Need help switching residencies- FM to surgery

[VA Hopeful Dr]

I'm always amazed, in this era of increasing training and credentialing, when people advocate less. It would seem to be more prudent to ask a fully trained OB/GYN what they think about FM doing OB.


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Well in fairness, outside of the boonies the OBGYN is always going to think at least slightly about their own practice when asked about that - more obstetrics providers means less busy overall.

Now that said, I think FM doing OB should be for mainly areas where there isn't OB - or the existing OBs are too busy to handle all the pregnant patients. Same with ER - no EM-residency trained doc is going to want to work full time at the middle of nowhere ED that sees 4 patients/day.

Its interesting, you talk to actually practicing family docs who did OB, inpatient, and ER and almost to a person they will admit that they don't really miss those days. Its only the way-overexcited students that feel differently.

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[SansaStarkMD]

That's fair but OBGYN's are going to think that way when taking on any partner regardless of training.

 

[VA Hopeful Dr]

That's fair but OBGYN's are going to think that way when taking on any partner regardless of training.

Yes but they'll worry less about having to rescue another OBGYN from badness than they would an FP, even one with the OB fellowship.

 

[Winged Scapula]

Well in fairness, outside of the boonies the OBGYN is always going to think at least slightly about their own practice when asked about that - more obstetrics providers means less busy overall.

Now that said, I think FM doing OB should be for mainly areas where there isn't OB - or the existing OBs are too busy to handle all the pregnant patients. Same with ER - no EM-residency trained doc is going to want to work full time at the middle of nowhere ED that sees 4 patients/day.

Its interesting, you talk to actually practicing family docs who did OB, inpatient, and ER and almost to a person they will admit that they don't really miss those days. Its only the way-overexcited students that feel differently.

Fair enough and perhaps I was being naïve to think that that would be some OB/GYN's who would look at it from a safety standpoint and not be so preservationist as the only think about their bottom line.


Therefore while I agree that it's reasonable to train FM to deliver babies where no OB care is otherwise available, I'm not convinced that the OP sees it that way. It's my sense is that she thinks they should play a bigger role with less training. That's my issue.


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[VA Hopeful Dr]

Fair enough and perhaps I was being naïve to think that that would be some OB/GYN's who would look at it from a safety standpoint and not be so preservationist as the only think about their bottom line.


Therefore while I agree that it's reasonable to train FM to deliver babies where no OB care is otherwise available, I'm not convinced that the OP sees it that way. It's my sense is that she thinks they should play a bigger role with less training. That's my issue.


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And that's fair, and I certainly don't think the bottom line is the only (or even majority) factor - we can't ignore it completely. Safety certainly plays a role, but if that was the only part then no OB would agree to serve as back up for the midwives.

 

[SansaStarkMD]

Just to clarify, if I were to go the FM OB route, I would be delivering my own patients, not joining an OB group with their back up. If I messed up bowel or bladder I would call general surgery just like the OBGYN's.

 

[drsender]

Just to clarify, the OP will not be doing an OB fellowship in the hopes of finding another route to the OR.

After ~six months of residency in a small community hospital unopposed FM residency, I have to disagree with SansaStarkMD's views on FM training. I was also attracted by the possibility of working in the clinic, hospitalist shifts, small ER's, possibility of OB, etc. The reality is, fewer and fewer docs are doing this. It is exceedingly difficult to be trained well enough in all these areas in 3 years to be competent across all those domains. Even getting enough c-sections around all of your primary training is very difficult, let alone somehow getting enough OR time to gain broader surgical competence.

The push toward further specialization is not entirely political. There is a reason that entire residencies are devoted to OB/Gyn, ER, etc. I would strongly encourage you to consider choosing a residency if you will not be happy with outpatient family medicine. You will find that it is possible to do other things with FM training, though there is significant resistance from hospitals and other doctors. This may seem trivial now, but it is difficult to be in a position where you are treated poorly by your peers who have more training than you. Furthermore, there is a strong push by health systems to be time-efficient and meet quality measures, which is extremely difficult if you are trying to work in multiple arenas simultaneously. This is made more difficult by the increasing administrative burden of working with different EMR's.

You will not have a hard time finding FM doctors and residents who will validate your idea of what family medicine can be. I would challenge you to find recent grads who are doing exactly what you imagine yourself doing. Things in medicine are changing in ways that put both official and unofficial barriers to what can be done by family medicine doctors. I convinced myself that family medicine is something it is not. There are a lot of people who really enjoy it and make a huge impact in people's lives. You might be one of those. However, I would strongly encourage you to make sure you have a realistic idea of what you are signing up for. The comments above reflect a lot of experience that should not be disregarded. Information you are putting together from family medicine programs that are trying to recruit you is going to be quite biased.

I hope that my situation will serve as a cautionary tale. Though given your response to the above comments, I'm sure you will find ample reasons to disregard my advice as well

 

[drsender]

Although this thread has moved on, I'll go ahead and share some updates. I was able to get an interview at a surgical residency through contacts with school, so I told my program director I was looking at options. He has been extremely supportive and offered to hold my position in case I didn't get a position, which is far more than I could have asked.

