Pros and Cons of Family Medicine

[johndoe44]

I thought this would make for an interesting discussion. I am currently interviewing for both Internal and family medicine residency positions and since I have completed an internship in internal medicine already, I am now just learning about family medicine and the scope of practice.

While I am still likely to rank Internal programs, lately I am not so sure. I have actually been thinking a lot about the many interviews that I have been on and I wanted to throw out some observation and see if others could elaborate further or provide their own personal experiences in either field.

So, really the reason I went into internal medicine in the first place was because I really enjoyed being able to speak with patients, love pharmacology and also enjoy a bit of clinic work. I am also fascinated with cardiology and was working on case reports and other personal projects. However, now that I am going through this process a second time, I have had time to really research the process of getting a medical fellowship in cardiology; which is extremely difficult. None of the other subspecialties interests me (just a personal note) at all and I feel many of the other subspecialties do not offer much benefit as most general internists can treat those patients (Diabetes, hypothyroidism, Autoimmune dz, asthma, COPD, HTN, infections, etc). Do not misinterpret this as me saying we do not need specialists; of course we do I am just saying that it seems to me that what most specialists see as their "bread and butter" most internists can offer those same services. So, if I were not going into a specialty that I loved like cardiology I would likely not want to go into any of the other branches.

This has allowed me to reflect a lot on the role of family medicine doctors and why I have always been so "against" becoming one. Honestly, I cannot fully explain why I feel this way but I know this is a general thought among many entering the field. The encounters I have had with FM programs have been above and beyond my own expectations. Family docs seem to be a little more "down to earth" and are not overly academic but still keep up with changing guidelines and medications. I also learned that there are quite a bit of family doctors who are working in rural hospitals as emergency docs, I met a few who are doing colonoscopies and EGD's, surprisingly many of them are doing surgery and C-sections on a daily basis all while having a practice and teaching positions. I even read about the compensation and it seems that a family doc in a clinic setting makes around the same as an internist in a clinical setting.

So my question is, what am I missing? The lifestyle and people in family seem great and they all seem to be quite happy with their jobs and have a lot of free time to spend with their own families. I guess my question is, why are there not more people going into family? If your going to be a hospitalist or work in an outpatient clinic, why not just train as a family medicine resident instead of internal medicine?

Just a thought. Any and all opinions would be appreciated.

---

Members don't see this ad.

 

[dyeguy21]

A lot of people don't want to stay in rural areas and deal with mostly HTN and diabetes. It's great to be a person's doctor, but some feel that saving someone's life in an ICU setting or a trauma bay is more rewarding.

In the big city centers, there is also a general push to have PA's and NP's take a larger role in patient care (Patient Centered Medical Home). This leads more and more to having the physician become a manager of other providers of care, rather than the patient's primary point of contact, something for which most got into the profession.

Essentially, it seems that a lot of people feel that pure primary care is becoming an NP and PA game, while going to MD/DO means that you either become a hospitalist or specialize. Thus, the new model of care is NP/PA primary who either refers to a specialist or admits to a hospitalist who then consults specialty when needed.

 

[organdonor]

I enjoy family medicine as we have the broadest scope of practice of any specialty. There is no other field of medicine where you can see children, adults, pregnant women, deliver babies, do colonoscopies, do C sections, work in hospitals, work in clinics, ER's and anything in between. I enjoy knowing that I've got the knowledge base to take care of almost any patient that could walk in the door in any town in America. In Family Medicine you can pretty much work as hard as you want to or be part time, salaries will vary accordingly.

Why are you repeating residency?

 

[organdonor]

I enjoy family medicine as we have the broadest scope of practice of any specialty. There is no other field of medicine where you can see children, adults, pregnant women, deliver babies, do colonoscopies, do C sections, work in hospitals, work in clinics, ER's and anything in between. I enjoy knowing that I've got the knowledge base to take care of almost any patient that could walk in the door in any town in America. In Family Medicine you can pretty much work as hard as you want to or be part time, salaries will vary accordingly.

Why are you repeating residency?

Cons would be that some will look down in you for being in family medicine, and that some think we can be replaced by mid levels (we can't) and the compensation can be lower ( this is highly dependent on how hard you want to work) than more procedure oriented fields.

 

[mercaptovizadeh]

From my perspective, as someone going in med-peds, the major disadvantage of FM is that the training is too superficial, they do not get the respect they merit from their colleagues, there's no potential for subspecialization, and the pay is inadequate.

For FM to be an attractive model for most medical students, the training would have to be on the order of 7-8+ years (2 years IM, 2 years peds, and 3-4 years to cover ob/gyn and general surgery) and the pay would have to be much better, i.e. 350-400K+.

 

[Beacopp665]

From my perspective, as someone going in med-peds, the major disadvantage of FM is that the training is too superficial, they do not get the respect they merit from their colleagues, there's no potential for subspecialization, and the pay is inadequate.

For FM to be an attractive model for most medical students, the training would have to be on the order of 7-8+ years (2 years IM, 2 years peds, and 3-4 years to cover ob/gyn and general surgery) and the pay would have to be much better, i.e. 350-400K+.

Sad as it is to say I know a lot of people who didn't apply FM that truly enjoyed it because of a general lack of respect and stigma that goes with FM (you got a bad board score etc.) They ended up in IM, Peds, OB, even Med/Peds but it's a shame they had to cut out parts of the field they liked just because of the issues alluded to in the above post.

 

[Bacchus]

Caring what others think about your specialty is going to cause a lot of worrying you don't need. Apply to the specialty you like. While the scope of specialization isn't as varied, FM does offer fellowships in sports med, geriatrics, palliative care, obstetrics and OMM/OMT (osteopathic). The field is rather broad so you can definitely find what you want to do and tailor residency that way.

 

[Mad Jack]

From my perspective, as someone going in med-peds, the major disadvantage of FM is that the training is too superficial, they do not get the respect they merit from their colleagues, there's no potential for subspecialization, and the pay is inadequate.

For FM to be an attractive model for most medical students, the training would have to be on the order of 7-8+ years (2 years IM, 2 years peds, and 3-4 years to cover ob/gyn and general surgery) and the pay would have to be much better, i.e. 350-400K+.

You could never keep all of those skills sharp at once, it's just not possible. You'd have to lean toward being the OB guy of your group, or the gen surg guy for your group, and then you'd lose the OB skills or the peds skills or whatever you chose to neglect. That's sort of the problem with being a generalist- you can't master everything, and if you choose to push too hard toward mastering one thing, you lose your skills in other areas, thus making you more of a specialist than a generalist.

 

[ThoracicGuy]

I thought this would make for an interesting discussion. I am currently interviewing for both Internal and family medicine residency positions and since I have completed an internship in internal medicine already, I am now just learning about family medicine and the scope of practice.

While I am still likely to rank Internal programs, lately I am not so sure. I have actually been thinking a lot about the many interviews that I have been on and I wanted to throw out some observation and see if others could elaborate further or provide their own personal experiences in either field.

So, really the reason I went into internal medicine in the first place was because I really enjoyed being able to speak with patients, love pharmacology and also enjoy a bit of clinic work. I am also fascinated with cardiology and was working on case reports and other personal projects. However, now that I am going through this process a second time, I have had time to really research the process of getting a medical fellowship in cardiology; which is extremely difficult. None of the other subspecialties interests me (just a personal note) at all and I feel many of the other subspecialties do not offer much benefit as most general internists can treat those patients (Diabetes, hypothyroidism, Autoimmune dz, asthma, COPD, HTN, infections, etc). Do not misinterpret this as me saying we do not need specialists; of course we do I am just saying that it seems to me that what most specialists see as their "bread and butter" most internists can offer those same services. So, if I were not going into a specialty that I loved like cardiology I would likely not want to go into any of the other branches.

This has allowed me to reflect a lot on the role of family medicine doctors and why I have always been so "against" becoming one. Honestly, I cannot fully explain why I feel this way but I know this is a general thought among many entering the field. The encounters I have had with FM programs have been above and beyond my own expectations. Family docs seem to be a little more "down to earth" and are not overly academic but still keep up with changing guidelines and medications. I also learned that there are quite a bit of family doctors who are working in rural hospitals as emergency docs, I met a few who are doing colonoscopies and EGD's, surprisingly many of them are doing surgery and C-sections on a daily basis all while having a practice and teaching positions. I even read about the compensation and it seems that a family doc in a clinic setting makes around the same as an internist in a clinical setting.

