Do you need to be rural to do full scope family medicine?

[Passionseeking]

Ok so apologies if I sound ignorant or anything because I'm just a premed applying next year, but anyways I've been doing a lot of research and it seems like full scope family medicine is the ideal specialty for me.

The PCP I grew up with was a "referral machine" and honestly really ruined my vision of what a doctor was. She always seemed depressed, the slightest issue I had while growing up she'd refer to derm, pt, e.t.c, and the only thing she actually did for me that didn't require me being sent somewhere were physicals/ wellness visits.

No offense to her but I would HATE to be practicing like that, idc how much money you make by seeing tons of patients a day if you end up referring 80% of them away, it's like a glorified traffic flagger.

This initially turned me off to family medicine because I wrongfully thought that all they did was refer and manage a1cs all day + wellness visits. (I also shadowed a PA and that's all he does too)

However after doing reading on full scope family medicine, it's honestly like the perfect specialty. I love the idea of having such a broad knowledge, forming long relationships with patients, being able to manage practically anything that walks through your doors, and having the most variety when it comes to age and disease pathology.

I don't wanna be that doctor that's only good at that niche thing that they do but would be lost doing something else. Ex: like a psychiatrist managing diabetes or an ortho surgeon managing asthma. I know I'll never be as good as a specialist in anything, but I much prefer knowing a little about a lot rather than a lot about a little.

However it seems to me that the only way to work as a full scope FP, you need to live in a place with terrible wifi, nearest Starbucks 150 miles away, stuff like that. I can't imagine living like that, and I don't want to live in a busy city, but it seems like even if you're in the suburbs you turn into a referral machine because specialists are still nearby.

So my solution would be a direct primary care practice, where not only would you cut out dealing with insurance, but you're free to do whatever you're comfortable with.

So my question is if I'm correct about what I said would a DPC practice in an urban area be able to practice full scope, or is there a way to be a FP in an urban or suburban area without referring out anything with the slightest complexity

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[FrustratedFamDoc]

What sort of hours are you wanting/willing to work?

 

[Passionseeking]

Nope, you do not need to be rural.

Obviously DPC is a little different from this but most FM residency programs would love to hire full scope FM docs, and plenty are in large cities.

In my small to midsize city of ~800k in the metro area with multiple Starbuckses and good wifi, we have community family docs who do traditional inpatient/outpatient practice. Not many community docs who deliver but I think it's more a lack of interest from the doctors themselves (FM docs deliver at both local hospital systems due to residency programs so it's not an "only OBGYNs deliver at this hospital" issue. There are also some smaller critical access hospitals with LOTS of people doing full scope outpatient+inpatient+OB within a super reasonable driving distance of downtown.

Also worth noting, if you're doing DPC and you're doing inpatient/OB you're going to be dealing with insurance on that side of things unless you're willing to let your patients get completely hosed for tens of thousands of dollars+ worth of care you're not billing insurance for. Hospitals probably also won't be super enthused with giving privileges to a doctor who does not do insurance things.

Thanks so much for that thorough response. It's nice to see in residency programs and hospitals you have the opportunity to work full scope, but I was hoping it could be possible in an strictly outpatient setting.

Also a better question would be do you think family doctors are still valuable and will be in the foreseeable future? I ask because the argument is made that if you're a family medicine doing things for a patient that a specialist could be doing, then you're doing your patients a disservice. Many people say that the best thing a family physician should do would be refer anything out that a specialist could handle. Not only is that not an interesting way to work but that could be done by PAs and NPs who get paid less.

I love the idea of primary medicine on paper but with the increasing access of specialists I can see why the field may be in danger. I'm really praying that I'm wrong and please educate me if I am because I'm only a premed, but it just seems like the things a family medicine is expected to handle could be done by a midlevel, and anything more complex should be referred out

 

[Passionseeking]

What sort of hours are you wanting/willing to work?

In terms of being an attending anything 40-50 would be ideal.

In my ideal future I'd be a family physician managing a great deal of what comes through my door, ample time to talk with the patient, and would only refer when I really needed to ( like 10% or less). I'd rather work 50 hours like that than 30 hours being a referral machine.

 

[InternistDO]

Thanks so much for that thorough response. It's nice to see in residency programs and hospitals you have the opportunity to work full scope, but I was hoping it could be possible in an strictly outpatient setting.

Also a better question would be do you think family doctors are still valuable and will be in the foreseeable future? I ask because the argument is made that if you're a family medicine doing things for a patient that a specialist could be doing, then you're doing your patients a disservice. Many people say that the best thing a family physician should do would be refer anything out that a specialist could handle. Not only is that not an interesting way to work but that could be done by PAs and NPs who get paid less.

