FM vs EM: What is the reality of continuity of care?

[ninjamaterial210]

MS4 here waffling between FM and EM. And the question everyone asks me and I see posted everywhere is "well... do you want continuity of care?" How are we to know what real continuity of care is when we're only in a clinic for 1 month at a time? In general I'm passionate about meaningful encounters with people. But long-term relationships with patients? Like, I understand the value of the patient having a doc that knows them. But what's the expectation? That they will be your friends? That you will make a deeper impact on their health? What's unique about the doctor-patient relationship that makes continuity a selling point? Because you still only see them so often. For example, if you really value long-term relationships I imagine it would also be fulfilling to work in an ED with all kinds of different co-workers with different backgrounds and titles that you enjoy seeing, growing with, and doing hard things alongside. Those people you see every week. Clinic patients you only see a few times a year and there's like 3,000 of them.

I have a particular interest in working with teens/young adults, and I've always wanted to be a physician-teacher, mentor, counselor. But how much of a bond can you actually build with a kid you only see 2-3x per year for 15 minutes? When they are absorbing input from culture and peers all day everyday, how impactful are your biannual check-ins? I've kinda forfeited the idea I'm going to make the depth of patient relationships I imagined in FM, and changed trajectory toward EM and on my days off maybe teaching a class or getting involved in some non-profit to mentor young people more regularly.

But I really want to know your experiences.

Primary care docs: What is fulfilling to you about continuity of care? How much of a bond can you reasonably make in your patient encounters? Do patients make genuine life changes based on your recommendations? What were your expectations of the doctor-patient relationship, and what is reality?

EM docs: Does it often bother you when you can't do more for certain patients? Ever disappointed that you can't follow-up with them and will likely never see them ever again? How's the comradery amongst your co-workers?

TL;DR: Just answer the Q in the title.

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[Lexdiamondz]

For example, if you really value long-term relationships I imagine it would also be fulfilling to work in an ED with all kinds of different co-workers with different backgrounds and titles that you enjoy seeing, growing with, and doing hard things alongside

Sometimes.

EM is a highly mobile specialty - people go from job to job alllll the time so you often arent working with the same folks day in and day out.

On the clinical side of things - the vast majority of patients who are "regulars" in the ED are deeply unpleasant to work with. Drug seekers, malingerers, people with axis II personality disorders, the homeless & itinerants and the decompensated schizophrenics are the only patients you get "continuity of care" with and they almost universally suck arse.

and changed trajectory toward EM and on my days off maybe teaching a class or getting involved in some non-profit to mentor young people more regularly.

The job market in EM is problematic to say the least. The notion that you will enjoy the same degree of flexibility and free time as ER docs of years past is pretty naive. And that is if you can find a job at all. Do FM and be happy.

 

[AMEHigh]

I’m on my phone so I’m not going to type much, but yes continuity is "a thing." I love just chatting with my patients and I usually put relevent social things in my notes like about to graduate from high school and getting X job so I can bring it up next time I see them.

I have no clue if I’m actually "changing their lives" or being a HUGE influence in their lives, but patients request to only be seen by me and I do feel like I "bond" really well with some patients.

I took care of a mom and her 2 teen daughters recently (yay family med) and an issue came up with 1 of the teens and the mom specifically told me the teen felt really comfortable with me and wanted to talk further with me about an issue.

I really love it!

 

[ninjamaterial210]

The job market in EM is problematic to say the least. The notion that you will enjoy the same degree of flexibility and free time as ER docs of years past is pretty naive. And that is if you can find a job at all. Do FM and be happy.

Thanks for the input. Yeah, I was afraid of this... and the escape hatch of urgent care seems worst of all

 

[ninjamaterial210]

FM resident, but have my own small panel of continuity patients for whom I am the PCP during my residency - I am in clinic 2-4 half days/week regardless of rotation, and my patients see me specifically for all their appointments unless for some reason they need to be seen more urgently than I can accommodate on my schedule. Sorry in advance for the length, this is something I am really passionate about

