What is the FM "sweet spot" in terms of disease complexity?

[SpanishMusical]

Hi everyone,

I am very interested in family medicine, and this question is coming from a place of ignorance more than anything else. I've been hearing a lot about midlevel encroachment (although I don't want this to turn into a midlevel post, and am more interested in the FM side of these questions) and the like, and it's making me have some questions about FM as a field:

1. If someone has a "more simple" problem (sore throat, uncomplicated HTN), why not go to a PA or independent NP? Assuming they have the training to handle these routine cases, what's the need of the physician?
2. If someone has a "more difficult" problem (complicated pregnancy, weird valvulopathy, etc), why would they go to the PCP instead of the specialist (after getting the specialist referral)? In other words, why go to a generalist when there's always someone "better" (emphasis on the air quotes!) you could see?
3. In other words, I guess my question comes down to: what is the FM "sweet spot" of conditions complicated enough a physician needs to handle them, but not so complicated/esoteric a specialist is needed?

I mean no disrespect with these questions, and I think they may reflect my own lack of knowledge of the scope/expertise that FM docs possess more than anything; I've been asked some of these questions before when I've mentioned an interest in FM, and I haven't really had a great response. Part of my ignorance may also be from an upbringing on the East Coast, where specialists for everything (as I understand it) is more common. I would really appreciate any insight into this issue, and again, I am sorry if any of this comes off as disrespectful of the profession.

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[VA Hopeful Dr]

Hi everyone,

I am very interested in family medicine, and this question is coming from a place of ignorance more than anything else. I've been hearing a lot about midlevel encroachment (although I don't want this to turn into a midlevel post, and am more interested in the FM side of these questions) and the like, and it's making me have some questions about FM as a field:

1. If someone has a "more simple" problem (sore throat, uncomplicated HTN), why not go to a PA or independent NP? Assuming they have the training to handle these routine cases, what's the need of the physician?
2. If someone has a "more difficult" problem (complicated pregnancy, weird valvulopathy, etc), why would they go to the PCP instead of the specialist (after getting the specialist referral)? In other words, why go to a generalist when there's always someone "better" (emphasis on the air quotes!) you could see?
3. In other words, I guess my question comes down to: what is the FM "sweet spot" of conditions complicated enough a physician needs to handle them, but not so complicated/esoteric a specialist is needed?

I mean no disrespect with these questions, and I think they may reflect my own lack of knowledge of the scope/expertise that FM docs possess more than anything; I've been asked some of these questions before when I've mentioned an interest in FM, and I haven't really had a great response. Part of my ignorance may also be from an upbringing on the East Coast, where specialists for everything (as I understand it) is more common. I would really appreciate any insight into this issue, and again, I am sorry if any of this comes off as disrespectful of the profession.

1. Because "more simple" problems often aren't.
2. Because often times we can manage "more difficult" problems just fine
3. Whatever you want it to be. That's honestly one of the best aspects of FM is that you can tailor your practice to what you want it to be.

 

[deleted87716]

what is the FM "sweet spot" of conditions complicated enough a physician needs to handle them, but not so complicated/esoteric a specialist is needed?

Pretty much any FP's practice.

 

[SpanishMusical]

1. Because "more simple" problems often aren't.
2. Because often times we can manage "more difficult" problems just fine
3. Whatever you want it to be. That's honestly one of the best aspects of FM is that you can tailor your practice to what you want it to be.

Thanks for this answer -- if you don't mind, I'm curious as to what you feel your "upper level" in terms of complexity is? Would you handle pre-eclampsia yourself, for example, or refer out? Bipolar?

As far as tailoring your practice, I assume that also means tailoring your skills, which I'm guessing happens mostly in residency? If you find a need for a service exists in your community that you don't feel as comfortable in (maybe a lot of MSK, for example), have you found that CME is enough to fill in the gaps you need to feel competent/comfortable safely treating patients, or do you tend to refer those cases more often by virtue of your skillset?

Thanks for your patience in answering these questions -- I don't really have any mentors in FM (for reasons I won't go into here), so this is super helpful for me to get an idea as to what FM practice looks like as I go into clerkships.

 

[InternistDO]

A lot of your questions will be answered during your clinical rotations--it can be hard to understand why your points 1 and 2 are not as simple as they seem until you're more involved in clinical medicine.

But broadly, for your point #1 it's because "simple" issues are often complicated, and/or can be easily missed. Most sore throats are viral pharyngitis that will get better regardless of medical attention, yes, but some are cancers, some are Lemierres syndrome, some are functional disease, some are GERD, some are HIV, etc etc. It's impossible to ask patients or schedulers to make this distinction, which is the risk of using NPs/PAs in the broad primary care world where you just have to cross your fingers and hope that they recognize serious pathology when they see it. The nice thing about being a primary care physician is you can treat almost all of those things I listed without referring.

For point #2 there are definitely conditions best treated by specialists--it's a rare FM physician who is going to treat HELLP by themself and certainly no PCP is doing heart caths or TAVRs for valvulopathies. But many of these conditions are quite rare in the grand scheme of things (though it may not seem like it if you're on the cardiology service). So while you won't be stenting a STEMI at 3am as a PCP (thank god), you'll be medically managing people with coronary artery disease, heart failure, hyperlipidemia, afib, etc.

