Your Input Needed on My Take on Family Medicine

[futureMD2015]

I'm very interested in Family Medicine particularly because I like having patients that I get to know well and follow up with on a regular basis.

I know that when it comes to actually practicing, things can get rather mundane and my magic bubble can burst pretty quickly: same patients showing up frequently with the same problems because they're not listening to advice, not taking their meds, many patients not even following up with you. After a while, I can see how it can become more of a routine job that you might not want to get up and do every day. The relationship with the patient might not be as important anymore. I've seen many family physicians at hospitals (I haven't seen any private practice ones) who go through their patient lists for the day, and really not caring whether to follow up with them or not.

My dream is to be able to make a difference in the lives of these patients that need help the most. Starting from people who go to the ER and never to a regular physician to just people who don't follow up on their meds/appointments. Giving them a call and remind them of an appointment, see how they're doing after prescribing medications. If they don't show up for a visit, give them a call. If they repeatedly don't respond, make it an in house call, just do whatever it takes to get these people on a good track. Is this too glorified of a view on the specialty? Am I able to make such a difference if I make the effort?

---

Members don't see this ad.

 

[jhonyguy04]

Honestly I think you have to balance your life well. It is important to care about your patients, but not to the point that its gonna interfere with your personal life, such as family. As a FP, I think you will have too many patients that are not collaberate with their own health, and you simply will not have enough time to stalk all these patients. You just try your best to provide the best health they can get, but you also need your patient's compliance in order for the treatments to work, so it is up to them if they want to get better.

 

[osumc2014]

I'm very interested in Family Medicine particularly because I like having patients that I get to know well and follow up with on a regular basis.

I know that when it comes to actually practicing, things can get rather mundane and my magic bubble can burst pretty quickly: same patients showing up frequently with the same problems because they're not listening to advice, not taking their meds, many patients not even following up with you. After a while, I can see how it can become more of a routine job that you might not want to get up and do every day. The relationship with the patient might not be as important anymore. I've seen many family physicians at hospitals (I haven't seen any private practice ones) who go through their patient lists for the day, and really not caring whether to follow up with them or not.

My dream is to be able to make a difference in the lives of these patients that need help the most. Starting from people who go to the ER and never to a regular physician to just people who don't follow up on their meds/appointments. Giving them a call and remind them of an appointment, see how they're doing after prescribing medications. If they don't show up for a visit, give them a call. If they repeatedly don't respond, make it an in house call, just do whatever it takes to get these people on a good track. Is this too glorified of a view on the specialty? Am I able to make such a difference if I make the effort?

Why not? although it does sound alittle idealistic, but if that is your passion then do it!

 

[gertie1]

FutureMD, I think your intentions are good and seem to be more akin to those practicing rural medicine. Doing home visits for those unable to come to the office and focusing on follow up are two things that very much needed in primary care, particularly for elderly and/or otherwise compromised patients. I'm planning on attending PA school and want to focus on primary care and would like to work in an office where this sort of mind-set exists. The trick, however, would be to not become over-involved in patient's lives.....not an easy task at times.

 

[Perrotfish]

I'm very interested in Family Medicine particularly because I like having patients that I get to know well and follow up with on a regular basis.

I know that when it comes to actually practicing, things can get rather mundane and my magic bubble can burst pretty quickly: same patients showing up frequently with the same problems because they're not listening to advice, not taking their meds, many patients not even following up with you. After a while, I can see how it can become more of a routine job that you might not want to get up and do every day. The relationship with the patient might not be as important anymore. I've seen many family physicians at hospitals (I haven't seen any private practice ones) who go through their patient lists for the day, and really not caring whether to follow up with them or not.

My dream is to be able to make a difference in the lives of these patients that need help the most. Starting from people who go to the ER and never to a regular physician to just people who don't follow up on their meds/appointments. Giving them a call and remind them of an appointment, see how they're doing after prescribing medications. If they don't show up for a visit, give them a call. If they repeatedly don't respond, make it an in house call, just do whatever it takes to get these people on a good track. Is this too glorified of a view on the specialty? Am I able to make such a difference if I make the effort?