So my question is, what am I missing? The lifestyle and people in family seem great and they all seem to be quite happy with their jobs and have a lot of free time to spend with their own families. I guess my question is, why are there not more people going into family? If your going to be a hospitalist or work in an outpatient clinic, why not just train as a family medicine resident instead of internal medicine?

Just a thought. Any and all opinions would be appreciated.

Given your situation with your resignation for the prior residency program, I wouldn't limit your chances on matching...

That said, most of the FM docs in my area are clinic based only. The hospitalists are all IM trained.

 

[johndoe44]

Given your situation with your resignation for the prior residency program, I wouldn't limit your chances on matching...

That said, most of the FM docs in my area are clinic based only. The hospitalists are all IM trained.

I agree. I am definitely not limiting my options and I fully intend to rank many programs and I have had enough that I feel optimistic I will land a nice spot somewhere. What my thoughts have been lately though is should I rank a really great family program I love before other internal medicine programs I have interviewed at? After thinking about this, I am actually very excited about several of the family programs I have had the opportunity to visit with.

I agree that there are many PAs and NP's who do perform primary care roles and likely will expand into other areas, what I have been seeing is a more "team" approach with the family docs in a supervisory role but still providing care and seeing patients along with PA's and NP's; which I think is great and the PA's that I have met have a tremendous amount of respect for the MD/DOs they work with and the relationship seems more symbiotic than anything else.

All of that being said, I just feel that I need to rank my IM programs high? I think it is my pride but I honestly think I would be happier as a family medicine doc and maybe this is what I need to do? I know they don't make 300+ and they work hard, but I think the balanced lifestyle and the relatively "good" compensation 180-220K, that sounds good to me.

Sad as it is to say I know a lot of people who didn't apply FM that truly enjoyed it because of a general lack of respect and stigma that goes with FM (you got a bad board score etc.) They ended up in IM, Peds, OB, even Med/Peds but it's a shame they had to cut out parts of the field they liked just because of the issues alluded to in the above post.

I completely agree and this was my exact experience. I loved my family rotation and also loved my internal rotation but when I had to choose between the two I easily chose IM. Again, I am really starting to rethink all of that. I just want to be happy and comfortable and enjoy my work and I think FM offers that opportunity. I just was interested to hear everyone's opinions.

 

[mercaptovizadeh]

I agree. I am definitely not limiting my options and I fully intend to rank many programs and I have had enough that I feel optimistic I will land a nice spot somewhere. What my thoughts have been lately though is should I rank a really great family program I love before other internal medicine programs I have interviewed at? After thinking about this, I am actually very excited about several of the family programs I have had the opportunity to visit with.

I agree that there are many PAs and NP's who do perform primary care roles and likely will expand into other areas, what I have been seeing is a more "team" approach with the family docs in a supervisory role but still providing care and seeing patients along with PA's and NP's; which I think is great and the PA's that I have met have a tremendous amount of respect for the MD/DOs they work with and the relationship seems more symbiotic than anything else.

All of that being said, I just feel that I need to rank my IM programs high? I think it is my pride but I honestly think I would be happier as a family medicine doc and maybe this is what I need to do? I know they don't make 300+ and they work hard, but I think the balanced lifestyle and the relatively "good" compensation 180-220K, that sounds good to me.



I completely agree and this was my exact experience. I loved my family rotation and also loved my internal rotation but when I had to choose between the two I easily chose IM. Again, I am really starting to rethink all of that. I just want to be happy and comfortable and enjoy my work and I think FM offers that opportunity. I just was interested to hear everyone's opinions.

I think it's a mistake to do this.

FM is by and large in most locations outpatient adult medicine with a smattering of peds. The pediatrics training is superficial, as anyone in IM-peds residency can tell you, there is no comparison between 2 full years of pediatrics including ED, PICU, and NICU and numerous floor months and the 4-6 months of peds done in FM residency. The ob/gyn training and future practice model is also completely haphazard. There are still some FMs who do deliveries and even C sections but nowadays most avoid it because of the liability. And the pregnancy care is limited pretty much to benign well controlled pregnancies - just like midwives. Anything slightly out of the ordinary (I am talking gestational diabetes or chronic hypertension - not to mention eclampsia or HELLP or acute fatty liver...) and that woman is going straight to ob.

With FM your fellowships are severely restricted. If you have the opportunity to do IM instead, I advise you take it, since you will have many more opportunities down the line open to you.

 

[styphon]

I think it's a mistake to do this.

FM is by and large in most locations outpatient adult medicine with a smattering of peds. The pediatrics training is superficial, as anyone in IM-peds residency can tell you, there is no comparison between 2 full years of pediatrics including ED, PICU, and NICU and numerous floor months and the 4-6 months of peds done in FM residency. The ob/gyn training and future practice model is also completely haphazard. There are still some FMs who do deliveries and even C sections but nowadays most avoid it because of the liability. And the pregnancy care is limited pretty much to benign well controlled pregnancies - just like midwives. Anything slightly out of the ordinary (I am talking gestational diabetes or chronic hypertension - not to mention eclampsia or HELLP or acute fatty liver...) and that woman is going straight to ob.

With FM your fellowships are severely restricted. If you have the opportunity to do IM instead, I advise you take it, since you will have many more opportunities down the line open to you.

I disagree completely.

I practice as a Family medicine doctor in a rural area (but we are 1 hour from a major city). My previous job was Inpt, OB, and peds. My current job is outpt - but I see peds and OB but I currently do not deliver as our administration has been replaced.. I do not refer "anything slightly out of the ordinary" during pregnancy - I have a high level of comfort with diabetes, even during pregnancy.

Jobs I interviewed at - mostly rural areas, even in high density states - have FM do deliveries with an OB back up for c-sections. In inner city clinics - they also had FM delivery, but it was usually clusted - multiple FM's who cover each other w/ OB back up for c-sections. I can think of one innercity clinic staffed ONLY with FM which manage VBACs and inductions and use the in hospital OB for c/sections. in the midwest it leans toward Family medicine - there is a high level of FM who do c/sections and do not have OB backup.

I do agree that FM has restricted fellowships - none are boarded, BUT they are great if you want to be a FM with additional skills. Specifically sports medicine and OB/high risk(which usually teaches C-sections) and HIV(rare, found in large cities).

I also have issue with the "lack of respect". I think this is most common among medical students and residents - AKA people who have never practiced independently and if you are concerned with what 25 y/o med students think of you, there . Specialists DEPEND on IM/FM for referrals and hence are quite friendly. I am on great terms with specific cardiologists, nephrologists, hematologists, etc - and they get my referrals.

I also have issue with the "low salary". If you want to maximize your income and want big bucks - of course you avoid FM (along with peds, psych, general IM), but that is obvious. If you are an American graduating from an American Medical School you should not have a problem getting at 175+ job your first year. If you are a FMG or have "black marks" or "red flags" - you may have to settle for 150$.

 

[MedicineMan99]

I disagree completely.

I practice as a Family medicine doctor in a rural area (but we are 1 hour from a major city). My previous job was Inpt, OB, and peds. My current job is outpt - but I see peds and OB but I currently do not deliver as our administration has been replaced.. I do not refer "anything slightly out of the ordinary" during pregnancy - I have a high level of comfort with diabetes, even during pregnancy.

Jobs I interviewed at - mostly rural areas, even in high density states - have FM do deliveries with an OB back up for c-sections. In inner city clinics - they also had FM delivery, but it was usually clusted - multiple FM's who cover each other w/ OB back up for c-sections. I can think of one innercity clinic staffed ONLY with FM which manage VBACs and inductions and use the in hospital OB for c/sections. in the midwest it leans toward Family medicine - there is a high level of FM who do c/sections and do not have OB backup.

I do agree that FM has restricted fellowships - none are boarded, BUT they are great if you want to be a FM with additional skills. Specifically sports medicine and OB/high risk(which usually teaches C-sections) and HIV(rare, found in large cities).

I also have issue with the "lack of respect". I think this is most common among medical students and residents - AKA people who have never practiced independently and if you are concerned with what 25 y/o med students think of you, there . Specialists DEPEND on IM/FM for referrals and hence are quite friendly. I am on great terms with specific cardiologists, nephrologists, hematologists, etc - and they get my referrals.

