New Article -- Family Medicine: Challenges for the Solo Practitioner

zipmedic said:

Hello! There is a new article on the SDN Front Page that may be of interest to you -- Family Medicine: Challenges for the Solo Practitioner. Here is a brief excerpt from the article:




Thank you,
zipmedic
Editor-in-Chief
SDN Front Page

Click to expand...

It's very interesting but I have to say that flying solo in medicine is no longer okay. It just doesn't make sense anymore. Big corporations get away with all kinda things and you being an indivisual business is just not smart. Medicine is just like the corporate world. You join a big organization and advance in the ranks or move to another big organization that is more likely to allow you to advance. The organization will make sure that your rights are protected... including the rights of practicing and reimburisement. It's just too bad that FM is scattered. Bigger groups is better is in my opinion... solo is not as good if you are going to fight competition.

I thought it was a good article but it contained bad news for future FPs who want to practice the full scope of family medicine. Turf wars and finances will keep you from practicing the way you were trained. I hope this is not the "future of family medicine."

skypilot said:

I thought it was a good article but it contained bad news for future FPs who want to practice the full scope of family medicine. Turf wars and finances will keep you from practicing the way you were trained. I hope this is not the "future of family medicine."

Click to expand...

Unfortunately, almost all indicators say it is. FM is fast becoming the "Limited Generalist" specialty - or non-specialty. I think you can still obtain the very broad procedural training at this point at a handful of places, but you will have to go pretty darn rural to use it. And even then it will be a struggle, especially to find partners. And in the not so distant future, it most likely will be absolutely impossible to even get trained in this model of care. I wish it wasn't this way more than anything but I fear it is. If you are interested in this topic, you may want to read Dr William McMillian Rodney's thoughts on the Limited Generalist model of care and it's implications. Basically, his basic premise is that soon the full scope training will no longer be available because there are not enough people coming through the system now getting and applying that type of training and that makes it impossible to educate the next generation of full scope practitioners. His contends that Family Medicine as a specialty has pretty much neutered itself as it is no longer capable of producing adequately trained full scope practitioners. I tend to agree with him even though it hurts me to do so.

Tn Family MD said:

Unfortunately, almost all indicators say it is. FM is fast becoming the "Limited Generalist" specialty - or non-specialty. I think you can still obtain the very broad procedural training at this point at a handful of places, but you will have to go pretty darn rural to use it. And even then it will be a struggle, especially to find partners. And in the not so distant future, it most likely will be absolutely impossible to even get trained in this model of care. I wish it wasn't this way more than anything but I fear it is. If you are interested in this topic, you may want to read Dr William McMillian Rodney's thoughts on the Limited Generalist model of care and it's implications. Basically, his basic premise is that soon the full scope training will no longer be available because there are not enough people coming through the system now getting and applying that type of training and that makes it impossible to educate the next generation of full scope practitioners. His contends that Family Medicine as a specialty has pretty much neutered itself as it is no longer capable of producing adequately trained full scope practitioners. I tend to agree with him even though it hurts me to do so.

Click to expand...

I think that things may change big time in Family Practice if national healthcare becomes a reality in the 5 or so years, basically, there would be a large number of healthy people who need physicals and annual check ups, but are otherwise well. What our country can do well at this point is acute care, but we are really bad at preventive care. I think that national healthcare would increase the job that family practicioners do, i.e. which is mostly ambulatory medicine at this point, i.e. the 40 million uninsured need insurance so that with preventive healthcare, i.e. counciling for HTN and DM, they don't become a huge healthcare cost down the line. This country is setting itself up for big problems, i.e. skyrocketting obesity has people in the US scratching their heads, but eventually we are going to feel the impact of this later down the line, i.e. as these people use up more and more healthcare dollars and decreased productivity. But yes, right now Family Practice residencies are closing their doors, there aren't enough people to fill all of the positions.