I personally have really enjoyed the continuity of care I get with my patients. No, I wouldn't consider my patients my friends - it's a professional relationship, not a personal one (although some of them I genuinely like and enjoy talking to). But you get to see the impact of the work that you do with them at every appointment, especially with chronic illnesses. I get to see Mike's depression and suicidality basically disappear after getting him into counseling and starting an SSRI. I get to see Barb's A1c go from 15% to 7% with meds and working really hard with her on lifestyle changes and weight loss. I get to help Sarah through a miscarriage of a wanted first pregnancy, see her for a preconception counseling visit a little while later, then celebrate her new pregnancy with her at her first prenatal visit, care for her through her pregnancy, and ultimately deliver her baby, and then take care of the baby too. I get to diagnose Kevin with alcoholic liver disease...then help him quit drinking and watch his liver enzymes go back to normal and a lot of the drinking-related symptoms and problems he was having get better. I get to get Martha's polypharmacy sorted out AND get her chronic pain and severe depression under better control and watch her mental status and ability to care for herself and do the things she enjoys improve significantly. These are all real stories of my own patients.

Obviously there are just as many failures as there are success stories, but I find the success stories bring a lot of meaning and joy to my day. And even the failures can still be meaningful, although sometimes sad...I had a nursing home patient who got COVID, I saw him when he was diagnosed, made the decision to transfer him to our hospital when he got hypoxic, and cared for him on the floor, then stepdown, then in the ICU where he finally passed away. I think me knowing him and his family and his preferences and goals of care made that process a little less difficult for them than it might have been otherwise. I also really enjoy taking care of entire families/multiple generations - I find it gives me a lot more insight into the home, family, and social dynamic that helps me take better care of my patients. And I do think having that relationship/trust/knowledge with your patients also makes them more likely to take your advice when you recommend something.

For relatively young and healthy folks, it's true that you might only see them 1-2x/year. But for patients with ongoing problems and chronic illnesses, I see them once a month or once every couple months, and I really do get to know them. And honestly even the annual checkups can be a great opportunity to build relationships with your patients and make an impact. It's an opportunity to get people to quit smoking, eat healthier, exercise more, get on birth control if they're having sex and not wanting a kid soon, talk someone into getting a COVID vaccine, get their cancer screenings...not everybody will take you up on those opportunities but some will. I actually LOVE wellness visits for this reason.

TL;DR: I do find continuity of care extremely fulfilling, and do find I can make a good bond with some patients in a way that positively affects their care.

Wow this is awesome. Thanks for taking the time to write this out... really a perspective shifter for me. I'm glad to know there is still some serious optimism about the role after doing it for a few years. And go Barb go!

 

[Ironheme]

I have the privilege of learning about not only the patient but their family...They'll update me on so and so that's getting married, new baby. I have gotten presents from patients in the clinic (handmade/homemade goods) because they appreciate me. I have been able to catch cancers BEFORE it's become a massive time bomb. You learn about the human side of medicine and care through generations. I've had a more long term impact in the clinic.

The ER shifts and UC shifts that I've done were massively soul sucking for me. I felt like a Jack-in-the-Box doc with urgent care. Most of the patients could not care less about long term/side effects of meds. They just wanted what they wanted then and there. I appreciated ER shifts more because again, more of an impact - in contrast to clinic, this was more immediate. Catching things that could kill them RIGHT NOW, or getting them to the right place (ICU, med/surg, go home). If you like shift work, like high reward high speed/risk cases, then ER might be the fit for you.

If you HATE working nights, want more flexibility in schedule (part time sound appealing?), and want to see the same patients that you've managed well, then FM might be for you. Perhaps instead of thinking what you absolutely love doing, think about what you absolutely hate doing and that might help with your specialty dilemma. The best thing I've found is experiencing the shifts and flow for yourself though.

 

[ninjamaterial210]

If you HATE working nights, want more flexibility in schedule (part time sound appealing?), and want to see the same patients that you've managed well, then FM might be for you.

3/4 time would be sick, but I was under the impression that in clinic the number of hours offered is inversely proportionate to the amount of grievance you get from your patients wanting more scheduling flexibility. Not sure I'd want that to be the conversation starter every other time I walk in the room.

 

[AMEHigh]

Also, I know there are fellowships with EM but otherwise FM gives you SO SO much more flexibility. We can work in so many work environments, also full time and part-time and per diem pretty easily. I know so many family docs and I would say they all have very different jobs and things they specialize in. Even in a large city where I live I have a few friends that are still practicing very full spectrum doing inpatient, OB, peds and hospitalist work. I have several acquitances who are HIV specialists, also addiction medicine. And quite a few who do gender affirming care which is also very rewarding and where you get to know people well.

