations you are the end of the line for peoples healthcare, either by choice or some other restricting reason.

 

[andon]

where were you? and was he the primary surgeon?

 

[EdibleEgg]

It's not about what you "get" to do, it's about what you are "trained" to do and are safely comfortable doing.

What I have seen rural FP's do in various states. Not everyone does all of these.

C-Sections
Colonoscopy
EGD
Appendectomy (Montana)
T&A (Montana)
Paracentesis
Cardiac Stress Test
Thoracentesis
Setting bones under conscious sedation
Central lines
ICU
Vent management
Bronchoscopy

Then all the usual stuff that I do
casting, joint injections, nail removal, skin biopsy, suturing wounds, taking off lesions, OMT, I&D, etc.

I do most of the the things on this list. No appy's, c-sections, or T &A's. Bronchs are emergent, no diagnostic. I'm in a town or around 40K. 99214's are still my bread and butter though.

 

[elfmonkey]

During my rural FM rotation I regularly went to the OR with the FP doc to do appy's EGD, colonoscopy, laproscopic procedures, ulnar nerve transposition, median nerve release, etc.

Sometimes in certain rural locations you are the end of the line for peoples healthcare, either by choice or some other restricting reason.

What laparoscopic procedures ?!

 

[375RGRRGT]

where were you? and was he the primary surgeon?

I was in the upper midwest

Primary surgeon was a general surgeon however this individual was a FP physician


For the most part they all were older "old school" docs that knew more than you could imagine and were from the days before subspecialization but the trend continues in medical education here.

I can state that without residents and being the ONLY med student around I was able to do more than most. I did do one away rotation and it really sucked in comparison but the thing is, it would have sucked if I was a resident at this program too because they didn't get to do much in comparison either.

 

[375RGRRGT]

What laparoscopic procedures ?!

Nearly all gyne procedures.

 

[AlmostJesus]

I was reading the other day that the University of North Dakota FM residency added a rural residency track with two spots in rural areas. I know one of the places they have the rural tracks is in a town of 1200 that is the only hospital for 70+ miles. The FP docs do appys, c-sections, choles, etc. There is one surgeon but he prefers open procedures vs the FP's who do things laproscopically generally.
I would imagine that after going through that residency, you might be well trained to be a (super) rural FP doc
I found this from a hospital that closed a couple years ago. While their last 15 years were pretty tumultuous, in their beginnings, they were truly an example of the small town jack of all trades family doc hospitals. They have a pretty interesting scrapbook from over the years
http://www.hovensd.com/Holy Infant Hospital/Historical Photo Pages/holy_infant_scrapbook.htm
http://www.hovensd.com/images/Holy ...is, Sr Cecilia, Sr Evangelette anesthesia.jpg
ED procedural sedation
http://www.hovensd.com/images/Holy Infant Hospital/History Photos/photos/0450 1948 Statistics.jpg
Anesthetics given
http://www.hovensd.com/images/Holy ...y Photos/photos/0750 1948 Surgical report.jpg
Surgeries done - all by the one doctor staffing the hospital
http://www.hovensd.com/images/Holy ...tos/photos/0880 1944 Analysis of services.jpg

 

[bluewillark]

I trained med/peds for 2 years, spent a year in Iraq with the Army, returned home and finished 2 more years in FP. I practice in rural Oklahoma and do all common FP procedures + EGD, colonoscopy, hemorrhoidectomy, thoracentesis, paracentesis, vent management, LP, central lines, art lines conscious sedation, casting. Dont do OB now only because hospital dropped that service due to overhead costs. As long as you are trained to do the procedure and your hospital credentials you to do it, you are fine. Medical Boards are glad to have rural docs who provide such care. I've never once had insurance question my credentials before paying me. Most docs in rural OK who have similar practices stand to make as much as some specialists in the bigger towns. I have a buddy from med school who is also FP and does appy's, gallbladders, and C sections. He is single and works 12 hour days, but makes on average around $800K a year.

 

[Bumbl3b33]

I trained med/peds for 2 years, spent a year in Iraq with the Army, returned home and finished 2 more years in FP. I practice in rural Oklahoma and do all common FP procedures + EGD, colonoscopy, hemorrhoidectomy, thoracentesis, paracentesis, vent management, LP, central lines, art lines conscious sedation, casting. Dont do OB now only because hospital dropped that service due to overhead costs. As long as you are trained to do the procedure and your hospital credentials you to do it, you are fine. Medical Boards are glad to have rural docs who provide such care. I've never once had insurance question my credentials before paying me. Most docs in rural OK who have similar practices stand to make as much as some specialists in the bigger towns. I have a buddy from med school who is also FP and does appy's, gallbladders, and C sections. He is single and works 12 hour days, but makes on average around $800K a year.

I've always been curious...how does one get trained to do lap appy's/ choleys in an FP residency? Is it that these people feel like they've gotten the 'base' of FP down and seek out these skills during training, or are some residencies advertised as being able to teach its residents basic surgeries? Pardon my ignorance...if it's not clear, I'm MS-0 (applying right now, but working in hospital right now and super duper loving rural FPs' inpt/outpt/ER combo punches). I really hope FP's continue to be able to do surgeries by the time I am an attending!