In terms of improving the health of your patients, there's no question that a competent FP has the greatest impact. There's strong statistical evidence that adding FM docs to a commuity significantly improves the community members' quality of life and longevity, while adding a subspecialist, even in a seemingly life and death field like cardiology, doesn't have much statistical effect. If you make the effort, it will definitely make a huge difference and save plenty of lives.

That being said, FM is a profession of clinics, and I would say the majority of docs find clinics unattractive. On my FM rotation I found that the idea of building relationships with patients over years was completely undermined by how little time you had to spend with them. I think the average US FP has about 15 minutes per patient. That's incuding documentation, prescription writing, etc, meaning you'll be lucky to get 10 minutes in the actual room. The visits are also getting shorter with increasing patient loads and decreasing compensation. I knew one FP whose practice was down to 4 minutes, total, per patient. That left about 30 seconds of time to actually be in the room: the doc couldn't possibly take a history or do a physical, he pretty much just needed to concur with whatever diagnosis the patient/CNA came up with. It's a grind, and it's not a good enviornment to build up lasting interpersonal relationships. If I have 30 seconds with you I'm definitely not asking about your kids.

I'd say, as other have, that your best chance of getting what you're describing is to work in a small FM group in a rural community. The impact on the health of the community is obvious. You get to see your patients out of clinic and therefore acctually build up relationships with them. The lack of fellowship trained docs means that you'll get to manage cases that would otherwise have been managed by IM subspecialists. You can also do procedures (OB/Gyn, Basic Derm and Botox) that are both lucrative and very hard for an Urban FP to break into, and which can allow you to cut down on your census so that you can spend more time with each patient. You can do cool little extras like being the sports doc for the local football teams, or taking leadership roles in the community. Finally a combination of government and free market incentives means that rural FPs can earn tens of tousands more per year even though they're working in an enviornment where a dollar goes a lot farther. The $150K that FPs make in New York buys a crappy aparment, the $200K that FPs earn in rural Louisiana buys the largest mansion in town with money to spare.

If possible do your FM rotation in a rural area, or failing that do a rural FM elective. Don't base your decision entirely on an urban residency program attached to your school. Also the AAFP (the family medicine organization) is easily the best organization for preclinical students to join: membershi is free, their publication is readable and educational at your level, their conferences (especially the national conference) are designed with students in minds and an excellent choice for you to attend, and they offer some cool scholarship programs for medical students including a paid rural preceptorship after your first year of medical school. That being said, study for class and Step 1 with the assumption that you're going to end up wanting Ortho, because no matter how much you like FP during your preclinical when you hit roations you might find out that's exactly what you do want.

 

[futureMD2015]

Thanks so much for the helpful comments all. Perrotfish, it's very true that it's mostly time that undermines building a good doctor-patient relationship for FP in an academic hospital setting. I have considered rural medicine and it is very attractive to me for the reasons that you've laid out above. At the same time, (and I'm not sure if this is the case in other areas because I'm not very experienced), in the city that I currently live in, there seems to be more challenges with the inner-city patient population than the patients in rural areas. I guess if that's the population that I would like to help then I would be looking at working at a community hospital or somewhere to that effect?

As for your last comment, no worries about studying hard. I'm incapable of not working hard (in a good way). I'm also considering OB-GYN, so keeping my options open for now.

 

[Perrotfish]

At the same time, (and I'm not sure if this is the case in other areas because I'm not very experienced), in the city that I currently live in, there seems to be more challenges with the inner-city patient population than the patients in rural areas. I guess if that's the population that I would like to help then I would be looking at working at a community hospital or somewhere to that effect?
.

If you worked in the inner city you could set up your own practice, work in a private FP group, or work in a clinic attached to a hospital.

That being said, I still think that FP is really at its best in rural area because:

1) As I mentioned earlier, urban areas seem to emphasize a model where you have an insanely fast visit, then refer to a specialist for anything remotely complicated. The continuity with your patients is sometimes painfully limited. However unique and important the challenges of urban patients may be, you might not have an opportunity to really address them. The incredibly narrow scope of practice makes me think that urban areas don't need more FPs so much as they need more NPs and PAs.

