Why does everyone lose their minds over FM having a wide scope of practice, but lets midlevels do literally anything?

[SLC]

You must definitely live in an area in which people have the technology skills, reading skills and money to do that. Some of my patients don't even have phones. I'll often have patients sign up for the portal on our desk top while I'm putting in orders or filling out something and the ability of many of them to read and get through the instructions is often low. For those that are signed up on the portal I'd say about half the messages I send end up going unread.

I love my patients and the work that I do but for the person who asked about how we do it, it's not always a simple we can just send them everything through a portal and never call them to follow up or discuss issues. I don't mind calling patients and working on paperwork. Often times the expense to take public transportation to get to us is a burden or if they have childcare issues. I'd rather not make them drag 3 kids in to the office if I can just fill the paperwork out when their company faxes it to me.

Just wanted to point that out in case someone reading does work with a population similar to mine.

Nope, rural and underserved. But these days, basically everyone has a smartphone.

But even in the worst areas, illiteracy is still not that common.

For those rare few who don’t have access to get on the portal; that’s when I write a note and have staff call the patient.

---

Members don't see this ad.

 

[AMEHigh]

Nope, rural and underserved. But these days, basically everyone has a smartphone.

But even in the worst areas, illiteracy is still not that common.

For those rare few who don’t have access to get on the portal; that’s when I write a note and have staff call the patient.

Yeah definitely different world here, ha.
Plus a lot of my patients don’t speak English so I prefer to use verbal trained translation vs just using google to send something on the portal.

 

[SLC]

Yeah definitely different world here, ha.
Plus a lot of my patients don’t speak English so I prefer to use verbal trained translation vs just using google to send something on the portal.

Yeah, I’m trilingual, including Spanish so that definitely helps. We have lots of Spanish only migrant farm workers here.

 

[Roxas]

I haven't called a patient personally (before COVID) in several years.

I don't fill out forms, my staff does and I just sign them.

99% of refills require an office visit, train your patients in this and life gets way better.

Your residency program has you doing this all wrong. You can’t work harder than your patients do.

I don’t call patients, I don’t speak to them on the phone. I will communicate through my MA. But if they want to speak to me personally then it’s an office visit.

I don’t fill out nonsense paperwork, if you have a form you need filled out, you come in to the office so we can work on it together.

We have a patient portal, all results communication goes through there. If it’s critical, my staff will call the patient at my direction but otherwise people know to check their portal. And if they call for results, they’re directed to the portal where generally I’ve typed a message explaining the results and their significance and any recommended course of action.

In to work at 8, out by 5 is my motto.

You guys don't know how much I needed to hear this. My program isn't nearly as bad as @Splenda88 , but I feel like the whole "tasks" aspect is one of the biggest turn-offs to outpatient medicine. Prior to covid I was doing just 1-2 half days of clinic per week and felt like I was getting a ton of daily tasks. Patients asking for refills, lab results, questions that for some reason get directed to me. It just feels like juggling trying to keep 50 balls in the air. I can't imagine what it's like with a patient panel of 1200+.

I cannot wait to have a job with support staff that actually knows what they're doing, or that I can train with my preferences. At our resident clinic the most senior nurse we have has been there like 3 months and she is terrible. The icing on the cake is she's "training" the newer nurses to be equally if not more terrible. Despite all this I actually really like clinic overall (reaffirming that I probably belong in outpatient) but man there are some real headaches sometimes.

I have to hold on to hope that it will get better from here.

 

[SLC]

You guys don't know how much I needed to hear this. My program isn't nearly as bad as @Splenda88 , but I feel like the whole "tasks" aspect is one of the biggest turn-offs to outpatient medicine. Prior to covid I was doing just 1-2 half days of clinic per week and felt like I was getting a ton of daily tasks. Patients asking for refills, lab results, questions that for some reason get directed to me. It just feels like juggling trying to keep 50 balls in the air. I can't imagine what it's like with a patient panel of 1200+.

I cannot wait to have a job with support staff that actually knows what they're doing, or that I can train with my preferences. At our resident clinic the most senior nurse we have has been there like 3 months and she is terrible. The icing on the cake is she's "training" the newer nurses to be equally if not more terrible. Despite all this I actually really like clinic overall (reaffirming that I probably belong in outpatient) but man there are some real headaches sometimes.

I have to hold on to hope that it will get better from here.

Don’t worry, residency clinic is a disaster almost everywhere. By its very nature there’s little stability (different doctors every single day, residents of all different skill and experience levels, rotating door of office staff, rotating door of patients). It’s (minimally) controlled chaos on a good day. I mean, in 3 years, I can think of maybe 8-10 patients I can state I had enough continuity with to know them and remember them. Most of the time it was people I was seeing for the first time, who’d seen other residents several times, but who’s residents were not in clinic.

My residency was inner city east coast (Boston area); and being out where I am now, even though the patients are low SES in general. Which makes accessIng care an issue. The continuity And stability in staff alone takes like 80% of the frustration away. And I get enough face time with people to help them see the point in what I’m telling them.