I also have issue with the "low salary". If you want to maximize your income and want big bucks - of course you avoid FM (along with peds, psych, general IM), but that is obvious. If you are an American graduating from an American Medical School you should not have a problem getting at 175+ job your first year. If you are a FMG or have "black marks" or "red flags" - you may have to settle for 150$.

+1

Family medicine is the way to go. We can basically get training to do anything we want (from circumcisions to colonoscopies to C-sections to appendectomies to cosmetic procedures). We have more comprehensive training than any doctors in America in our residencies. Many doctors go through a lot of excess training to try and piece together the training a family doctor gets (combined IM/ER residencies or IM/Peds residencies come to mind). We can also get board specializations in sleep medicine, FP OB, sports medicine, adolescent medicine, palliative care, etc. just to name a few. And you can practice in any setting in the country- everywhere from a rural ER to an urban urgent care.

As a family doctor, you always have an excuse to know something or learn a procedure. You never have to say, "Oh, that's not my specialty- I need to refer you out for that."

Oh and lack of respect? That comes from ignorant pre-meds and ignorant residents. Lack of income? If you set up your practice right, you can earn as much or more money than any specialist.

 

[michaelrack]

I do agree that FM has restricted fellowships - none are boarded, BUT they are great if you want to be a FM with additional skills. $.

FM is eligible for boarded sleep fellowships

 

[Baller MD]

+1

Family medicine is the way to go. We can basically get training to do anything we want (from circumcisions to colonoscopies to C-sections to appendectomies to cosmetic procedures). We have more comprehensive training than any doctors in America in our residencies. Many doctors go through a lot of excess training to try and piece together the training a family doctor gets (combined IM/ER residencies or IM/Peds residencies come to mind). We can also get board specializations in sleep medicine, FP OB, sports medicine, adolescent medicine, palliative care, etc. just to name a few. And you can practice in any setting in the country- everywhere from a rural ER to an urban urgent care.

As a family doctor, you always have an excuse to know something or learn a procedure. You never have to say, "Oh, that's not my specialty- I need to refer you out for that."

Oh and lack of respect? That comes from ignorant pre-meds and ignorant residents. Lack of income? If you set up your practice right, you can earn as much or more money than any specialist.

But who would go to a family doc for colonoscopies instead of a GI doc? Genuinely curious.

 

[MedicineMan99]

But who would go to a family doc for colonoscopies instead of a GI doc? Genuinely curious.

In very rural communities, it's a common occurrence.

 

[evilbooyaa]

But who would go to a family doc for colonoscopies instead of a GI doc? Genuinely curious.

It's usually a matter of patient travel time and convenience to go to a FM for a colonoscopy (or a C-section).

A FM doc isn't going to be doing either of those except far in the rural boonies. If you don't see yourself as someone who is willing to live quite far from the nearest city, then sure, it's a possibility. I'm not sure who lives 1 hour outside a city (a major city?) and is doing C-sections and Colonoscopies as a FM. How much training do FM docs receive in that during residency? I can't imagine the number of procedures or hours is anywhere near what an OB/Gyn and GI, respectively, put into the mentioned procedures.

I would recommend FM to those who are primarily outpatient focused, enjoy long-lasting relationships with their patients, treat an entire family (dad, mom before and after her kids, her kids, her kids' kids, etc.), and in the vein above, like to see adults, peds, and OB. It's OK if you prefer one or two of those groups over the other one, as you can likely find a job that lets you somewhat specialize (focus on peds and OB and leave general adult medicine for someone else, for example).

I consider IM/Peds combined to be for someone who wants to work in an inpatient setting in a major metropolitan (or suburban) area. I know FM docs can be hospitalists (and even run the ED) in rural areas, but that job opportunity is trending down (at least I'd imagine) as more EM docs graduate. The only FP residents I knew from my FM rotation who became hospitalists became nocturnists (n = 2, the other 6-8 I met became OP-focused primary care physicians)

Maybe things are done differently west of the mississippi, but I don't think a FM doc doing C-sections, high-risk OB (more complicated than gestation diabetes, IMO), and/or colonoscopies is as common as the previous posters seem to represent it.

 

[MedicineMan99]

It's usually a matter of patient travel time and convenience to go to a FM for a colonoscopy (or a C-section).

A FM doc isn't going to be doing either of those except far in the rural boonies. If you don't see yourself as someone who is willing to live quite far from the nearest city, then sure, it's a possibility. I'm not sure who lives 1 hour outside a city (a major city?) and is doing C-sections and Colonoscopies as a FM. How much training do FM docs receive in that during residency? I can't imagine the number of procedures or hours is anywhere near what an OB/Gyn and GI, respectively, put into the mentioned procedures.

I would recommend FM to those who are primarily outpatient focused, enjoy long-lasting relationships with their patients, treat an entire family (dad, mom before and after her kids, her kids, her kids' kids, etc.), and in the vein above, like to see adults, peds, and OB. It's OK if you prefer one or two of those groups over the other one, as you can likely find a job that lets you somewhat specialize (focus on peds and OB and leave general adult medicine for someone else, for example).

I consider IM/Peds combined to be for someone who wants to work in an inpatient setting in a major metropolitan (or suburban) area. I know FM docs can be hospitalists (and even run the ED) in rural areas, but that job opportunity is trending down (at least I'd imagine) as more EM docs graduate. The only FP residents I knew from my FM rotation who became hospitalists became nocturnists (n = 2, the other 6-8 I met became OP-focused primary care physicians)

Maybe things are done differently west of the mississippi, but I don't think a FM doc doing C-sections, high-risk OB (more complicated than gestation diabetes, IMO), and/or colonoscopies is as common as the previous posters seem to represent it.

This is very region-dependent.

Family medicine residents can learn any of these procedures in residency, but it depends. For instance, in the Alaska residency it's a big part of the curriculum. However, in urban residencies, you don't learn how to do appendectomies unless you seek it out in an elective. How do FPs get good at C-sections? Simple- they have OB fellowships for Family Physicians. This enables them to take care of high-risk OB patients and perform C-sections. Many Family Doctors do this even in urban communities- although the easiest way to do this is if you are a Family Medicine faculty member.

I live in urban Chicago, there are lots of Family Doctors here and lots of Family Doctors who work as hospitalists. I'd argue Family Doctors are even better prepared than Internists to do inpatient medicine because we can see the big picture and we understand how these patients will be managed as an outpatient. (Internal medicine residents do not get as much outpatient experience as family medicine residents do).

As I've been in the job market all over the country, in both urban and rural areas, I can say that no employer has ever cared that I'm a Family Physician. No one has ever said, "Oh, we only hire ER doctors" or "We only hire internists". In fact, many have loved the fact that as an Urgent Care physician, I can see infants and OB patients. Hospitals also appreciate this. The jobs you get as hospitalists, UC doctors, or outpatient primary care doctors depends on you as a person and your personal experience- not just on your residency.

 

[galactus]

FM docs can do fellowships that have a board exam (sports med, geriatrics, adolescent, hospice, sleep). What I tell med students is that FM fellowships deal with more of subset of a population, instead of an organ system.
Half my residency class became hospitalists. 2 of them do c-sections and ER coverage. Half the ER staff I did residency in were trained in FM. Everyone in my residency class (except me) does inpatient medicine. I ended up doing sports and I love it, but I still have a traditional family practice. It's more versatile than people think!

In the end, do whatever specialty makes you happy! If it's FM, then great! If you feel IM is where your true passion is (or if you feel like doing a subspecialty), then go for it

 

[ThoracicGuy]

This is very region-dependent.

Family medicine residents can learn any of these procedures in residency, but it depends. For instance, in the Alaska residency it's a big part of the curriculum. However, in urban residencies, you don't learn how to do appendectomies unless you seek it out in an elective. How do FPs get good at C-sections? Simple- they have OB fellowships for Family Physicians. This enables them to take care of high-risk OB patients and perform C-sections. Many Family Doctors do this even in urban communities- although the easiest way to do this is if you are a Family Medicine faculty member.

An FP doing an appy is not something I would ever want to see done... It better be an emergency that you just couldn't get to a general surgeon in time for that. You just can't learn enough to do an appy in a 3 year FM residency even with an extra year fellowship.