2) In terms of FPs per capita, FPs are overconcentrated in Urban areas. This is bad enough by itself, but it's even worse when you consider that FPs are really the only source of healthcare in rural area, where a city is also served by a massive number of specialists. Rural medicine needs you more.

3) As I mentioned earlier, rural FPs work less for more respect and more pay (on average) than urban FPs. It pays to go where you're needed.

Anyway, just my opinion.

 

[TexasPhysician]

Very idealistic indeed. Your patients may love you, but your way isn't the way to make money. Remember that you have a good amount of overhead, and if you don't see X number of patients/day, you will have trouble with that whole income thing.

 

[mataku527]

I have similar interests to you and am currently a M4. The general consensus you will get from talking to most other medical students is all the crap that FM gets and that clinics are boring, the patients are non-compliant, blah blah blah, and quite frankly to try and describe the field of family medicine when most of these people have little to no experience with them will get you nowhere. I really think it's something you will have to experience for yourself to see if it is something you want. My sentiments are similar to yours in that I do want to make a difference and I think the best opportunity for that is through family medicine.

I have had both types of family medicine experiences: where the doc no longer gives a crap and spends 5 minutes with the patients and just throws medications at them with little to no H&P. At the same time, I have worked with a doctor who spends LOTS of time with hs patients, including taking phone calls to talk his patient into going to the hospital rather tihan commit suicide. Both of these doctors had very similar salaries, albeit the second one worked a lot more.

You will hear a lot about how you can only do real family medicine in rural areas, but similar to you, I am from a major city. Guess what? There are a very large underserved population in most major cities. You will need to find the strong programs within your city. The program I am looking at has family medicine docs that run the inpatient service and runs the OB floor including C-sections, all in a major city. While doing all this, many of these docs also dedicate time internationally. Similar to them, my plan after residency and MCH fellowship, I will work with the underserved at an FQHC while seeing my patients at the hospital and doing C-sections. I hope to dedicate ~3months/year overseas, but will more realistically be doing 1-2months/year.

A lot of people say FM is boring, but I honestly think all the other specialties are boring. How much you treat your patients and how much you refer will be up to you and with the underserved, sometimes you are the only one that is willing to take the time to understand their complex disease. Furthermore, at some point you will know most of the medicine you need for your practice, the only thing that really changes is the patients. Yah, some patients will be non-compliant and you will learn to let things go, but at the same time, what are you doing to help them besides telling them? FM programs are the only place where they are starting gardens at their hospital for the community, running mentor programs for at risk high school students, healthy cooking classes for their patients, workout classes for their patients, and so on and so forth. Change comes from the ground up.

alas, this is only MY opinion, I am clearly biased.

 

[osumc2014]

Very idealistic indeed. Your patients may love you, but your way isn't the way to make money. Remember that you have a good amount of overhead, and if you don't see X number of patients/day, you will have trouble with that whole income thing.

not to mention you have sooo many patients to see, is spending more time on some and not seeing other's (or at later date) worth it?

 

[sindadel]

Putting passion into practice is a lifelong game and it's the only game worth playing. It's important to set and maintain boundaries, but I think you'll find a lot of opportunities to help those who really need help. Perhaps you won't be able to do it full time at first, but even one day a week of clinic targeted at an underserved population makes an enormous impact.

 

[futureMD2015]

Thanks so much everyone for the input. I'll be shadowing family practice in an urban setting for now due to travel constraints, but I'll make sure to do some work in rural areas once I'm in med school.

 

[MossPoh]

As a bit of a side note, every specialty can get mundane. The majority of your practice is going to be in a certain grouping of things...those things just change with each specialty. For many people, that ends up being comforting as one gets older in a way. Also, it means you tend to look forward to the personal interactions more than the other junk that you can do on autopilot. Nothing is exciting when you do it hundreds upon hundreds of times.