 

[AMEHigh]

Yeah, I’m trilingual, including Spanish so that definitely helps. We have lots of Spanish only migrant farm workers here.

Ahh that’s awesome. I’m def not trilingual.
Spanish is a big language here but so are a lot of West African languages and Arabic.

 

[TwistedTea]

To expand upon this a little bit: in this example I can probably do 90% of what endocrine can for diabetes. Its that last 10% that gets tricky - pumps, U-500, stuff like that.

Same with most fields. I can do CHF about as well as cards up to a point, and that point is when they start talking about the need for ICDs, LVADs, and transplant.

Its why the traditional way of thinking about it is accurate. If we imagine medical knowledge as a swimming pool, FPs know the first 2 feet of the whole pool. A specialist knows the full 6 feet depth but only in their corner of the pool.

And nurse practitioners know the first two inches

 

[Captain_Falcon]

To expand upon this a little bit: in this example I can probably do 90% of what endocrine can for diabetes. Its that last 10% that gets tricky - pumps, U-500, stuff like that.

Same with most fields. I can do CHF about as well as cards up to a point, and that point is when they start talking about the need for ICDs, LVADs, and transplant.

Its why the traditional way of thinking about it is accurate. If we imagine medical knowledge as a swimming pool, FPs know the first 2 feet of the whole pool. A specialist knows the full 6 feet depth but only in their corner of the pool.

Where would you say EM fits into that pool analogy? And Psych?

 

[SXMMD]

Where would you say EM fits into that pool analogy? And Psych?

EM: 1 ft in primary care side of pool 3-4 feet in emergency/trauma/acute care side of pool.

Psych: afraid of drowning, not in the pool

Jokes aside, I don't think the analogy was meant to be a literal measuring tool...

 

[TwistedTea]

EM: 1 ft in primary care side of pool 3-4 feet in emergency/trauma/acute care side of pool.

Psych: afraid of drowning, not in the pool

Jokes aside, I don't think the analogy was meant to be a literal measuring tool...

We should honestly be measuring in saunameters

 

[Captain_Falcon]

EM: 1 ft in primary care side of pool 3-4 feet in emergency/trauma/acute care side of pool.

Psych: afraid of drowning, not in the pool

Jokes aside, I don't think the analogy was meant to be a literal measuring tool...

Lol yeah I know the analogy doesnt work across the board. I was interested about EM though because a couple EM doctors ive met have said they partially chose the field because you have to be the 2nd smartest in regards to every field

And Psych- I honestly was anticipating something like "they're in their own hot tub wearing vests and bow ties" lol

 

[VA Hopeful Dr]

Where would you say EM fits into that pool analogy? And Psych?

A quote another SDNer used awhile back that I really like:

EM is the acute care generalist, FM is the chronic care generalist.

Psych is considered a specialist, so they know the full depth. It just happens to be the imaginary pool 1 block over.

 

[Instatewaiter]

PGY3 FM resident here at an academic medical center with the majority of specialty residencies present.

IM program here has multiple medicine floor teams with a rotating cap that pawns new patients onto the next team when capped (set at a modestly low number) and then to the private hospitalist group once all teams cap. Also, private hospital in town that they do not work at. They admit all clinic patients up to the cap and if anyone needs ICU they transfer care to the unit team.

FM program has one floor team at each hospital. At the university hospital we also admit all clinic patients and utilize the MICU, CICU, SICU, and NeuroICU as open units and manage all our own patients in the unit. Service never caps and frequently hits 25-30 patients for 3-4 residents. Vast majority of patients have many comorbidities at odds with one another (ESRD on HD, CHF with EF < 20, high MELD cirrhosis, etc) with very few bread and butter pyelo in an otherwise healthy admissions. Manage our own inpatient pediatrics and on call FM labor and delivery with this team, as well.

Private hospital similarily has a single team covering that functions as a private hospitalist group and is on 24 hour unassigned call every 4 days. ICUs largely open over there too with us managing the majority of our critical patients.

At the university hospital, patient census volumes are private hospitalist >>> FM > IM, not including the extra volume at the second hospital.

So, are we just a unique residency or is the difference between FM and IM general inpatient training less pronounced than many would indicate?

Few points:
1) IM has caps created by the acgme. Usually 10 as an intern, 20 per resident. This tends to be the standard cap. Weaker programs tend to have lower caps. By rules, if you reach the cap, has to either be managed by the resident or another team.

2) very good evidence that a closed ICUs have better outcomes. So good for you guys for managing your patients unlike those IM folks doing what's right for the patient .

3) There is nothing wrong with getting another doc involved. Don't let your ego get in the way of patient care. There should be no guilt in getting a specialist involved but there is if you get them involved after it is too late.

 

[Instatewaiter]

And nurse practitioners know the first two inches

Hate to tell you but it all depends on the NP.