I love the idea of primary medicine on paper but with the increasing access of specialists I can see why the field may be in danger. I'm really praying that I'm wrong and please educate me if I am because I'm only a premed, but it just seems like the things a family medicine is expected to handle could be done by a midlevel, and anything more complex should be referred out

Increasing evidence is showing that zillions of specialists do not in fact do a better job than PCPs. Obviously specialists are needed--you need cardiology to cath STEMIs, read echos, manage complex heart failure, etc--but they are helpful for specific conditions. Every study that's been done shows that higher supply of primary care doctors is better for patient health, leads to less specialty referrals and procedures, and reduces cost. The big goal with CMS/insurance right now is to do more things in primary care as opposed to in specialty offices or in the hospital.

 

[AMEHigh]

No you don’t. I know lots of FM docs who live in cities who do inpatient, outpatient, some OB, HIV care, gender affirming care, HIV care, abortion care, and the list goes on.

 

[avatarftw]

Ok so apologies if I sound ignorant or anything because I'm just a premed applying next year, but anyways I've been doing a lot of research and it seems like full scope family medicine is the ideal specialty for me.

The PCP I grew up with was a "referral machine" and honestly really ruined my vision of what a doctor was. She always seemed depressed, the slightest issue I had while growing up she'd refer to derm, pt, e.t.c, and the only thing she actually did for me that didn't require me being sent somewhere were physicals/ wellness visits.

No offense to her but I would HATE to be practicing like that, idc how much money you make by seeing tons of patients a day if you end up referring 80% of them away, it's like a glorified traffic flagger.

This initially turned me off to family medicine because I wrongfully thought that all they did was refer and manage a1cs all day + wellness visits. (I also shadowed a PA and that's all he does too)

However after doing reading on full scope family medicine, it's honestly like the perfect specialty. I love the idea of having such a broad knowledge, forming long relationships with patients, being able to manage practically anything that walks through your doors, and having the most variety when it comes to age and disease pathology.

I don't wanna be that doctor that's only good at that niche thing that they do but would be lost doing something else. Ex: like a psychiatrist managing diabetes or an ortho surgeon managing asthma. I know I'll never be as good as a specialist in anything, but I much prefer knowing a little about a lot rather than a lot about a little.

As a previously idealistic but now a youngish attending with some experience under my belt: lack of time is an issue.

You have 20 minutes to see your patient. Not to spend talking with your pt and eliciting a history, but 20 minutes for the nurse to room the patient and for you to do a history and physical, diagnose, come up with a plan, and document. You could document all your notes at home but then you'd be bringing home 1+ hours of work a day.

Your patient is a newly diagnosed diabetic with an A1c of 11%, severe anxiety, insurance issues so you have to explain to them how to get their meds with goodrx.com. They also have chronic back pain with several specialist and imaging notes to review, "tingling" in their body, and admin is telling you to also do their pap smear, colonoscopy screening, and other preventative items at each visit.

So we have 4 complaints +/- preventative health items that we try to address in 20 minutes.

I don't like referring as much as I do but unless you want to be 50 min behind with all your patients and have them angrily leave the clinic, leading to a meeting with your supervisor to discuss the patient grievance that was just filed against you, you have to to focus on the big issues and refer out some things. That or ask them to make another appt. Trouble is that sometimes pts won't accept this.

Now not every visit is like this and some people get more than 20 min per patient, but if you get a few of these cases in a row you can get really behind. You also have to manage your patient messages as they come in during the day.

 

[deleted87716]

As I have said on many occasions, "I am the 'doctor for all of you,' but not all in one visit."

 

[avatarftw]

As I have said on many occasions, "I am the 'doctor for all of you,' but not all in one visit."

Oh yeah I agree. Most patients are understanding but not all the time.

Private practice and employed medicine are different in work conditions also; I don't know if you're private or employed.

 

[deleted87716]

Oh yeah I agree. Most patients are understanding but not all the time.

Private practice and employed medicine are different in work conditions also; I don't know if you're private or employed.

Owner/employee in a private practice.

 

[Passionseeking]

So let me back up and ask: what do you mean by full scope? To me full scope means outpatient + inpatient + OB. "Strictly outpatient" to me does not mean full scope.


So I'm biased because I'm in FM, but I 100% feel family doctors are still valuable. Insurance companies, hospitals, and policymakers are starting to see this as well. TONS of great data out there on the value of primary care - improved mortality rates, decreased healthcare costs, etc. Reimbursements for primary care are steadily increasing, patients are getting better and better coverage on their insurance plans for preventive care, hospitals are getting more and more incentives for good preventive care and chronic disease management. FM in particular is one of the most flexible specialties out there, so I don't foresee a disaster on the horizon by any means.