The premise of Family Practice is almost the ideal situation where a doctor who knows you and your family basically sees you for physicals, sees your kids, delivers your babies and does procedures like maybe you need an appendectomy, and know about you so that when you are depressed they prescribe an SSRI. Honestly, if my wife was pregnant I would want an Ob/Gyn to do the delivery even if it was non-complicated because they know much much more than a Family Practice doctor, and if I was hospitalized with a serious illness, I would like an internist to take care of me not a Family Practice doctor, albeit some Family Practice doctors may be great, but you get good at what you do alot of. I think family medicine should be retooled into a specialty into Ambulatory Medicine, right now there is alot that can be done better in the clinic in terms of tracking medications the patient is on, knowing when to refer to a specialist, and even make sure that the proper screening exams are done, I think Family Practice should discontinue ob/gyn and general surgery training, it is not practical to train someone in something they won't use, add a little more inpatient medicine and pediatrics and apply evidence based medicine to clinical practice so basically the Family Practice doc becomes the overall *manager* of your healthcare, is responsible for your health maintenance and prevention, i.e. deal with bp screening, diabetes screening, cancer screening, and maybe does Pap smears in the clinic, but during acute problems gets sent to the internist, pediatrician or ob/gyn. Family Practice doctors ask specialists as surgeons, internist and other docs often asked Family Practice doctors what do with a patient who walks in with x. If FPs were taught how to excell in the clinic and become excellent patient managers, then this would help turn FP into a "specialty" in a sense, and may be they could bill for this. The set of skills for a good ambulatory patient visit are different from those need to run a ward in a hospital, you have to be part ob/gyn, part neurologist, part psychiatrist etc. . . whereas in the hospital you may have 10 different doctors on the case each focus on one organ system, or maybe more for the general medical attending. I propose changing Family Practice into a General Ambulatory and Preventive Medicine Residency. I think HMOs would pay for that big time, as would the government, an ounce of prevention is worth a pound of cure, maybe the system could be worked so that you don't see 40-50 patients a day, but less, but basically your quality time with patients will prevent of alot of costly care down the road . . .

BogglestheMind said:

I think that things may change big time in Family Practice if national healthcare becomes a reality in the 5 or so years, basically, there would be a large number of healthy people who need physicals and annual check ups, but are otherwise well. What our country can do well at this point is acute care, but we are really bad at preventive care. I think that national healthcare would increase the job that family practicioners do, i.e. which is mostly ambulatory medicine at this point, i.e. the 40 million uninsured need insurance so that with preventive healthcare, i.e. counciling for HTN and DM, they don't become a huge healthcare cost down the line. This country is setting itself up for big problems, i.e. skyrocketting obesity has people in the US scratching their heads, but eventually we are going to feel the impact of this later down the line, i.e. as these people use up more and more healthcare dollars and decreased productivity. But yes, right now Family Practice residencies are closing their doors, there aren't enough people to fill all of the positions.

The premise of Family Practice is almost the ideal situation where a doctor who knows you and your family basically sees you for physicals, sees your kids, delivers your babies and does procedures like maybe you need an appendectomy, and know about you so that when you are depressed they prescribe an SSRI. Honestly, if my wife was pregnant I would want an Ob/Gyn to do the delivery even if it was non-complicated because they know much much more than a Family Practice doctor, and if I was hospitalized with a serious illness, I would like an internist to take care of me not a Family Practice doctor, albeit some Family Practice doctors may be great, but you get good at what you do alot of. I think family medicine should be retooled into a specialty into Ambulatory Medicine, right now there is alot that can be done better in the clinic in terms of tracking medications the patient is on, knowing when to refer to a specialist, and even make sure that the proper screening exams are done, I think Family Practice should discontinue ob/gyn and general surgery training, it is not practical to train someone in something they won't use, add a little more inpatient medicine and pediatrics and apply evidence based medicine to clinical practice so basically the Family Practice doc becomes the overall *manager* of your healthcare, is responsible for your health maintenance and prevention, i.e. deal with bp screening, diabetes screening, cancer screening, and maybe does Pap smears in the clinic, but during acute problems gets sent to the internist, pediatrician or ob/gyn. Family Practice doctors ask specialists as surgeons, internist and other docs often asked Family Practice doctors what do with a patient who walks in with x. If FPs were taught how to excell in the clinic and become excellent patient managers, then this would help turn FP into a "specialty" in a sense, and may be they could bill for this. The set of skills for a good ambulatory patient visit are different from those need to run a ward in a hospital, you have to be part ob/gyn, part neurologist, part psychiatrist etc. . . whereas in the hospital you may have 10 different doctors on the case each focus on one organ system, or maybe more for the general medical attending. I propose changing Family Practice into a General Ambulatory and Preventive Medicine Residency.