I live in urban Chicago, there are lots of Family Doctors here and lots of Family Doctors who work as hospitalists. I'd argue Family Doctors are even better prepared than Internists to do inpatient medicine because we can see the big picture and we understand how these patients will be managed as an outpatient. (Internal medicine residents do not get as much outpatient experience as family medicine residents do).

That's like saying a DO can treat a patient better because they see the big picture. IM trained residents get plenty of clinic time in their residencies. They also get a far larger inpatient experience as a group on average compared to FP residents. I'd argue that IM trained dotors are better prepared at taking care of inpatients. For the most part, the outpatient long term care isn't as important in treating the immediate acute issues at hand.

 

[LocumOnly]

As I've been in the job market all over the country, in both urban and rural areas, I can say that no employer has ever cared that I'm a Family Physician. No one has ever said, "Oh, we only hire ER doctors" or "We only hire internists". In fact, many have loved the fact that as an Urgent Care physician, I can see infants and OB patients. Hospitals also appreciate this. The jobs you get as hospitalists, UC doctors, or outpatient primary care doctors depends on you as a person and your personal experience- not just on your residency.

You should post the bold part in the EM forums. Maybe this was really your experience... but I wouldn't count on doing FM to secure a job in an ED, and I certainly wouldn't advise this route over an EM residency. Many EDs have already moved towards BC EPs only and many more will likely make this shift in the future.

 

[LocumOnly]

.

 

[evilbooyaa]

This is very region-dependent.

Family medicine residents can learn any of these procedures in residency, but it depends. For instance, in the Alaska residency it's a big part of the curriculum. However, in urban residencies, you don't learn how to do appendectomies unless you seek it out in an elective. How do FPs get good at C-sections? Simple- they have OB fellowships for Family Physicians. This enables them to take care of high-risk OB patients and perform C-sections. Many Family Doctors do this even in urban communities- although the easiest way to do this is if you are a Family Medicine faculty member.

I live in urban Chicago, there are lots of Family Doctors here and lots of Family Doctors who work as hospitalists. I'd argue Family Doctors are even better prepared than Internists to do inpatient medicine because we can see the big picture and we understand how these patients will be managed as an outpatient. (Internal medicine residents do not get as much outpatient experience as family medicine residents do).

As I've been in the job market all over the country, in both urban and rural areas, I can say that no employer has ever cared that I'm a Family Physician. No one has ever said, "Oh, we only hire ER doctors" or "We only hire internists". In fact, many have loved the fact that as an Urgent Care physician, I can see infants and OB patients. Hospitals also appreciate this. The jobs you get as hospitalists, UC doctors, or outpatient primary care doctors depends on you as a person and your personal experience- not just on your residency.

I guess I'll defer to your experience in the field (especially regarding paragraph 3), but in regards to your first paragraph (doing an OB fellowship after FM), I was commenting on doing all of these things as a FP without additional training. I was not aware of OB fellowships for FM docs.

However, I disagree with you on the second paragraph. I would imagine that an IM trained resident that spent the majority of their time on a hospitalist-like service would have more ability fresh out of residency compared to a FP resident. Again, n=1, but where I did my FM rotation, the majority of the residents spent the majority of their time in the clinic as opposed to in-patient work. Seems like other FM residents have had different experiences.

I completely agree with thoracic guy regarding the appy. I think a FP doing appys (even after a year of fellowship) is not something I would want over a GS-trained surgeon (again, with the caveat that both people have been out of residency for the same amount of time). If it's not emergent, I'd want a GS-trained surgeon. In the same vein, I wouldn't want a vascular (or breast, or any other post-GS subspecialty) surgeon who doesn't routinely do appys (but has GS certification due to his residency) to take out my appendix.

Also, FPs historically covered EDs due to there being no separate EM residency (at least not in the numbers that EM residencies exist now) until recent history.

I guess things differ in different areas of the country, but I personally would want an OB/Gyn with a number of C-sections under their belt doing the C-section on my family member as opposed to a FP (even one that was trained in fellowship [a 1-year fellowship I'm assuming?])

As a side question, as a FP who seems to do operations (at least C-sections), how many do you do on average? Let's say average # of C-sections/month as an attending. I'm more understanding of FPs covering high-risk OB if there is an OB/Gyn on call who could do the C-section in case things started to go badly.

I'd think an urgent care (I'm assuming by this you mean something like a med express) physician is quite different in the acuity-level compared to even a community ED, but I don't know enough about urgent cares or community EDs to make solid statements on that topic. IMO, an urgent care is a level of acuity leaning significantly more towards an outpatient clinic setting than a true hospital or ED setting. For example, if you see something acute that needs immediate work-up, imaging and acute (including surgical) treatment (as opposed to history, physical, followed by treatment), most urgent cares would usually send it to the ED.

 

[gutonc]

I do so love it when the med students and residents start lecturing the attendings about what they can and can't do.

 

[styphon]

REALITY:
Family medicine scope of practice depends on your specific program training (is it ob heavy? inpt heavy?), your drive/electives (were you fixated on getting the # needed for c-sopes?), and the local area you practice in . You have control of all of these factors.

I know of a family medicine attending who does colonoscopies in a major city - he gets referrals from other family medicine clinics (to answer "where do the patients come from")-he does 40-50/month. In additional for privileges I think it is +100 c-scopes with no intervention and +50 c-scopes with biopsy.

In NY state (a state not thought of for FM doing c/sections) hospitals require 200-250 c/sections as primary surgeon during training to get privileges, so in the fellowship the goal is to get this number - I am unsure what other states require.

Hospitalist experience does depend on the residency, my residency was heavy for inpatient training. If you want to be a hospitalist - I would suggest finding a program similar. Before deciding on my current job - I was offered jobs at major city hospitals (one of them where I trained), as a hospitalist.

Now the problem is "I want to be a family doctor who does c/s and colonoscopies and do inpt". This would be very hard to do as the time you would spend getting a specific procedure would make it near impossible to get the numbers for the other procedures.

 

[Brigade4Radiant]

From my perspective, as someone going in med-peds, the major disadvantage of FM is that the training is too superficial, they do not get the respect they merit from their colleagues, there's no potential for subspecialization, and the pay is inadequate.

For FM to be an attractive model for most medical students, the training would have to be on the order of 7-8+ years (2 years IM, 2 years peds, and 3-4 years to cover ob/gyn and general surgery) and the pay would have to be much better, i.e. 350-400K+.

NO NO that is one of the worst suggestions I've ever read about residency training period.

 

[Brigade4Radiant]

Also all specialists have respect for Family med docs in the community the lack of prestige only exists in Academia. Remember as a specialist you just don't "get" patients they have to be referred to you.

 

[Bacchus]

Also all specialists have respect for Family med docs in the community the lack of prestige only exists in Academia. Remember as a specialist you just don't "get" patients they have to be referred to you.

Unless you're one of the lucky few where referrals aren't necessary... but I say that as a physician myself.

Oh, I'm all sorts of tachy... let me call my cardiologist friend

Snarkiness aside, I agree with you.

 

[MedicineMan99]

You should post the bold part in the EM forums. Maybe this was really your experience... but I wouldn't count on doing FM to secure a job in an ED, and I certainly wouldn't advise this route over an EM residency. Many EDs have already moved towards BC EPs only and many more will likely make this shift in the future.

I was referring to rural EDs. Many use Family Medicine docs. Sure, not level 1 trauma facilities. But lots and lots of FM doctors work in ERs and Urgent Cares throughout the country.