Obviously I’m biased but there are few appeals to EM in my opinion if you look at the long term picture. I agree shift work is nice but changing schedules and doing nights gets old really really fast. I’m a night owl and I’m not even "old" and I don’t think my body could handle shifting schedules and working nights anymore. I think it’d be seriously harmful to my body/health.

 

[ninjamaterial210]

Also, I know there are fellowships with EM but otherwise FM gives you SO SO much more flexibility. We can work in so many work environments, also full time and part-time and per diem pretty easily. I know so many family docs and I would say they all have very different jobs and things they specialize in. Even in a large city where I live I have a few friends that are still practicing very full spectrum doing inpatient, OB, peds and hospitalist work. I have several acquitances who are HIV specialists, also addiction medicine. And quite a few who do gender affirming care which is also very rewarding and where you get to know people well.

Obviously I’m biased but there are few appeals to EM in my opinion if you look at the long term picture. I agree shift work is nice but changing schedules and doing nights gets old really really fast. I’m a night owl and I’m not even "old" and I don’t think my body could handle shifting schedules and working nights anymore. I think it’d be seriously harmful to my body/health.

Sounds amazing. You guys are all making a really strong case for FM. But at what point does all the opportunity and optimism get drowned out by paperwork and other nuances of the job? From what I've seen, FM consistently ranks near the bottom of the physician job satisfaction metrics every year.

 

[AMEHigh]

Sounds amazing. You guys are all making a really strong case for FM. But at what point does all the opportunity and optimism get drowned out by paperwork and other nuances of the job? From what I've seen, FM consistently ranks near the bottom of the physician job satisfaction metrics every year.

Well that’s why I said FM is very flexible. I’m not going to give too many details but my job is not one in which I see 35 patients a day and am drowning in paperwork. I mean honestly I wish I were independently wealthy and didn’t have to work at all, but since I want to travel and do fun things I have to work and I really love my job. I never work after my hours doing paperwork. Every once in awhile an important lab value will come in on my day off (I work 4 days a week), so I’ll log in and call or text the patient with the result if needed. Other than that I am not drowning in paperwork and I picked my "specialty" within FM and my job specifically for that reason.

 

[KnuxNole]

I'm not sure what you mean by 1 month at a time, do you mean that you would be in clinic once a month? Continuity clinic in residency is weekly and 2-5 half days(or more) depending on program, year and rotation. In training as you build your patient practice you will follow up with your own patients more in addition to having the chance to visit your patient in the hospital and nursing home(again program varies with this).

To answer your question, long term relationships with your patients and families over the years. You do not get that in EM, unless you count the frequent flyer coming in for his/her 10th DKA. You build relationships with your patients over their health, helping them with their diseases over the years, trust in physicians. As a primary care physician, if someone is sick, usually the first person they will reach out or visit is you. Patients who like you will bring their spouse, parents, kids, grandparents, etc. With end of life care they will want to turn to their own doctor vs. a random hospitalist or random EM doc.

 

[ninjamaterial210]

I'm not sure what you mean by 1 month at a time, do you mean that you would be in clinic once a month?

I’m a med student, so referring to the 1 month FM rotation.

 

[InternistDO]

I bailed on EM as a 4th year when I realized that I'd never be satisfied seeing a patient for a few hours, doing a small workup, and then never seeing them again. Yes, you get to know your coworkers, but you get to know your coworkers in every job--if you're the only doc working at a tiny ER somewhere with a handful of nurses that's a very different social experience than working at a PCP office with 5 other physicians and a fleet of MAs, RNs, and social workers.

It sounds like you want to do FM and see your patients more than once. It sounds like continuity is important to you and making an impact on patients is important to you, and I think it's very frustrating to have that attitude in EM because most of your impact is on critically ill patients but 90% of your ER patients are not in any way critical.

You should not assume that continuity means that you are best friends with your patients or acting as a parental figure for all your pediatric patients--you're their doctor, not their family member. You will form bonds with people and you will see them at both very difficult and very happy moments in their life. Some of them will follow your advice and take their medications and do very well. Some will ignore your advice (and yet keep showing up) and will do poorly (and of course some will ignore you and somehow do great anyway).