Click to expand...

Ummmm, yeah, I think you totally missed the point. The out-pt clinic only practice you describe is exactly the Limited Generalist to which I was referring. The problem is, not many people are going to find that type of practice appealing, ergo there will not be anyone wanting to do it. The type of Family Practice that is full spectrum is much more appealing and cost effective, but unsustainable in the real (urban) world where everyone, like you, wants that specialist to deliver their normal, routine care. It is unnecessary and very expensive and very disjointed and certainly not what is best for MOST patients. I think that if we do end up with socialized health care (and the only way I would support socialized health care) is if we had tons of FP docs delivering full spectrum care. But we don't have that and so socialized health care won't save any money because we don't have the generalists to send people to, only the expensive specialists. And there is already a specialty for preventive medicine. It's called Preventive Medicine. and no one wants to do it. Because there is no MONEY in it. And as far as the "overall manager" concept for FP docs. They tried that in the 90's. It didn't work then and it won't work now either. Because there is no money in it and it is not very enjoyable work either. Your ideas suck.

Tn Family MD said:

Because there is no money in it and it is not very enjoyable work either. Your ideas suck.

Click to expand...

Come on now, ease up.

As far as enjoyable, that is an opinion and varies from person to person (although one can infer general interest by application numbers).

Tn Family MD said:

The problem is, not many people are going to find that type of practice appealing, ergo there will not be anyone wanting to do it. The type of Family Practice that is full spectrum is much more appealing and cost effective, but unsustainable in the real (urban) world where everyone, like you, wants that specialist to deliver their normal, routine care.

And as far as the "overall manager" concept for FP docs. They tried that in the 90's. It didn't work then and it won't work now either. Because there is no money in it and it is not very enjoyable work either. Your ideas suck.

Click to expand...

I think that alot of people would find training that emphasizes ambulatory training intriguing, and alot of physicians would like to have a pure ambulatory based practice, we are already there in some respects as many family practicioners only do clinic. Dermatology is largely office based, and I think that is pretty competitive these days, why?, because it allows great lifestyle. Leaders in Family Practice need to advertise the good lifestyle opportunities of ambulatory only care of patients.

Tn Family MD said:

It is unnecessary and very expensive and very disjointed and certainly not what is best for MOST patients. I think that if we do end up with socialized health care (and the only way I would support socialized health care) is if we had tons of FP docs delivering full spectrum care.

Click to expand...

Family docs have never delivered "full spectrum care" (and never will) i.e. complicated ob/gyn cases need to go to ob/gyns or else the patient isn't getting the level of care required, complicated pediatric cases involve pediatricians and pediatric specialists, and complicated/more detailed surgery goes to surgeons. I respectfully disagree that having family docs do "full spectrum" care is best for patients. I really don't understand what you are arguing as family docs are a new type of doctor, but I don't think FPs will be taking over anything from any ob/gyn, pediatrician or internist, more and more FPs are being limited because hospitals want the hospitalists to be internists and pediatricians who have better in-hospital training. Is a hospital with general pediatricians, neonatologists, etc. . . going to have a family practicioner start seeing newborns after just a couple months exposure to pediatrics compared to more extensive training for a pediatrician? I don't think so, nobody can know everything, and I don't think that anyone can become the "super doctor" doctors that everyone hoped that FPs would become back in the 1980s i.e. do surgeries, ob/gyn, peds, hospitalist and everything under the sun, it is dangerous that is why! If you ever build a house, and you have an electrician who dabbles in plumbing, and he offers to do the plumbing too because he had done a couple, do you know what often happens? He messes up and you have to go hire the professional plumbers to get the job done, end of story. It is better for patients to have physicians strengthen themselves in a specific areas.