 

[Wahoowa23]

I am a family med resident about to finish. I plan on utilizing mid levels to their maximum potential. All those important but not so challenging annual physicals, HTN checks, paps, etc., they can have them.
I will see the new patients initially and difficult diagnostic cases and admit our sick patients. I am comfortable with critical care and can manage an airway.
When they need elective procedures that specialist do that I do better, they will see me (my Adenoma Detection Rate is going to be better then most GIs because I actually will take more time on my patients). I agree with one of the posters that you will end up specializing within your own practice -- I will bring primary prevention of cancer directly to my patients: cervical cancer (via paps-->colpos-->LEEPs), CRC (flex sigs or cscopes, whichever is safer for a particular patient), cutaneous dysplasia (via screenings, biopsy and resections where indicated). When a patient comes in for an urgent need to have a laceration repaired or a fracture splinted, I won't contribute to bankrupting the system by sending them to an ER so a hospital can charge them and their insurer exorbitant fees to make the hospital's ends meet. Nor will I order unnecessary studies because I don't trust the patient's follow up etc. If I think my patient is so sick they need to go to the ER, I will just admit them. Imagine a doctor taking care of his own patient! Thus the ER doc and the Hospitalist doesn't need to order a million tests and studies to learn about a patient they don't know.
I will only be able to pull this off by partnering with mid levels to handle all the meaningless scut that burns out doctors today (long notes to get paid by insurance companies, onerous EMRs w meaningful use parameters, inboxes, corporate oversight), and focusing on procedures and complex medical issues my patients face. Because as far as I'm concerned, with a license to practice medicine and surgery in the state of California, I will do so without wasting all the education and training that I have painstakingly attained thus far on scut that any NP or PA can handle.
As far as OB is concerned. I will HAPPILY share that very high risk practice with Obstetrics. I will continue to follow them and their children postpartum thus providing the family treatment all in the same location. That said, if one of my pregnant patients needs to have an emergency delivery or csection and no OB is available, I'm far more qualified than any ED doc (I have done over 30 csections and delivered 75 vaginal deliveries some of which were operative). So, the OB training was not a waste and never will be. Finally if we ever have a natural disaster or if zombie day strikes, you would much rather have doctors like me around than a specialist that is limited to a process, disease type or organ. They have their place and we need them, but family medicine is here to stay because there will always be people like me who want to be responsible for the entire patient and thrive on all aspects of medicine.
I am unique in that I finished to PGY2 in both EM and Pathology before I came to family medicine. These indeed give me the additional training necessary to make my style of practice doable and thus I agree that family medicine training needs to be longer. IM would not have been the right choice because the internest is not support by ACP or ABIM to practice so broadly. Family Medicine is the ONLY specialty that supports my broad interests right out of residency. I did not do a residency in primary care, there is no such specialty.
Luckily, legally it doesn't matter where or who I am boarded with since a license is all that is truly required to practice medicine. I look forward to the day when a class action or anti trust lawsuit is brought against the ABMS. They have directly contributed to the fractured and expensive health care system we have today. I also look forward to true socialization of medical care where the business incentive to quarter out the medical profession into turfs based on procedures is removed. Because I don't see any GI docs or dermatologists working in the underserved area I'm opening my practice in. That interest in rural medicine did not stop them from fighting my interest in doing "their" procedures while in training.
Want to see a group of professionals lose their cool, suggest family medicine can meet the needs of CRC prevention by do screening colonoscopies to an urban GI doc! In the UK, where medicine is socialized, GPs do it all the time safely and effectively.

 

[Gastrapathy]

Since you brought it up, the Canadian data is pretty clear that non-GIs contribute way more than their share to the missed rightsided cancers.

 

[Shikima]

I feel like I want to start a slow clap or something...

 

[SLC]

I think it's a mistake to do this...The ob/gyn training and future practice model is also completely haphazard. There are still some FMs who do deliveries and even C sections but nowadays most avoid it because of the liability. And the pregnancy care is limited pretty much to benign well controlled pregnancies - just like midwives. Anything slightly out of the ordinary (I am talking gestational diabetes or chronic hypertension - not to mention eclampsia or HELLP or acute fatty liver...) and that woman is going straight to ob.

With FM your fellowships are severely restricted.

This post does not at all represent reality. I just finished my first OB month and I can 100% guarantee that residents in my program are successfully managing gestational diabetes, gestational HTN, pre-eclampsia. It's seen as fairly routine in our program and residents are expected to be competent in these areas. We pride ourselves on learning to manage high risk pregnancy.

Additionally, FM fellowships are generally designed to enhance skills as a Family Physician, not change skill-set entirely. An OB fellowship is designed to expand pregnancy care abilities of an FP, Geriatrics to enhance skills in that area, etc.

About the only fellowship I can immediately think of that sort of changes the practice of an FP is a palliative care fellowship. But those are open to FP, IM, Surg, Peds alike.

 

[VA Hopeful Dr]

Since you brought it up, the Canadian data is pretty clear that non-GIs contribute way more than their share to the missed rightsided cancers.

There is all manner of data showing that increased repetition increases skill and outcomes. Very few FPs are going to have the volume of even an average GI/surgeon. If the choice is FP or no scope, go with FP. If its FP or GI, I'm going with GI and I am an FP.

 

[VA Hopeful Dr]

This post does not at all represent reality. I just finished my first OB month and I can 100% guarantee that residents in my program are successfully managing gestational diabetes, gestational HTN, pre-eclampsia. It's seen as fairly routine in our program and residents are expected to be competent in these areas. We pride ourselves on learning to manage high risk pregnancy.

Additionally, FM fellowships are generally designed to enhance skills as a Family Physician, not change skill-set entirely. An OB fellowship is designed to expand pregnancy care abilities of an FP, Geriatrics to enhance skills in that area, etc.

About the only fellowship I can immediately think of that sort of changes the practice of an FP is a palliative care fellowship. But those are open to FP, IM, Surg, Peds alike.

Yeah, in the areas where FPs still deliver there is often no OB or only 1-2 OBs. They usually try and restrict themselves to sections and certain types of high risk pregnancies - twins being the most common.

Diabetes, pre-eclampsia - those are not especially difficult to manage if you know what you're doing.

 

[SLC]

Yeah, in the areas where FPs still deliver there is often no OB or only 1-2 OBs. They usually try and restrict themselves to sections and certain types of high risk pregnancies - twins being the most common.

Diabetes, pre-eclampsia - those are not especially difficult to manage if you know what you're doing.

Exactly. By the way, our residents even manage (and deliver) twin gestations. Had one come through during my most recent month that was a continuity delivery for one of the residents.

 

[Wahoowa23]

There is all manner of data showing that increased repetition increases skill and outcomes. Very few FPs are going to have the volume of even an average GI/surgeon. If the choice is FP or no scope, go with FP. If its FP or GI, I'm going with GI and I am an FP.

That is correct. That's why it needs to be a regular part of my practice to maintain the skill set. I already have more numbers than the American Board of Surgery requires for board certification. I went with ASGE standards, instead which recommends 140 cscopes for privileging (many more than surgery). With that in mind, I am supporting a few other group practices in the area to keep my numbers up.
That is unfortunate you don't know any FPs doing these effectively or hold this stigma when the reality and potential is there.

 

[Wahoowa23]

There is all manner of data showing that increased repetition increases skill and outcomes. Very few FPs are going to have the volume of even an average GI/surgeon. If the choice is FP or no scope, go with FP. If its FP or GI, I'm going with GI and I am an FP.

This blog sums up why FPs are the biggest threat to our decaying scope of practice:
http://www.kevinmd.com/blog/2013/08/family-physicians-threat.html

 

[VA Hopeful Dr]

That is correct. That's why it needs to be a regular part of my practice to maintain the skill set. I already have more numbers than the American Board of Surgery requires for board certification. I went with ASGE standards, instead which recommends 140 cscopes for privileging (many more than surgery). With that in mind, I am supporting a few other group practices in the area to keep my numbers up.
That is unfortunate you don't know any FPs doing these effectively or hold this stigma when the reality and potential is there.

Man, you're just running all over the board spreading your wonderful thoughts.

I know several FPs doing scopes, deliveries, sections, and inpatient care - and that's just from my residency program during my 3 years there.

I also know several FPs who gave up doing some of those same procedures when the data came out showing that more repetition = better outcomes. If you're doing 10 scopes/month and the general surgeon next door is doing 50, you are doing your patients a disservice by not referring those out.

 

[VA Hopeful Dr]

This blog sums up why FPs are the biggest threat to our decaying scope of practice:
http://www.kevinmd.com/blog/2013/08/family-physicians-threat.html

I see what is happening to our field as little different to the decline of the general surgeon. I know general surgeons are quite skilled at vascular work, but if I have a patient with a AAA I am sending to the vascular surgeon. General surgeons are very good at breast cancer, but I'm going to send to a trained breast-surgeon if I have that option.

I personally believe that we need to take back the complex outpatient care before we go chasing procedures. You're still in residency, so you won't have seen this yet, but out in the real world there are many family doctors who are punting even the simple things you think your mid-levels are going to be doing.