A well trained np in a very specific area actually knows quite a bit more than the pcp about that area. Obviously the FM is going to know a whole lot more about a whole lot more but in a specific area when youve done only that for 10 years you're going to know it pretty well no matter if you're a PA or a doc.

 

[KeikoTanaka]

Hate to tell you but it all depends on the NP.

A well trained np in a very specific area actually knows quite a bit more than the pcp about that area. Obviously the FM is going to know a whole lot more about a whole lot more but in a specific area when youve done only that for 10 years you're going to know it pretty well no matter if you're a PA or a doc.

But that isn't really relevant to this conversation because no Family Nurse Practitioner is going to have such knowledge of an arbitrary random field more than a Family Physician unless of course they were in a specialty before transitioning to family practice. But then I'd be worried about their 90% of other knowledge they should know to practice FM.

 

[Instatewaiter]

But that isn't really relevant to this conversation because no Family Nurse Practitioner is going to have such knowledge of an arbitrary random field more than a Family Physician unless of course they were in a specialty before transitioning to family practice. But then I'd be worried about their 90% of other knowledge they should know to practice FM.

I have never understood why they would let an NP work unsupervised in such a broad field. No way a 2 year online degree is going to teach an NP enough to be anywhere near a competent pcp.

But an np working for instance only in heart failure for years is going to have a better understanding of how to manage difficult CHF because it is not as broad as all of medicine.

 

[MedicineZ0Z]

Few points:
1) IM has caps created by the acgme. Usually 10 as an intern, 20 per resident. This tends to be the standard cap. Weaker programs tend to have lower caps. By rules, if you reach the cap, has to either be managed by the resident or another team.

2) very good evidence that a closed ICUs have better outcomes. So good for you guys for managing your patients unlike those IM folks doing what's right for the patient .

3) There is nothing wrong with getting another doc involved. Don't let your ego get in the way of patient care. There should be no guilt in getting a specialist involved but there is if you get them involved after it is too late.

1. 7-10 is the sweet spot range (probably 7-8) in terms of maximizing learning. Part of a resident's job is indepth learning and not just pure patient care.

2. Indeed. But closed or open ICU is the hospital's decision and the can be a byproduct of the available resources. You make it sound like the IM residency decides that the hospital's ICU will be closed ?? lol. Plenty of IM residencies out there with open-ICUs too without a fellow.

3. Only if the specialist is actually a physician who will personally examine the patient properly. And not calling an NP who will see the patient and have the attending do a walk-by at 5pm. The former is a available consult and the latter is nothing more than sharing liability.

 

[TwistedTea]

Hate to tell you but it all depends on the NP.

A well trained np in a very specific area actually knows quite a bit more than the pcp about that area. Obviously the FM is going to know a whole lot more about a whole lot more but in a specific area when youve done only that for 10 years you're going to know it pretty well no matter if you're a PA or a doc.

It is possible but we were discussing primary care here, not the corner field of sleep medicine in the 6 foot deep section.

(using as an example since back in med school I did a week with a sleep medicine NP who was very good). but Good NPs are def not the normal. I would also lead the argument its probably better for NPs to work in super specialized areas instead of primary care since the breadth of knowledge is so much narrower. Primary care is the worst field for midlevels, unless you want a referral machine.

 

[KeikoTanaka]

It is possible but we were discussing primary care here, not the corner field of sleep medicine in the 6 foot deep section.

(using as an example since back in med school I did a week with a sleep medicine NP who was very good). but Good NPs are def not the normal. I would also lead the argument its probably better for NPs to work in super specialized areas instead of primary care since the breadth of knowledge is so much narrower. Primary care is the worst field for midlevels, unless you want a referral machine.

A referral machine who can bill just as much as a physician, requires half the salary of a physician, and sends patients to more physicians to bill for more things. A capitalistic healthcare giant's dream.

 

[TwistedTea]

A referral machine who can bill just as much as a physician, requires half the salary of a physician, and sends patients to more physicians to bill for more things. A capitalistic healthcare giant's dream.

I think it will catch up with them sooner or later, same with dishonest contractors, mechanics, etc. Word gets out fast if you suck and also if you screw people.

I think most people want a primary care doctor, not midlevel. If I am paying the same for each service you can damn well bet I would rather have the Lexus instead of the Chevy.

 

[studentxx8800]

A referral machine who can bill just as much as a physician, requires half the salary of a physician, and sends patients to more physicians to bill for more things. A capitalistic healthcare giant's dream.

Other ways to see it are that excessive referral create back log in the system, expensive cares that are unnecessary take away time and resources for patients who actually need it (a problem for places that aim for the model of efficiency), and also lots of patients are unhappy when they are referred for things that specialists end up telling them were minor and unnecessary especially if it takes a long time to see such specialists. A shortage of patients is not really a major concern (at least pre-COVID era) for hospital system tbh. Plenty of fat and sick people in this country and that number goes up every year and not by a small margin