As to why we don't have every condition managed by the appropriate specialist, well, first its expensive (for the system) and inconvenient for the patient--who wants to see a cardiologist for your HTN, a nephrologist for your CKD from the HTN, and a pulmonologist for your COPD when your PCP can manage all of those? Second, specialists see the world from the lens of their specialty and often have conflicting recommendations (cards says diurese, nephro says give fluids) which can leave patients confused and poorly managed. They can also often lose the big picture when seeing patients because they're so focused on one system. Finally, specialists tend to want to do specialist things, which often means procedures and big tests (as an example, the more cardiologists are in an area, the more people get heart caths). These procedures, while they can be helpful, are sometimes dangerous and unnecessary and it can be the job of PCPs to shield patients from specialists more excitable instincts.

What you feel comfortable with as a PCP is going to depend on your geographic location and your training, but you can tailor it to what you're comfortable with. Yes, there are FM doctors who refer everything that moves to a specialist, but they are not doing their patients any favors.

As a disclaimer, I'm an IM (primary care) resident in the Northeast, not FM, but I think its applicable to both specialities.

 

[MedicineZ0Z]

Hi everyone,

I am very interested in family medicine, and this question is coming from a place of ignorance more than anything else. I've been hearing a lot about midlevel encroachment (although I don't want this to turn into a midlevel post, and am more interested in the FM side of these questions) and the like, and it's making me have some questions about FM as a field:

1. If someone has a "more simple" problem (sore throat, uncomplicated HTN), why not go to a PA or independent NP? Assuming they have the training to handle these routine cases, what's the need of the physician?
2. If someone has a "more difficult" problem (complicated pregnancy, weird valvulopathy, etc), why would they go to the PCP instead of the specialist (after getting the specialist referral)? In other words, why go to a generalist when there's always someone "better" (emphasis on the air quotes!) you could see?
3. In other words, I guess my question comes down to: what is the FM "sweet spot" of conditions complicated enough a physician needs to handle them, but not so complicated/esoteric a specialist is needed?

I mean no disrespect with these questions, and I think they may reflect my own lack of knowledge of the scope/expertise that FM docs possess more than anything; I've been asked some of these questions before when I've mentioned an interest in FM, and I haven't really had a great response. Part of my ignorance may also be from an upbringing on the East Coast, where specialists for everything (as I understand it) is more common. I would really appreciate any insight into this issue, and again, I am sorry if any of this comes off as disrespectful of the profession.

It's not black and white like that... You would have a mix and it would be a spectrum of complexity.
Some patients are healthy with minimal issues. Some patients have a long list of chronic illnesses. And some are in the middle.
And then you would have some patients with rare diseases as well mixed in. You should be able to workup/diagnose a reasonable number of rare diseases within most specialties, as a PCP. You may also be comfortable managing some of them, depending on what it is and what niche(s) you are interested in.

 

[MedicineZ0Z]

Thanks for this answer -- if you don't mind, I'm curious as to what you feel your "upper level" in terms of complexity is? Would you handle pre-eclampsia yourself, for example, or refer out? Bipolar?

As far as tailoring your practice, I assume that also means tailoring your skills, which I'm guessing happens mostly in residency? If you find a need for a service exists in your community that you don't feel as comfortable in (maybe a lot of MSK, for example), have you found that CME is enough to fill in the gaps you need to feel competent/comfortable safely treating patients, or do you tend to refer those cases more often by virtue of your skillset?

Thanks for your patience in answering these questions -- I don't really have any mentors in FM (for reasons I won't go into here), so this is super helpful for me to get an idea as to what FM practice looks like as I go into clerkships.

You can manage preeclampsia (if you're also someone who does OB) and bipolar (assuming you have some psych patients in your panel beyond depression/anxiety) as a family medicine doc. Other less common things like hyperthyroidism or hyperaldosteronism or other conditions that are in the single digit percentage frequency prevalence, you should be able to recognize --> diagnose and treat by yourself. You should not need CME to learn and manage things that any doctor should in theory know about. CME is for developing niche(s).

 

[cabinbuilder]

Thanks for this answer -- if you don't mind, I'm curious as to what you feel your "upper level" in terms of complexity is? Would you handle pre-eclampsia yourself, for example, or refer out? Bipolar?

As far as tailoring your practice, I assume that also means tailoring your skills, which I'm guessing happens mostly in residency? If you find a need for a service exists in your community that you don't feel as comfortable in (maybe a lot of MSK, for example), have you found that CME is enough to fill in the gaps you need to feel competent/comfortable safely treating patients, or do you tend to refer those cases more often by virtue of your skillset?

Thanks for your patience in answering these questions -- I don't really have any mentors in FM (for reasons I won't go into here), so this is super helpful for me to get an idea as to what FM practice looks like as I go into clerkships.