Tn Family MD said:

And there is already a specialty for preventive medicine. It's called Preventive Medicine. and no one wants to do it. Because there is no MONEY in it.

Click to expand...

I think that if there was a national push to reign in health costs by training more physicians in preventive health, i.e. specifically family practice doctors, they could be compensated for this better somehow. Somebody just needs to sit down and crunch some numbers and realize that preventive healthcare will save alot of life and money.

Tn Family MD said:

And as far as the "overall manager" concept for FP docs. They tried that in the 90's. It didn't work then and it won't work now either. Because there is no money in it and it is not very enjoyable work either. Your ideas suck.

Click to expand...

A primary care physician is supposed to be the overall manager of a patient's healthcare, i.e. refer to surgeons, etc. . . I'm sure you know it is important to know what surgery your patient had, etc. . . the problem is that it takes time to get records and stuff sent in, but if we looked at the whole process and were able to streamline how information amoung doctors is shared, then patient care would become better. I am talking about improving resident education of FPs, and improving how the health system operates, if you teach residents a skill, then perhaps you can charge for it later on, regulations may change, but it is best to teach FP residents how to care for their patients.

Tn Family MD said:

Ummmm, yeah, I think you totally missed the point. The out-pt clinic only practice you describe is exactly the Limited Generalist to which I was referring. The problem is, not many people are going to find that type of practice appealing, ergo there will not be anyone wanting to do it. The type of Family Practice that is full spectrum is much more appealing and cost effective, but unsustainable in the real (urban) world where everyone, like you, wants that specialist to deliver their normal, routine care. It is unnecessary and very expensive and very disjointed and certainly not what is best for MOST patients. I think that if we do end up with socialized health care (and the only way I would support socialized health care) is if we had tons of FP docs delivering full spectrum care. But we don't have that and so socialized health care won't save any money because we don't have the generalists to send people to, only the expensive specialists. And there is already a specialty for preventive medicine. It's called Preventive Medicine. and no one wants to do it. Because there is no MONEY in it. And as far as the "overall manager" concept for FP docs. They tried that in the 90's. It didn't work then and it won't work now either. Because there is no money in it and it is not very enjoyable work either.

Click to expand...

I would edit out the personal attacks but basically I agree with you. Who wants to be a FP if all you do is well visits and referrals to specialists? If I were an FP I would at least want to have a panel of procedures I was competent in and be able to deliver babies if I wanted too. Maybe not appendectomies but at least vasectomies, colposcopies, flex sigs, etc. Not just refer every mole and cyst removal out to derm or surgery!

skypilot said:

I would edit out the personal attacks but basically I agree with you. Who wants to be a FP if all you do is well visits and referrals to specialists? If I were an FP I would at least want to have a panel of procedures I was competent in and be able to deliver babies if I wanted too. Maybe not appendectomies but at least vasectomies, colposcopies, flex sigs, etc. Not just refer every mole and cyst removal out to derm or surgery!

Click to expand...

I agree that Family Practicioners should be trained to do office-based procedures, there alot of these like colonoscopies (who does rect-sigs anymore?), cryoablation, etc. . . hence my proposal to just focus on stuff that you can fix in the clinic. Of course everydoctor should know how to deliver a baby if need be in an emergency, but really people who eat, live and breathe delivering babies, i.e. ob/gyns should be delivering pregnancies I believe, because if something goes wrong they are the best ones to have on the case, period. Most physicians have largely ambulatory practices, and a majority of them love it!