My interview went really well and I have another coming up. I think my chances of matching this year are still pretty shaky, but I am really glad I went for it. I have gotten mixed opinions from program directors about preliminary positions, so I'm still on the fence about what I will do in the soap if I don't match.

 

[SansaStarkMD]

Just to clarify, the OP will not be doing an OB fellowship in the hopes of finding another route to the OR.

After ~six months of residency in a small community hospital unopposed FM residency, I have to disagree with SansaStarkMD's views on FM training. I was also attracted by the possibility of working in the clinic, hospitalist shifts, small ER's, possibility of OB, etc. The reality is, fewer and fewer docs are doing this. It is exceedingly difficult to be trained well enough in all these areas in 3 years to be competent across all those domains. Even getting enough c-sections around all of your primary training is very difficult, let alone somehow getting enough OR time to gain broader surgical competence.

The push toward further specialization is not entirely political. There is a reason that entire residencies are devoted to OB/Gyn, ER, etc. I would strongly encourage you to consider choosing a residency if you will not be happy with outpatient family medicine. You will find that it is possible to do other things with FM training, though there is significant resistance from hospitals and other doctors. This may seem trivial now, but it is difficult to be in a position where you are treated poorly by your peers who have more training than you. Furthermore, there is a strong push by health systems to be time-efficient and meet quality measures, which is extremely difficult if you are trying to work in multiple arenas simultaneously. This is made more difficult by the increasing administrative burden of working with different EMR's.

You will not have a hard time finding FM doctors and residents who will validate your idea of what family medicine can be. I would challenge you to find recent grads who are doing exactly what you imagine yourself doing. Things in medicine are changing in ways that put both official and unofficial barriers to what can be done by family medicine doctors. I convinced myself that family medicine is something it is not. There are a lot of people who really enjoy it and make a huge impact in people's lives. You might be one of those. However, I would strongly encourage you to make sure you have a realistic idea of what you are signing up for. The comments above reflect a lot of experience that should not be disregarded. Information you are putting together from family medicine programs that are trying to recruit you is going to be quite biased.

I hope that my situation will serve as a cautionary tale. Though given your response to the above comments, I'm sure you will find ample reasons to disregard my advice as well

No, this is a solid post. I really appreciate it. I like the idea of what family medicine currently is as well as what it will eventually be (outpatient/inpatient medicine). Because of what FM will eventually be, I've decided to pursue a combined residency that includes family medicine. My goal is to have a regular part time clinic schedule (satisfaction, joy, broad knowledge base), with my specialized niche on the side ($$$, job security).

 

[JustPlainBill]

Yes but they'll worry less about having to rescue another OBGYN from badness than they would an FP, even one with the OB fellowship.

Yep -- we used to have delivery privileges at one particular hospital where I did my residency -- even had an FM attending who had done an OB fellowship who did all of the OB/Gyn training for us in terms of continuity deliveries --- whenever we went in to deliver, I noticed the OB residents included our patients on their monitors and one night I asked why....and was told after much probing that they didn't trust us and were told by their attendings to be ready to bail us out if things got dicey, even to the point of taking over without permission if needed. There was always a BC OB attending on the L&D deck, usually asleep unless there was an emergency. We had a few during my tenure and were regularly bailed out by OB --- The FM faculty was treated as a first assist and never did any of their own CSections. Too much liability there for the institution.

Now, at JPS, the FM residency ran that place, including the L&D deck - -something about the politics of the institution. There was an FM attending who had several hundred CSections under their belt -- had joined the faculty from a small residency in the boondocks of WV --- I recall one night seeing this guy show up in slacks and sport coat, walk into the locker room, change into scrubs, scrub in and go do a CSection with an FM resident tagging along as a first assist to get training.

it can be done, but you better go to a place like JPS or UT Tyler to get the training or do both an FM residency with heavy emphasis on ER and an OB/Gyn residency --- your standard community FM residency just ain't going to equip you for what you're trying to do ---

and I would tell you, it really loses it's appeal. My recommendation: Get your 40 deliveries and then see how you feel about being up 72 hours in a row when 3 deliveries come in back to back -- it gets old, quickly.

 

[Smurfette]

I have a very good friend who is an FP who did a 1 yr OB fellowship and does c-sections. We have discussed this a lot between us, and I have confidence that it is being done safely in her environment. However, it is LIMITED SCOPE and it is a rural practice. She does not think she is a surgeon and is very conscientious as to what she is and is not trained to do. Because women labor in her hospital, they need the capability of doing c-sections because there is not time to transfer without risk to mom and baby. They will do scheduled c-sections in low risk patients. Low risk only. They also have a general surgeon available (who also rotates with c-section call) in case of any surgical problems (in her years there, I don't think the GS has had to bail anyone out---she would have told me). There is a low threshhold for transferring patients and have an OB group in the nearest large city available by phone to accept transfers and help guide management. The OBs will also review cases for them if there is a labor & delivery-related complication with mom or baby. My friend had a large # of sections (can't remember exact #) from her OB fellowship on top of a lot from her fairly OB heavy (and unopposed) residency. Anyone with new c/s privileges is mentored/proctored along until they have been signed off on by everyone else who has the privileges. FPs there do not do anything surgical other than c/s and tubals (at the time of c/s), and only a few in the group do them in order to make sure the ones that do have sufficient volume to maintain profiency.