 

[cabinbuilder]

I've always been curious...how does one get trained to do lap appy's/ choleys in an FP residency? Is it that these people feel like they've gotten the 'base' of FP down and seek out these skills during training, or are some residencies advertised as being able to teach its residents basic surgeries? Pardon my ignorance...if it's not clear, I'm MS-0 (applying right now, but working in hospital right now and super duper loving rural FPs' inpt/outpt/ER combo punches). I really hope FP's continue to be able to do surgeries by the time I am an attending!

When you schedule your rotations in residency you make sure you do a surgery rotation that is required or an elective surgery rotation with a surgeon who is very busy so you can learn how to do these cases on your own and be proficient to be able to practice on your own later. It's not that hard to do, just have to be aggressive in getting the training that you want.

 

[bluewillark]

I've always been curious...how does one get trained to do lap appy's/ choleys in an FP residency?

Very much depends on the residency. Best chances are in unopposed residencies (at hospitals where the only residency program is an FP program so there is no competition with residents from other specialties). My training program had 24 residents (8/year) in a relatively large community hospital that served as a regional referral center. We had 6 general surgeons on staff at the hospital who also acted as adjunct faculty for the residency program. 3 of the 6 were known to be much more likely to let residents take a greater hands-on approach in the OR rather than just letting us close up the incisions at the end. So, if you were a resident who had greater interest in learning surgical skills, you made certain to spend your rotations with them and let them know you were eager to learn. That said, the residents who wanted to do some of the basic general surgery procedures in practice would pretty much have to use all their elective months as general surgery months to add enough experience. The vast majority of residents didn't plan to do choles and appys in practice and there was probably only one resident every 2-3 years who really got aggressive enough to get comfortable doing them on their own. In the example of my friend, he also spent his f irst two years in practice doing them alongside an aging general surgeon in his home town and got more proficient with them. It was a good thing, because the surgeon died relatively suddenly and was the only surgeon in that town. Now this FP is the only doc there who does appys and choles.

 

[Bumbl3b33]

Very much depends on the residency. Best chances are in unopposed residencies (at hospitals where the only residency program is an FP program so there is no competition with residents from other specialties). My training program had 24 residents (8/year) in a relatively large community hospital that served as a regional referral center. We had 6 general surgeons on staff at the hospital who also acted as adjunct faculty for the residency program. 3 of the 6 were known to be much more likely to let residents take a greater hands-on approach in the OR rather than just letting us close up the incisions at the end. So, if you were a resident who had greater interest in learning surgical skills, you made certain to spend your rotations with them and let them know you were eager to learn. That said, the residents who wanted to do some of the basic general surgery procedures in practice would pretty much have to use all their elective months as general surgery months to add enough experience. The vast majority of residents didn't plan to do choles and appys in practice and there was probably only one resident every 2-3 years who really got aggressive enough to get comfortable doing them on their own. In the example of my friend, he also spent his f irst two years in practice doing them alongside an aging general surgeon in his home town and got more proficient with them. It was a good thing, because the surgeon died relatively suddenly and was the only surgeon in that town. Now this FP is the only doc there who does appys and choles.

so does he do mostly lap appys/choles now in order to be pulling in 800k?

 

[bluewillark]

No, he mostly makes that because he works crazy long hours. He is single and works at least 12 hours a day on weekdays. It just all adds up... lots of office visits, hospital visits, nursing home rounds, lots of procedures, delivers babies, etc. He's a machine. He owns and runs his own clinic, so he gets to keep all profit past overhead. When he's in clinic, he has 4 exam rooms going with a nurse (LPN) for each room who also acts as a scribe for his EHR system. Nurses put in all data as he "dictates" to them and then he just signs the note and orders/Rx's at the end. He can move right on to the next room/nurse without pause. He also lives in a bed and breakfast (which he also owns), so doesn't have to worry about keeping up a house at all.

 

[Bumbl3b33]

No, he mostly makes that because he works crazy long hours. He is single and works at least 12 hours a day on weekdays. It just all adds up... lots of office visits, hospital visits, nursing home rounds, lots of procedures, delivers babies, etc. He's a machine. He owns and runs his own clinic, so he gets to keep all profit past overhead. When he's in clinic, he has 4 exam rooms going with a nurse (LPN) for each room who also acts as a scribe for his EHR system. Nurses put in all data as he "dictates" to them and then he just signs the note and orders/Rx's at the end. He can move right on to the next room/nurse without pause. He also lives in a bed and breakfast (which he also owns), so doesn't have to worry about keeping up a house at all.

I don't know how that's fiscally viable to have 4 FTE RN per MD. Either way, would it be inappropriate for me to ask you who this person is or where he/she practices? I'd love to have someone like this as a mentor in medical school or even chat with before med school starts.