In the last 2 months, I've picked up 2 new patients who had referrals in place for endocrinology for diabetes their former FPs weren't able to get under control. Both of them are now at goal 95% of the time, and would be 100% if Bojangles disappeared tomorrow. My personal family physician (and old friend from residency) refers out any arthritis that stops responding to PO NSAIDs. I can keep those patients from needing to see ortho with twice yearly steroid shots for years. Last week, I spent 30 minutes teaching a patient some home exercises that prevented needing to see PT for her back pain. The list goes on and on.

If we can't prove our value by doing what we all should should be doing, and doing it well, then why would anyone trust us to do more complicated things?

 

[Wahoowa23]

I see what is happening to our field as little different to the decline of the general surgeon. I know general surgeons are quite skilled at vascular work, but if I have a patient with a AAA I am sending to the vascular surgeon. General surgeons are very good at breast cancer, but I'm going to send to a trained breast-surgeon if I have that option.

I personally believe that we need to take back the complex outpatient care before we go chasing procedures. You're still in residency, so you won't have seen this yet, but out in the real world there are many family doctors who are punting even the simple things you think your mid-levels are going to be doing.

In the last 2 months, I've picked up 2 new patients who had referrals in place for endocrinology for diabetes their former FPs weren't able to get under control. Both of them are now at goal 95% of the time, and would be 100% if Bojangles disappeared tomorrow. My personal family physician (and old friend from residency) refers out any arthritis that stops responding to PO NSAIDs. I can keep those patients from needing to see ortho with twice yearly steroid shots for years. Last week, I spent 30 minutes teaching a patient some home exercises that prevented needing to see PT for her back pain. The list goes on and on.

If we can't prove our value by doing what we all should should be doing, and doing it well, then why would anyone trust us to do more complicated things?

I agree. There are too many that are apt to pass the buck. I resist this trend in my training all the time from attendings I am supposed to be learning from. I was a GP attending in the US Navy for three years before I went back GME. That said, I am reluctant to endorse the value of FM residency training that does not include procedural training. My case is special. I don't need help being a traffic cop for patients. I did that with just an internship under my belt. I want to offer an additional service of primary prevention of cancer (skin, colon, gastroesophageal, cervical, anal) to my patients in addition to the usual services offered on an ambulatory level. That means doing my own colpos, egds, cscopes and skin cancer bx's and excisions. I do believe the logic is faulty that we should send procedures we can do ourselves off to other doctors based on numbers of repetition alone. With this logic family medicine docs shouldn't even close a laceration anymore -- send it to the ER because they do more (they will probably get a PA, Ha!).
I think there should be two types of family medicine tracks:
PCP(ambulatory track): 2 years of training
Full scope(ambulatory, inpatient, procedures): 4+ years of training

Unfortunately, the PCP track will offer little more privileges than what a PA/NP have, but at least training wont last so long and then pay wont be deferred. I still think an MD could very well manage the PA/NP for more complex issues in a sort of medical home format and maintain some primacy. Canada only requires 2 years and this seems reasonable to practice family medicine there. Fulls scope option will give the resident additional time (like I have had) to perform other procedures. I know you are a family medicine doctor, and an attending in that field, however, I have 7 years of postgraduate training. Our skill sets are very different. I have done the three residencies at the same institution and will likely be the only residency graduate from family med to have the options I have because of my background. That training though gives me a unique perspective on what family medicine could really be. I recommend you visit American Association for Primary Care Endoscopy and realize there are family medicine doctors all around the country doing endoscopy with higher adenoma detection rate than average. I only chose family medicine because AAFP still supports full scope (although many sadly don't within the field). I was told by several of my EM colleagues before I left that I was too smart for Family Med and that I should choose IM. I'm thankful I did not listen to them.

 

[Wahoowa23]

I must add that the logic offered would also take us away from attending to men, women (pregnant or otherwise), and children, whether in patient or outpatient. I adduce an article written by the Graham Center about scope of practice as it relates to children. With your argument, Family Medicine docs should not even care for children since pediatricians do it more frequently and exclusively. This same sort of logic would argue against family medicine doctors delivering babies or admitted their patients to hospitals. This sort of logic leads to the erosion of our profession, from within. We already have enough partialists from without our specialty that often tell people to only see a family medicine doc for the least complex of issues, but that if you have any real medical issues then you should seek out an internist or pediatrician.

Excerpted from: http://www.aafp.org/fpm/2005/0700/p45.html

The realities of hospital work
Family physicians are less likely than they were in the past to take care of sick children who are hospitalized, and this troubles some family physicians. “If the number of us who take care of our hospitalized patients continues to decline, it will be the deathblow for our specialty,” says Ed Hirsch, MD, a member of the AAFP Task Force on the Care of Children. Hirsch practiced full scope family medicine with obstetrics for 22 years in Illinois before recently taking a position as vice president of medical management with John Deere Health in Kingsport, Tenn. “If you're a parent, why in the world would you take your kid to a physician if you knew that when your kid got really sick and you needed that doctor more than ever, he or she wouldn't be there? If we don't take care of sick kids in the hospital, we may as well just do total ambulatory care and basically be midlevels.”
Brown says that in his experience patients frequently ask which hospitals their doctors admit patients to: “They want to know that they can see their physician when they're hospitalized.”
Hirsch and Brown both lament that growing numbers of otherwise willing residency graduates are leaving their residency programs feeling less than adequately prepared to take care of hospitalized children. “They are graduating residents who aren't as comfortable taking care of kids in the hospital as they should be,” says Hirsch. “You can't have eight residency faculty, none of whom do maternity care and only two of whom do intensive care types of work, and then expect the family physicians who train there to do full scope family medicine.” Increasing financial pressures have made it hard for residencies to offer salaries that are comparable to what most family physicians can earn in private practice, Hirsch says, which makes it hard to recruit experienced family physicians who have a full scope of practice.
Brown says changes in residency curriculum requirements may dilute family physicians' pediatrics experience. “It's not necessarily that they're spending less time doing pediatrics, although that is the case in some programs. It's that they're spending less time taking care of sick hospitalized kids. In the little over a year that I've been teaching, I've already seen our residents' experience diluted by changes in curriculum requirements. When you add something new to the curriculum, you have to cut something else. This is a problem for family physicians who want to take care of kids because, quite frankly, what helps you decide whether to take care of a certain segment of the population is the worst-case scenario you can envision and whether you're going to be comfortable taking care of patients in these scenarios.”
Other dynamics also make it difficult for family physicians to care for hospitalized children. In many cities with children's hospitals, family physicians have fewer and fewer opportunities to take care of sick kids, says Erica Swegler, MD, who practices in a family medicine group in the Fort Worth, Texas, area. “Sick kids are almost always referred to children's hospitals, or their parents elect to have them treated there. It doesn't make sense for me, geographically or economically, to maintain privileges at our children's hospital as well as at the two hospitals where most of my adult patients are admitted.”
Some family physicians have been excluded from the call service at their local hospital or take care of so few children who need to be admitted that they don't have enough volume to maintain admitting privileges. Others choose not to admit their own patients because they want to spend that time seeing patients in the office or they want to limit their work hours.
“I didn't know you take care of children!”
Family physicians aren't the only ones limiting their scope of practice in ways that may affect the number of children they take care of. The public and the media continue to have a narrow vision of what family physicians do. “One thing we learned as part of the Future of Family Medicine project is that we're not recognized by the public as the specialty that takes care of the whole family,” Phillips says.
And despite progress with the media (even “Dear Abby,” a long-time offender, suggested seeing a family physician in a recent column, Swegler says), media coverage remains a bone of contention for many family physicians.
“Family medicine is hurt so much by the absence of the mention of family physicians in tons of media,” Swegler says. Hirsch agrees: “Look at Redbook, Good Housekeeping, Ladies' Home Journal, and all the other so-called women's magazines. They all have columns about child care, and they always refer exclusively to pediatricians.”
Medical journals have made similar errors of omission. In May, JAMA published a patient education handout on childbirth that mentioned nurse midwives in addition to obstetricians but didn't mention family physicians.
“Public awareness continues to be a huge issue for the specialty. If only we could let them know that we exist, we could recoup some of that market share,” says Phillips.
Even existing patients aren't always aware of what their family physicians do. “We think it's fairly obvious,” says Swegler, who is also president of the Texas Academy of Family Physicians, “but on a weekly basis, someone in my practice has the revelation, ‘I didn't know you take care of children.’”