Paperwork, eh. It's getting better. There's always things like DPC if you really want to escape the paperwork, and finally it seems that CMS is realizing that good primary care is cheaper and better than fragmented emergency and specialist care and is trying to make that more of a reality.

 

[iforget2]

Well that’s why I said FM is very flexible. I’m not going to give too many details but my job is not one in which I see 35 patients a day and am drowning in paperwork. I mean honestly I wish I were independently wealthy and didn’t have to work at all, but since I want to travel and do fun things I have to work and I really love my job. I never work after my hours doing paperwork. Every once in awhile an important lab value will come in on my day off (I work 4 days a week), so I’ll log in and call or text the patient with the result if needed. Other than that I am not drowning in paperwork and I picked my "specialty" within FM and my job specifically for that reason.

When searching for a job how easy is it for you to ask an employer for things like working 4 days/week or having a cap at 20 patients per day? I wouldn't mind being paid less if it meant a chiller job

 

[VA Hopeful Dr]

When searching for a job how easy is it for you to ask an employer for things like working 4 days/week or having a cap at 20 patients per day? I wouldn't mind being paid less if it meant a chiller job

Depends on the employer, but you could come work with my group tomorrow and get those things.

 

[AMEHigh]

When searching for a job how easy is it for you to ask an employer for things like working 4 days/week or having a cap at 20 patients per day? I wouldn't mind being paid less if it meant a chiller job

I think I said it above but that’s one of the pros about FM it’s very flexible and there are tons and tons of different jobs out there. So if you want to go in to a typical outpatient large employer owned group you might not be able to say to every single one of them I want XYZ conditions, but there are certainly plenty of places that you can work part time and definitely different type of FM jobs that are "chill."

I live in a large city so my pay for what I do is less than if I lived in the Midwest, but for my city I get paid very well/above average to work 4 days a week which includes 1 day of admin since I have a leadership position. I also negotiated extra CME money and extra days off. So working less doesn’t always have to mean making less depending on the position.

 

[AMEHigh]

And as far as paperwork goes, ugh the healthcare system in general is a hot mess. So regardless of your speciality you’re going to have to deal with prior authorizations and other BS that is required due to insurance, the government or your institution. So unfortunately that’s the name of the game in medicine these days. Like I said before I love my job but then some BS will pop up from an insurance company and it’ll make your head explode, but you just learn to deal with and the positive experiences with the patients make it worth it for me.

 

[iforget2]

Depends on the employer, but you could come work with my group tomorrow and get those things.

Aight maybe I'lI hit you up in 5 years 😉

 

[Keona]

When searching for a job how easy is it for you to ask an employer for things like working 4 days/week or having a cap at 20 patients per day? I wouldn't mind being paid less if it meant a chiller job

I work 4 clinic days a week. 1 day is spent with nursing home and that amount varies but I have to see them every 60 days so some months I don’t go to the nursing home at all. I see 17-22 patients a day. Typically it averages out to 17-20 most often. I’m in a physician owned practice and will be a partner soon. My life won’t really change with what I’m doing once I’m a partner but I am so glad I didn’t go to a hospital owned system. Rural family medicine you can pretty much tell them what you want and negotiate a salary that corresponds to what you want.

 

[FrustratedFamDoc]

FM is a neat and frustrating field at the same time. We are merely consultants in our patients care. Navigators. They're the one driving the bus. They really can take it or leave it. They don't have to take what you're trying to sell. The better you make them feel, the more inclined they will be to take your advice. My advice is to learn to love psychiatry and do it well. Done right, your patients will LOVE you. Done wrong, you can help to turn your patients in to unemployed, divorced drug addicts.

I've been out of residency since 2012 and do a traditional 4 1/2 day out pt practice. My average age group is 30-55 but I have many that fall in to the 'older' category. My town is saturated in pediatricians, so bringing in the younger ones in general ain't happening.

Continuity to me means not having to start from scratch every time I see a patient. We can pick up where we left off last time, usually. I let them know from the get go that this is on them. I'm just a guy they see every so often that encourages, gives advice and deals drugs.

 

[deleted87716]

Depends on the employer, but you could come work with my group tomorrow and get those things.

Ditto.