Well it's currently a procedure-ruled world. The ambulatory setting is slowly being taken over by PAs and NPs. There is very little protection by the AMA and AOA to the ambulatory setting being physician only. Soon there will be none, heck several quotes from the nursing associations claim NPs do it for less and better than physicians (I know it's stupid and rediculous claims and their studies blow but politicians are not known for their ability to be interperting scientists, more like they are lawyers looking to trick judges.)

FM needs to establish a set of ambulatory procedures that they will do in mini centers or private practices that only they are able to do. These set need to be protected. The problem is that these procedures will always be claimed to be done better by the specialists. In order for FM to be protected, we need to show that FM is better at those procedures/medical managment than the specialists and doing this requires comparison studies, something FM does not like to do cause of the lack of attachment to academia. e.g. We should show that a patient with Diabetes being seen by an ambulatory IM doc is more likely to be admitted to a hospital than a patient being seen by an FM doc because of better sugar control (cause you are more skilled at it in ambulatory than the IM who is used to slamming with insulin in a hospital setting. This talks BIG to insurance companies and medicare. Suddenly you are $$ for them.

Faebinder said:

FM needs to establish a set of ambulatory procedures that they will do in mini centers or private practices that only they are able to do. These set need to be protected. The problem is that these procedures will always be claimed to be done better by the specialists.

Click to expand...

That's why many FM hopefuls (myself included) hope to practice in an area where there aren't many specialists. If there's nobody else around that can do the procedures, then the FM doc can step in. The only thing that concerns me is the challenge of keeping your skills/knowledge current when you're somewhat isolated from other practitioners.

I hate to see FM as a "rural-oriented" specialty, but that's what it seems to be if you want the opportunity to do more hospital-based procedures (or OB).

Shinken said:

That's why many FM hopefuls (myself included) hope to practice in an area where there aren't many specialists. If there's nobody else around that can do the procedures, then the FM doc can step in. The only thing that concerns me is the challenge of keeping your skills/knowledge current when you're somewhat isolated from other practitioners.

I hate to see FM as a "rural-oriented" specialty, but that's what it seems to be if you want the opportunity to do more hospital-based procedures (or OB).

Click to expand...

FM should not allow themselves to be pushed out into the hinterlands in order to practice skills that they are trained and qualified to do. If a FM doc has been trained properly in OB they should be able to deliver babies anywhere in the country not just in Backwater Alaska. Same goes for any procedure you can perform with skill and precision.

skypilot said:

FM should not allow themselves to be pushed out into the hinterlands in order to practice skills that they are trained and qualified to do. If a FM doc has been trained properly in OB they should be able to deliver babies anywhere in the country not just in Backwater Alaska. Same goes for any procedure you can perform with skill and precision.

Click to expand...

This is really the only sticking point for FM in general for me. I am wanting to go rural but I don't want to end up in Alaska or somewhere that isolated. And a procedural driven practice is not something I am willing to compromise. That is why I am looking at General Surgery programs. I can go mildly rural and still do whatever procedures I want. Otherwise I am gung-ho FM. Isn't that sad that our governing bodies and peers have allowed the situation to come to this. We should all be allowed to practice the medicine we are trained for irrespective of our specialty. But unfortunately most docs don't see it that way, turf battles ensue, and patients lose. It is akin to racism in my opinion.

skypilot said:

FM should not allow themselves to be pushed out into the hinterlands in order to practice skills that they are trained and qualified to do. If a FM doc has been trained properly in OB they should be able to deliver babies anywhere in the country not just in Backwater Alaska. Same goes for any procedure you can perform with skill and precision.

Click to expand...