 

[VA Hopeful Dr]

I was a GP attending in the US Navy for three years before I went back GME. I am not sure if there is any value to family medicine training that does not include procedural training. I don't need help being a traffic cop for patients. I did that with just an internship under my belt. I want to offer PRIMARY prevention of cancer to my patients in addition to prevention of cardiovascular disease. That means doing my own colpos, egds, cscopes and skin cancer bx's and excisions. With your logic, family medicine docs shouldn't even close a laceration anymore -- send it to the ER because they do more. Ha!
There should be two types of family medicine tracks:
Referral coordinator/PCP track: 2 years of training
Full scope/Rural track: 4+ years of training
Unfortunately, the PCP track will offer little more privileges than what a PA/NP have, but at least training wont last so long and then pay wont be deferred. Canada only requires 2 years and this seems reasonable to practice safely there. Fulls scope will give the resident additional time (like I have had) to perform other procedures. I know you are a family medicine doctor, and an attending in that field, however, I have 7 years of postgraduate training. Our skill sets are very different. I only chose family medicine because AAFP still supports full scope (although many sadly don't within the field).

Stop being obtuse. There is a difference between laceration repair and colonoscopies. For simple lacerations, the difference in outcomes for the doctor who has done 20 of them and the doctor that has done 200 is not huge - a slightly bigger scar at most. The difference in outcome between a doctor who does 10 scopes per month and the one who does 100 is a missed cancer that potentially kills an actual person. If your numbers for major procedures are sufficient to put your skill level on par with local specialists, then I will support you 1000%. Or if the choice is between you and no one (there's a reason rural docs have larger scope than the rest of us). If they aren't, then the evidence on this is quite clear: you will miss something, a patient will be harmed, and you'll deserve the lawyer-supervised courtroom rectal exam you'll receive. That's the major reason I stopped doing coloposcopies. The new guidelines came out right when I finished residency, so they are even less commonly needed than usual. In 2 years of regular office practice, I would have done 3 of them. To my mind (and, I should hope, to anyone's mind) that is not good enough when a poorly done colpo potentially means missing cancer.

 

[VA Hopeful Dr]

I must add that the logic offered would also take us away from attending to men, women (pregnant or otherwise), and children, whether in patient or outpatient. I adduce an article written by the Graham Center about scope of practice as it relates to children. With your argument, Family Medicine docs should not even care for children since pediatricians do it more frequently and exclusively. This same sort of logic would argue against family medicine doctors delivering babies or admitted their patients to hospitals. This sort of logic leads to the erosion of our profession, from within. We already have enough partialists from without our specialty that often tell people to only see a family medicine doc for the least complex of issues, but that if you have any real medical issues then you should seek out an internist or pediatrician.

Excerpted from: http://www.aafp.org/fpm/2005/0700/p45.html

The realities of hospital work
Family physicians are less likely than they were in the past to take care of sick children who are hospitalized, and this troubles some family physicians. “If the number of us who take care of our hospitalized patients continues to decline, it will be the deathblow for our specialty,” says Ed Hirsch, MD, a member of the AAFP Task Force on the Care of Children. Hirsch practiced full scope family medicine with obstetrics for 22 years in Illinois before recently taking a position as vice president of medical management with John Deere Health in Kingsport, Tenn. “If you're a parent, why in the world would you take your kid to a physician if you knew that when your kid got really sick and you needed that doctor more than ever, he or she wouldn't be there? If we don't take care of sick kids in the hospital, we may as well just do total ambulatory care and basically be midlevels.”
Brown says that in his experience patients frequently ask which hospitals their doctors admit patients to: “They want to know that they can see their physician when they're hospitalized.”
Hirsch and Brown both lament that growing numbers of otherwise willing residency graduates are leaving their residency programs feeling less than adequately prepared to take care of hospitalized children. “They are graduating residents who aren't as comfortable taking care of kids in the hospital as they should be,” says Hirsch. “You can't have eight residency faculty, none of whom do maternity care and only two of whom do intensive care types of work, and then expect the family physicians who train there to do full scope family medicine.” Increasing financial pressures have made it hard for residencies to offer salaries that are comparable to what most family physicians can earn in private practice, Hirsch says, which makes it hard to recruit experienced family physicians who have a full scope of practice.
Brown says changes in residency curriculum requirements may dilute family physicians' pediatrics experience. “It's not necessarily that they're spending less time doing pediatrics, although that is the case in some programs. It's that they're spending less time taking care of sick hospitalized kids. In the little over a year that I've been teaching, I've already seen our residents' experience diluted by changes in curriculum requirements. When you add something new to the curriculum, you have to cut something else. This is a problem for family physicians who want to take care of kids because, quite frankly, what helps you decide whether to take care of a certain segment of the population is the worst-case scenario you can envision and whether you're going to be comfortable taking care of patients in these scenarios.”
Other dynamics also make it difficult for family physicians to care for hospitalized children. In many cities with children's hospitals, family physicians have fewer and fewer opportunities to take care of sick kids, says Erica Swegler, MD, who practices in a family medicine group in the Fort Worth, Texas, area. “Sick kids are almost always referred to children's hospitals, or their parents elect to have them treated there. It doesn't make sense for me, geographically or economically, to maintain privileges at our children's hospital as well as at the two hospitals where most of my adult patients are admitted.”
Some family physicians have been excluded from the call service at their local hospital or take care of so few children who need to be admitted that they don't have enough volume to maintain admitting privileges. Others choose not to admit their own patients because they want to spend that time seeing patients in the office or they want to limit their work hours.
“I didn't know you take care of children!”
Family physicians aren't the only ones limiting their scope of practice in ways that may affect the number of children they take care of. The public and the media continue to have a narrow vision of what family physicians do. “One thing we learned as part of the Future of Family Medicine project is that we're not recognized by the public as the specialty that takes care of the whole family,” Phillips says.
And despite progress with the media (even “Dear Abby,” a long-time offender, suggested seeing a family physician in a recent column, Swegler says), media coverage remains a bone of contention for many family physicians.
“Family medicine is hurt so much by the absence of the mention of family physicians in tons of media,” Swegler says. Hirsch agrees: “Look at Redbook, Good Housekeeping, Ladies' Home Journal, and all the other so-called women's magazines. They all have columns about child care, and they always refer exclusively to pediatricians.”
Medical journals have made similar errors of omission. In May, JAMA published a patient education handout on childbirth that mentioned nurse midwives in addition to obstetricians but didn't mention family physicians.
“Public awareness continues to be a huge issue for the specialty. If only we could let them know that we exist, we could recoup some of that market share,” says Phillips.
Even existing patients aren't always aware of what their family physicians do. “We think it's fairly obvious,” says Swegler, who is also president of the Texas Academy of Family Physicians, “but on a weekly basis, someone in my practice has the revelation, ‘I didn't know you take care of children.’”

You still fail to grasp a fairly basic concept. Additional training doesn't always result in superior outcomes. We have robust data for major procedures that says more repetitions = better. For the more artful parts of medicine, for lack of a better term, this isn't as clear. Does 24 weeks of peds clinic in residency really result in better outcomes for the majority of kids compared to 20 weeks? I doubt it. Surgeons are much better cutters than we are, but does that mean that all of their I&D'ed abscesses heal while all of mine get worse? Of course not.

You need to understand, family doctors are generalists. There's nothing shameful in that. This means, from time to time, that other doctors will be better at things than we are. No one can know it all. However, being a generalist has lots of advantages.

Generally speaking, its the rare internist or pediatrician who is actually any good at GYN, and they certainly hate dealing with medical issues in pregnant patients. I don't deliver babies anymore, but I can manage pregnant patients with ease. Likewise, OBGYNs are great at general women's health but, again generally speaking, they are less skilled at uncomplicated HTN or diabetes. I have yet to meet a geriatrician that actually does outpatient procedures, even as simple as joint injections. This is where we step in. I can do your kid's well child checks and sick visits, treat his ADHD, do mom's yearly pap, manage dad's high blood pressure, and give grandma's knee a kenalog shot. We're family doctors because we can literally, and unlike anyone else, take care of the entire family. But there are limits, and its no shame admitting it.