It really comes down to the quality of your residency. Not every residency is the same so what your training is and comfort zone is mostly determined by who has trained you. My residency did not deal with pregnancy, psych issues, or infants so I do not take care of those types of cases. I did not do a lot of ICU medicine either. However, I did a ton of geriatric, multiple medical problems, geriatrics, lots of ortho, ER case, heavy IM cases so those are what I am comfortable with. There is no "right" answer to your question. IT's very individually tailored. Now in urgent care where I work, my NP have tons of OB/GYN and neurosurgery experience so she takes those cases that are better suited to her knowledge base and do cases the same for her.

 

[scharnhorst]

Hi everyone,

I am very interested in family medicine, and this question is coming from a place of ignorance more than anything else. I've been hearing a lot about midlevel encroachment (although I don't want this to turn into a midlevel post, and am more interested in the FM side of these questions) and the like, and it's making me have some questions about FM as a field:

1. If someone has a "more simple" problem (sore throat, uncomplicated HTN), why not go to a PA or independent NP? Assuming they have the training to handle these routine cases, what's the need of the physician?
2. If someone has a "more difficult" problem (complicated pregnancy, weird valvulopathy, etc), why would they go to the PCP instead of the specialist (after getting the specialist referral)? In other words, why go to a generalist when there's always someone "better" (emphasis on the air quotes!) you could see?
3. In other words, I guess my question comes down to: what is the FM "sweet spot" of conditions complicated enough a physician needs to handle them, but not so complicated/esoteric a specialist is needed?

I mean no disrespect with these questions, and I think they may reflect my own lack of knowledge of the scope/expertise that FM docs possess more than anything; I've been asked some of these questions before when I've mentioned an interest in FM, and I haven't really had a great response. Part of my ignorance may also be from an upbringing on the East Coast, where specialists for everything (as I understand it) is more common. I would really appreciate any insight into this issue, and again, I am sorry if any of this comes off as disrespectful of the profession.

Good question why not cut out the middle man ?

 

[deleted87716]

Good question why not cut out the middle man ?

You mean, insurance?

 

[Matthew9Thirtyfive]

If someone has a "more simple" problem (sore throat, uncomplicated HTN), why not go to a PA or independent NP? Assuming they have the training to handle these routine cases, what's the need of the physician?

Because they might not be, and if you don’t know what simple looking things could potentially be, you’re not going to recognize when to send it up. Like my wife’s friend who had an “ear infection and sore throat” that was seen by two different midlevels and given two different antibiotics. When he finally went to a physician, they sent him to the ED for a huge retropharyngeal abscess that was close to compromising his airway.

 

[Captain_Falcon]

Because they might not be, and if you don’t know what simple looking things could potentially be, you’re not going to recognize when to send it up. Like my wife’s friend who had an “ear infection and sore throat” that was seen by two different midlevels and given two different antibiotics. When he finally went to a physician, they sent him to the ED for a huge retropharyngeal abscess that was close to compromising his airway.

"But he was breathing fine at the time, how were we supposed to know?!"

 

[scharnhorst]

You mean, insurance?

they have no dog in this fight

 

[PrimaryCareDOToBe]

You got a lot of good comments here, so I'll just say this one thing very quickly as I don't believe it was said.

Sometimes, the specialists role is more confirmatory or diagnostic. If you're the PCP and you really need to get a Biopsy of an internal organ to get the answer to the question - They must go to the specialist to do the biopsy, run a special imaging study, perform a special medical test requiring precisely timed injections/readings, etc.

However, once the diagnosis has been reached, the specialist may or not may not add in new treatment or modify slightly the treatment the patient came in on.

From this point on, unless something drastically changes with this patient, the PCP will be able to, with the new knowledge gained from the specialist, manage this disease on their own titrating up and down the medications as needed.

Otherwise, you'd have one patient going to 4 different specialists every 1-3 months for refills/check-ups and paying out the ass to be seen all while taking up time from patients who actually need to be seeing the specialist.

Because of the broad scope of Primary Care, even if you are no longer actively sending a patient to a specialist in this moment, and the patient is seemingly stable, I would still want the Physician checking in because Polypharmacy is a huge issue and one bias I've noticed with midlevels is they can tend to think "More expensive med = Better med. Taking more meds to fix things solves all problems". Whereas Physicians don't need to necessarily memorize a list of side-effects for every drug because we've learned about them from the ground-up, the side-effect profile and toxicities are more intuitive for us, and someone with that level of clinical suspicion and acuity is who I want managing a complex patient between their periodic check-ins with their specialists.

"The Eyes Can Only See What The Mind Knows" - Midlevels are great at helping Physicians see follow-ups and help out with the flow, but a Physician should be in charge and should be putting their eyes/hands/thought on things to truly ensure things are going right. Midlevels don't always know what they don't know.

In an ideal world, since the PCP has a longer standing relationship with patients too, they should "theoretically" be able to also look at what a specialist says and go "I think you're wrong - X may be because of Z, but Y isn't because of Z, I know this patient, and Y is their baseline, so we may need further investigation into Y, this seems suspicious" and the Specialist may not have caught that not because they're a bad doctor, but just because they don't have the luxury of knowing a patient as in depth (theoretically).