Very, very strongly disagree with this. There is plenty that "could" be managed by a specialist that can be managed just as well by a well-trained FM doc, which is why we have three years of broad-spectrum training! If I refer all my diabetic patients to endo, all my hypertensive patients to cards, all my osteoarthritis patients to ortho, that does my patients a HUGE disservice. It benefits patients to have a PCP managing the bulk of their issues who is aware and able to manage their comorbidities rather than just the problems in one organ system, who is familiar with the patient's social situation and goals of care, who has an understanding of the overall clinical picture, etc. I'm sure we have all seen specialists do things to our patients that may be the right thing to do by the book, but don't make sense for a particular patient's situation because the specialist (reasonably and appropriately) only sees part of the picture. At a system level, this also significantly increases the burden on an already strained healthcare system with long wait lists for specialists, and increases the cost of care unnecessarily. It already takes me months to get my psychotic patients into a psychiatrist or my epileptic patients into a neurologist, now I'm supposed to refer them my dozens of patients with depression or hx stroke too? Now my patient has to see a whole separate doctor, with separate appointments, more time off work, more transportation needs, for something I'm perfectly capable of managing appropriately? This is particularly true for vulnerable patient populations.



Disagree with these as well. I don't think midlevels have the time or depth of training to handle what a good family doc can do. I think midlevels will lead to the PCP=referral monkey system you're describing. Well trained physician PCPs who are motivated to provide excellent care to their patients will not.



Here's an anecdote which nicely illustrates a few of these points. I had a patient on my primary care panel who was a lady in her 60s. Came in complaining of back pain and leg pain. Describing symptoms consistent with neurogenic claudication (pain related to pressure on the nerves coming out of the spine). We get an MRI and we find she has lumbar spinal stenosis, as I suspected. We know she has osteoarthritis causing her knee pain, which we have been managing conservatively. I offer her a variety of pain management strategies as well as physical therapy, which she refuses. She requests a referral to a neurosurgeon. I ask her if she wants to have surgery on her back. She says no. I say well then, I don't think seeing a surgeon is going to do much for you. Let's try this stuff I recommended and follow up in a few months.

Instead of doing that, she establishes with a new primary care provider, a nurse practitioner (I find out about all this later because her specialists were mistakenly forwarding me her notes instead of the new PCP). NP goes ahead and refers to neurosurgery. Neurosurgery agrees with my diagnosis. They get an EMG for some reason, which shows peripheral neuropathy (which we already knew she had). They talk about the possibility of surgery. She declines. They recommend conservative management, which I was already doing. They also refer her to ortho for what they think might be osteoarthritis (which we already knew she had). Ortho sees her. They feel she's not at a point where surgery is indicated. They recommend conservative management, which I was already doing.

So now this patient has seen two additional doctors who could have been seeing patients with brain tumors or hip replacements, missed several days of work, taken several Medicaid cabs to get to the appointments, had a procedure/diagnostic test that gave us zero new information, and spent god knows how many hundreds to thousands of dollars both from herself and her taxpayer-funded insurance, all to do the same. exact. thing. I was already doing.

Before saying anything I just want to say thank you so much for all you said it was super insightful! This was the type of response I was hoping for and it really gave me faith/ hope in the specialty.

To answer your first question I apologize if I was using the wrong definition of full scope, to me full scope just means that as a family care doctor you're managing as much as you are trained to and referring as little as you need to. Doing procedures like colonoscopies and c sections is super cool and I would love to do that, but for me what's more important is managing anything you're trained to. Ex: not referring every patient with pysch issues to a psychiatrist. The family doctor I grew up with I feel used very little brain power and referred anything that could be referred.

In regards to your second paragraph I was really hoping to hear something like that. I've heard time and time again that " even if a patient has what seems like a minor problem to an fm doc, it could be a precursor to a larger problem that the fm might not be aware of." Implying that fm docs can't see disease nuance. It's very comforting hearing you say that fm docs are literally trained to do that.


Lastly I really love the anecdote you provided and it really motivates me to pursue fm. Finding out a patient has spinal stenosis and handling it the same way that specialists would, capable to do things like this for ALL specialties is super cool, to me that's what being a true doctor feels like.

 

[Passionseeking]

Increasing evidence is showing that zillions of specialists do not in fact do a better job than PCPs. Obviously specialists are needed--you need cardiology to cath STEMIs, read echos, manage complex heart failure, etc--but they are helpful for specific conditions. Every study that's been done shows that higher supply of primary care doctors is better for patient health, leads to less specialty referrals and procedures, and reduces cost. The big goal with CMS/insurance right now is to do more things in primary care as opposed to in specialty offices or in the hospital.