Well, yes I agree. And FM docs can do OB in any city, it's just a matter of handling the insurance and doing enough deliveries to make it worthwhile economically. I know many FM docs doing OB in Cleveland, which is not rural by any means (more like a jungle, if you ask me...)

Also, the definition of rural is very flexible. You can be in a rural area that has been defined "rural" by the government but doesn't fit the stereotype of what a rural area is.

My point was that sometimes -unfortunately- FM docs will have to go to a place with few specialists. Since many specialists like to congregate in larger cities to make their practices more feasible, it usually means that larger cities are not very hospitable for FM docs that want to do tons of procedures. You can do procedures in cities that are not isolated at all, but what I'm lamenting is that it's difficult to do procedures in a specialist-infested area due to turf battles, and that's sad. Particularly because as a primary care doc one can learn a lot by being around specialists.

Shinken said:

Wellwhat I'm lamenting is that it's difficult to do procedures in a specialist-infested area due to turf battles, and that's sad. Particularly because as a primary care doc one can learn a lot by being around specialists.

Click to expand...

Yes, "infested with specialists!" They are pests after all

skypilot said:

Yes, "infested with specialists!" They are pests after all

Click to expand...

Well, it was more of a figure of speech, but there's some truth in it, no?

KentW said:

Interesting thread.

The original article that Zipmedic posted seems to point up one of the pitfalls of working for a big HMO, which is becoming a cog in the wheel. It doesn't have to be that way, however.

Solo practice is certainly viable, but it requires more work and involves more risk than a clock-punching salaried job. It's also potentially a lot more fulfilling. Being a solo practitioner = being an independent business owner/entrepreneur. They don't teach that in medical school. For that reason, it's not for everybody. Lots of people are doing it successfully, however.

Many of us have found that being in a larger, private group provides much of the independence afforded by a traditional solo practice, combined with the economies of scale and infrastructure of a larger organization.

As for scope of practice, ideally, each of us will decide that on our own. Family medicine is one of the most flexible fields there is in terms of being able to tailor your practice to your interests and schedule. Personally, I feel that I'm practicing the kind of medicine that I want to practice, despite not doing any hospital or OB. That's my choice, not something that was forced on me.

I feel that family medicine residency should prepare residents for full-spectrum practice, and it should be up to the individual whether or not they wish to limit their practice, not their training.

Click to expand...

Do other docs in your group practice hospital medicine and OB? Any resistance from your third party reimbursers? Thanks.

KentW said:

We have some people doing hospital. No reimbursement issues there...they're actually doing quite well. None of our FPs do OB...that's more of a regional thing, really. I've met a few people who are doing it outside the major metropolitan areas, however.

Click to expand...

Kent, suffering from avitar personality disorder?

anyone known of ppl that graduated from "city" programs and do full spectrum post-grad? just wondering if its been done and possible

thedman888 said:

anyone known of ppl that graduated from "city" programs and do full spectrum post-grad? just wondering if its been done and possible

Click to expand...

Absolutely! There are a number of FM docs that graduated from MetroHealth in Cleveland and practice full spectrum (OB + procedures + hospital + outpatient).

That's one thing I love about FM, it's so flexible you can tailor your practice to whatever you want.

Shinken said:

Absolutely! There are a number of FM docs that graduated from MetroHealth in Cleveland and practice full spectrum (OB + procedures + hospital + outpatient).

That's one thing I love about FM, it's so flexible you can tailor your practice to whatever you want.

Click to expand...

thats good to hear, do you know if they have also done ob fellowships in order to practice at rural places?

thedman888 said:

thats good to hear, do you know if they have also done ob fellowships in order to practice at rural places?

Click to expand...

Actually the vast majority of them did not do a fellowship. They're not doing high-risk or operative obstetrics, though, and most practice in larger cities. I only know of one FP that did not do a fellowship but was so well-trained that he does C-sections as well. That FP trained a while ago and I think FM residencies aren't as strong in OB nowadays (I could be wrong).