 

[Wahoowa23]

It seems that you are slow to understand my position. I can't reply better than with Dr Simmons' original article:

Why family physicians are a threat to themselves
Paul D. Simmons, MD | Physician | August 8, 2013
In recent months, AAFP President Reid Blackwelder has been editorializing and debating what they see as the encroachment of nurse practitioners (NPs) and other “mid-level providers” (physicians are, presumably, “upper-level”) on the practice territory of family physicians (FPs). Dr. Blackwelder has repeatedly said that NP and physician roles are “not interchangeable.” The AAFP’s position on this issue seems to be resistance to the increasingly common decisions by state legislatures to free NPs of physician oversight. Dr. Blackwelder and the AAFP are misallocating their energies and resources – NPs are not a threat to family physicians. We are a threat to ourselves.

Two vignettes serve to illustrate my point. First, a recent news headline (“Hospital Lifts Ban on Non-Specialists Delivering Babies“) announced that, after a long fight, a Texas FP finally got privileges to deliver babies. This is news? Sadly, yes. Second, while eating at one of my favorite restaurants recently, the waitress and I got to talking about her search for a doctor for her little boy. She knew I was a family doctor, but she was surprised to find out that I, too, take care of children, deliver babies and see patients in the hospital.
What do these anecdotes have to do with the AAFP’s quest against NP independent practice and protection of FP identity?

It is not nurse practitioners or physician assistants who have denied family physicians privileges to practice obstetrics, to do C-sections, to do endoscopy, to practice conscious sedation and to do minor surgeries – in other words, to practice the full scope of family medicine. It is our “partialist” (a delightfully accurate term that needs more circulation) colleagues who see us as a threat to their “turf” (and income) who have restricted our credentials and ability to practice.
It is not nurse practitioners or physician assistants who have done such a poor job shaping and marketing our image as “comprehensivists” that laypeople are surprised to learn that FPs take care of children, deliver babies, practice emergency medicine, do minor office procedures, and see hospitalized patients. It is we who have voluntarily given up our scope of practice in many areas, who are surrendering our hospital, obstetrical and surgical practices either in the name of an easier lifestyle or because of pressure to see more patients per day.

The AAFP is a subset of dinosaurs protesting the approaching meteor. In 2014, millions of Americans will gain health insurance and flood the primary care market. There simply will not be – there cannot be – enough FPs to fill the gap. NPs will serve that necessary role, and do an excellent job. Hundreds of thousands of Americans will soon identify NPs and PAs as their primary doctor. It will happen, it already has happened. There is no way the AAFP can prevent it.

Furthermore, as the family medicine skill set deteriorates, as the trends continue that fewer FPs do obstetrics, endoscopy, minor surgeries and hospital medicine, our practical skill sets (regardless of the oft-quoted “hours of training” differential) will asymptotically approach those of our NP colleagues. To the patient in the exam room, there will soon be no discernible difference between their self-limited family physician or their well-trained nurse practitioner. They just want a primary care clinician who can do a good job – and very soon, either one of us will.
If my professional organization, the AAFP, wants to know who is eroding the identity, role and practice spectrum of family physicians, they need not look at NPs. They need only look in the mirror.
Paul D. Simmons is a family physician.

 

[VA Hopeful Dr]

So I see a few things here that need addressing.

First, I find it laughable that you think midlevels are anywhere as good as we are at... well, at anything honestly. It looks that way now because a 10 minute visit is not enough time to really do a good job for anything complicated. Half of my patient population came to me because they got shifted to an NP at their last doctor's office and realized very quickly that they weren't as good as a physician.

Second, the article you posted seems to want to have all of us doing full scope so that we don't lose our identity. You know what the article does not mention a single time? Patient safety. As I've said many times already, for much of what both you and this article want to have FPs doing, there is significant evidence that volume matters and compared to our specialist colleagues, we just don't have it. I will state once again: if an FP in my area does as many scopes as the GI doctor, I will gladly send all my cancer screenings to him/her. But if you're doing 10 a month and the GI doctor is doing 100, I will be doing a disservice to my patients not to send them to the GI doctor.

Same thing with delivering babies. If you're doing 4-5/month and the OB next door is doing 20, there is significant evidence showing that the OB is providing superior care.

You're so obsessed with doing any procedures that you're allowed, you are forgetting the single most important tenant of medical ethics: do what is best for the patient. I'm going to repeat that so it sinks in. Do what is best for the patient.

Now that we have evidence that, for many procedures, the more you do the better you are, it is your obligation as a physician to refer to someone else if not doing so leads to your patient having inferior care.

 

[Wahoowa23]

I think we are just going to have to disagree. I will practice rurally where access to care is an issue. There must always be a balance between safety and access. I agree our first tenant is to first do no harm. I don't appreciate your reference to me getting a court administered rectal exam. It debased your argument. It is almost as if you want full scope to fail. You are welcome to practice anyway/anywhere you want. I was just sharing an alternative to your style of practice.

 

[VA Hopeful Dr]

I think we are just going to have to disagree. I will practice rurally where access to care is an issue. There must always be a balance between safety and access. I agree our first tenant is to first do no harm. I don't appreciate your reference to me getting a court administered rectal exam. It debased your argument. It is almost as if you want full scope to fail. You are welcome to practice anyway/anywhere you want. I was just sharing an alternative to your style of practice.

Ah, so you actually haven't been reading my responses at all (other than to get offended). That's cool.

Allow me to show you my very first post in this thread, with emphasis on the important part...

There is all manner of data showing that increased repetition increases skill and outcomes. Very few FPs are going to have the volume of even an average GI/surgeon. If the choice is FP or no scope, go with FP. If its FP or GI, I'm going with GI and I am an FP.

Rural is the ideal place for family docs to do full scope. There is no one here who is disagreeing with that. Hence my above post from several weeks back. Rural full scope practice is great, otherwise patients wouldn't have access to needed services. Non-rural full scope just makes you a cowboy, and likely a dangerous one at that.

Beyond that, I am fully aware of alternative methods of practice. A resident one year up from me spent 3 years doing c-sections in rural Missouri. Our chief resident my last year is doing traditional practice - hospital and outpatient, including nursing home rounds. The previous chief resident spent 2 years as a hospitalist. My first partner out of residency spent 14 years doing full-scope in rural Washington state - OB, inpatient, outpatient, scopes, everything except c-sections. I've done Urgent Care, outpatient clinic, disability work, even attended at the local state psych hospital and have just opened my own private practice. My next door neighbor is an FP doing full time ED work at the local VA hospital. But please, tell me more about what family doctors are capable of.

 

[Wahoowa23]

There is all manner of data showing that increased repetition increases skill and outcomes. Very few FPs are going to have the volume of even an average GI/surgeon. If the choice is FP or no scope, go with FP. If its FP or GI, I'm going with GI and I am an FP.

I run circles around most GIs. Last year I performed 400 colonoscopies and 400 EGDs. This narrow minded mentality holds family medicine back in hospital privileging leading to steady erosion of our scope of practice nationwide. This thinking is the cancer within family medicine. It is also the corporate rot that many in medicine now believe. Really all this capitalistic system wants is mid levels to replace primary care doctors. This is the nature of the system...so folks without special skills, watch out: Either you will be replaced or you will for less — welcome to the recipe for burnout on the front line.

 

[VA Hopeful Dr]

I run circles around most GIs. Last year I performed 400 colonoscopies and 400 EGDs. This narrow minded mentality holds family medicine back in hospital privileging leading to steady erosion of our scope of practice nationwide. This thinking is the cancer within family medicine. It is also the corporate rot that many in medicine now believe. Really all this capitalistic system wants is mid levels to replace primary care doctors. This is the nature of the system...so folks without special skills, watch out: Either you will be replaced or you will for less — welcome to the recipe for burnout on the front line.

Nice 5+ year necrobump.

Let me, once again, refer you to a previous post of mine that should settle this:

I will state once again: if an FP in my area does as many scopes as the GI doctor, I will gladly send all my cancer screenings to him/her.

You appear to meet that criteria. Good for you (I really mean that).

I can't say I really appreciate my thinking being called a cancer or narrow minded though. We can disagree without the insults.