That's actually super interesting, can you link any studies that show specialists don't do a better job than PCPs? Would be an interesting read

 

[Passionseeking]

As a previously idealistic but now a youngish attending with some experience under my belt: lack of time is an issue.

You have 20 minutes to see your patient. Not to spend talking with your pt and eliciting a history, but 20 minutes for the nurse to room the patient and for you to do a history and physical, diagnose, come up with a plan, and document. You could document all your notes at home but then you'd be bringing home 1+ hours of work a day.

Your patient is a newly diagnosed diabetic with an A1c of 11%, severe anxiety, insurance issues so you have to explain to them how to get their meds with goodrx.com. They also have chronic back pain with several specialist and imaging notes to review, "tingling" in their body, and admin is telling you to also do their pap smear, colonoscopy screening, and other preventative items at each visit.

So we have 4 complaints +/- preventative health items that we try to address in 20 minutes.

I don't like referring as much as I do but unless you want to be 50 min behind with all your patients and have them angrily leave the clinic, leading to a meeting with your supervisor to discuss the patient grievance that was just filed against you, you have to to focus on the big issues and refer out some things. That or ask them to make another appt. Trouble is that sometimes pts won't accept this.

Now not every visit is like this and some people get more than 20 min per patient, but if you get a few of these cases in a row you can get really behind. You also have to manage your patient messages as they come in during the day.

Ok that makes perfect sense, my question would be with not DPC? I feel like that solves every issue you mentioned and it almost sounds too good to be true. I know it's hard managing a business and all that but I think it's worth it to practice the way that you would ideally want to. I read reviews of local DPC practices near me where patients online talked about how their doctor talked to them for 90 minutes. Not only are you spending more than 4x more time with the patient, but you don't need to deal with insurance.

 

[FrustratedFamDoc]

Beware the long patient visits! Do you really want to hear the 10 minute version about someone’s grandson’s bad marriage, after you just heard it verbatim 3 months ago? After a while it will get exhausting. Remember, you’ve got work to do.

Unless someone comes in with some truly heavy duty stuff or it’s a procedure, there is almost never a good reason to spend more than 15 minutes in a room. We all get held hostage from time to time, but that’s not what I mean. Keeping the interview going and on point is a skill that takes a while to develop.

What we do is difficult but usually not all that complicated unless we choose to make it so.

 

[VA Hopeful Dr]

Increasing evidence is showing that zillions of specialists do not in fact do a better job than PCPs. Obviously specialists are needed--you need cardiology to cath STEMIs, read echos, manage complex heart failure, etc--but they are helpful for specific conditions. Every study that's been done shows that higher supply of primary care doctors is better for patient health, leads to less specialty referrals and procedures, and reduces cost. The big goal with CMS/insurance right now is to do more things in primary care as opposed to in specialty offices or in the hospital.

Raise your hand if you've had to referee between cardiology and nephrology with the former making the CHF/CKD patient too dry with aggressive diuresis and the latter trying to put the patient back in the hospital with fluid overload by completely stopping their diuretics

 

[FrustratedFamDoc]

Raise your hand if you've had to referee between cardiology and nephrology with the former making the CHF/CKD patient too dry with aggressive diuresis and the latter trying to put the patient back in the hospital with fluid overload by completely stopping their diuretics

I’ll see your cards/neph and raise you cards/GI in the frail, anticoagulated 80 y/o afibber on their 4th major gib in 3 months

 

[avatarftw]

Ok that makes perfect sense, my question would be with not DPC? I feel like that solves every issue you mentioned and it almost sounds too good to be true. I know it's hard managing a business and all that but I think it's worth it to practice the way that you would ideally want to. I read reviews of local DPC practices near me where patients online talked about how their doctor talked to them for 90 minutes. Not only are you spending more than 4x more time with the patient, but you don't need to deal with insurance.

Yes DPC is very good in theory. Personally I'd consider such a setup once I'm more financially steady. I've aggressively paid back my average sized med school loans with a VERY generous loan repayment program I was a part of as an attending at a low income clinic.

Since I lived very frugally for a doc I invested likely more than what specialist docs invest each yr. However, it still takes a lot of money to open up a practice and as covid showed, a lot of private practice physicians were hurt hard.

I know some DPC people who don't actually make much since they get so many patient messages. It likely varies by region though.

I would do DPC or concierge medicine not for the money but for the control. It's a big hassle filling out paperwork as a standard employed doc.

Some referrals are done for medicolegal reasons too.