"Full OB privileges" are NOT what these FPs are doing. Full OB privileges involves far more than doing c-sections. If the OP wants to do everything an OB does (or almost everything), the OP needs to do an OB residency. If the OP wants to do reproductive health, that's OB. If the OP wants to work in a rural environment as an FP (caring for men, women, and children, managing HTN and cholesterol and everything else a PCP does) and also deliver babies, then an FP residency followed by a 1 year OB fellowship may make sense.

 

[gutonc]

Just to clarify, the OP will not be doing an OB fellowship in the hopes of finding another route to the OR.
...
I hope that my situation will serve as a cautionary tale. Though given your response to the above comments, I'm sure you will find ample reasons to disregard my advice as well

You know, I was just about to close this thread since it had gone so far off the rails. Thanks for bringing it back and updating us. Good luck.

 

[drsender]

Update: Matched in categorical general surgery !!!! I matched in the third of 3 categorical spots I ranked, so it easily could have gone the other way. Even if I had ended up in a prelim spot, I would be glad that I went for it. I'm super happy about the program I'm going to and appreciate all the advice!

 

[Gastrapathy]

Congrats!

 

[bannie22]

Congratulations. Its always very heartwarming to see people reach their goals in spite of all the barriers. Well done!

 

[AdmiralChz]

That's great, way to stick to your guns OP! And double thanks for not allowing another poster (now banned!) to hijack the thread/story.

 

[okokok]

Congrats and thanks for sharing your journey & especially updates, very interesting!

Update: Matched in categorical general surgery !!!! I matched in the third of 3 categorical spots I ranked, so it easily could have gone the other way. Even if I had ended up in a prelim spot, I would be glad that I went for it. I'm super happy about the program I'm going to and appreciate all the advice!

 

[Winged Scapula]

Yeah! Congrats and welcome!

 

[northernpsy]

I was wondering what happened to OP. Glad everything worked out for ya.

 

[kemper6036]

How much experience to they get in abdominal procedures? What happens when they run into some adhesions from prior surgeries and make an enterotomy? I'd say 200+ c-sections is not enough to adequately do surgery. There's a reason that OBGYN and General Surgery are 4 and 5 year residencies. You will also have some issues with jobs. There will be pushback from boarded OBGYN for providing these services at the same hospital. There will be alot of politics involved in this. You're likely to end up mostly in rural locations for the most part.

As for magical training in magical locations? There's something to do with experience and practice. As I said earlier, you just don't get that in a 1-year fellowship. Just because people are doing it doesn't make it a good thing.

they call a general surgeon

 

[OTOSwap]

I used to love procedures until I realized how much time they take out of your day.

good point. the OR can be an extremely inefficient place. Delays in cases, delays getting out of the room, nursing checklists, pre-op checklists. That "I love the OR" was something you experience as a student when everything was new and you got to see medicine happening before your eyes versus rounding all day. However, most in surgery will tell you it is not worth it. This guy ate or drank, case is delayed now your operating case is starting at 8/9pm.

Calls in the middle of the night because the patient did XYZ and is bleeding. Calls in middle of the night when you are not on call because a patient you operated on 2 years ago is in the hospital again but since you operated on them you get called. There is a lot more to it then doing a case in the OR. Think long and hard before you make a bad decision. Lot's of fields do procedures and they get the great benefit of avoiding the awful inefficiency of the hospital operating room.

 

[Winged Scapula]

good point. the OR can be an extremely inefficient place. Delays in cases, delays getting out of the room, nursing checklists, pre-op checklists. That "I love the OR" was something you experience as a student when everything was new and you got to see medicine happening before your eyes versus rounding all day. However, most in surgery will tell you it is not worth it. This guy ate or drank, case is delayed now your operating case is starting at 8/9pm.

Calls in the middle of the night because the patient did XYZ and is bleeding. Calls in middle of the night when you are not on call because a patient you operated on 2 years ago is in the hospital again but since you operated on them you get called. There is a lot more to it then doing a case in the OR. Think long and hard before you make a bad decision. Lot's of fields do procedures and they get the great benefit of avoiding the awful inefficiency of the hospital operating room.

This is an extremely negative and nonrepresentative experience. I'm very happy with my choice even many years in , as are most of my friends and colleagues, and look forward to days in the OR much more than days in the office. The ones who are not happy are those who are chronically unhappy negative type of personalities who find fault in everything.

It's true that the OR is inefficient but there are tons of surgery centers around that want your business and will do whatever they can to get it including making things more efficient.

 

[AdmiralChz]

Not all practices and operating rooms are as inefficient as your garden-variety academic center.

Surgery absolutely isn't for everyone, but some people really enjoy the finer, technical aspects of it. I've got some great friends "across the curtain" who genuinely get satisfaction from the challenge and the work. Sure the hours and the duration of training is a bit of a drag, but the field takes dedication.