Family Medicine: Ideal vs Reality

[HipsterLorax]

Hey all. First off, I want to thank all of the contributors to this forum.. I mostly lurk but it has been truly informative and I love hearing all of the diverse experiences that everyone has.

In light of the recent posts about full-scope medicine training and procedures, I was curious how realistic it is to find jobs where you have the autonomy to practice medicine your way. I'm not opposed to living in a medium-smallish city (within reason) if I can find an "ideal" job and it's a decent place to live. But are there still jobs where you can apply all of the skills you learned in residency without having to live in the middle of nowhere (no offense, CB).

I'm asking this because I'm highly considering family medicine because I like the idea of being on the front lines and I find continuity of care very rewarding. I want to feel comfortable treating psych issues, doing procedures, seeing kids, prenatal care, DM/HTN/HLD, etc.. I love the variety of FM. But I'm worried that the private practice or smaller group jobs that are being absorbed by large groups/systems are going to want most of those things to go straight to specialty care. Which for me is philosophically NOT how I would want to practice. I've been spoiled because the family docs at my medical school are able to have really great practices that are "catered" to their interests (clinical weight loss, integrative medicine, sports, OB/maternal health etc.), but I think part of that has to do with being in academics (which I'm not sure I'm interested in).

I've read a lot about DPC and I'm very intrigued by that idea, but also hesitant as I'm not quite a business-minded person and I have a six-figure debt. Maybe by the time I graduate there'll be more DPC groups like Qliance, Iora, etc.

I would love to hear your thoughts on what the practice environments are like out there and if autonomy is actually decreasing for family docs in medium-sized towns.

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[JustPlainBill]

Well -- The practice I'm with is truly a one stop shop --- we've got, on site: Xray,sono,CT,MRI,treadmill stress, echo, IV abx/fluids, allergy testing, sleep lab, PT, balance testing, neuropathy testing, psych, EKG, Ob/gyn, cardiology -- FM providers do everything from peds to geri, procedures encompass all sorts of joint injections, US guided joint injections, biopsies, anti-aging medicine, boutique procedures, hair replacement -- we have a pharmacy on site also --- this is the the burbs and the average day is about 20- 24 patients per day -- most of us are running at least a PA if not several PAs/NPs and we've just started an extended hours clinic for nights/weekends --- almost forgot -- some providers do OMM also -- how do you want your practice to look and what intrigues you?

 

[VA Hopeful Dr]

Yeah, that's the nice part about family medicine - you can find a place to do pretty much anything you want if you're willing to look for it.

 

[HipsterLorax]

That sounds really awesome. I figure for cost purposes, practices like that are pretty much required to be partially staffed by mid-levels? Also, does malpractice significantly increased depending on how many procedures you incorporate in your practice?

how do you want your practice to look and what intrigues you?

I guess I'm still trying to figure that out. I've basically been stuck between FM and peds, so I'd definitely like to see kids. On top of bread and butter stuff, I like the idea of sports medicine (simple fractures, splints, casts, joint injections), ultrasound, basic psych stuff, prenatal care (probably not deliveries, but don't have enough exposure).. There's so many things I like and get excited about in primary care. I shadowed in allergy awhile ago and I think some of those basic skills and knowledge are well within reach of an FP, but don't see many doing it.

 

[JustPlainBill]

That sounds really awesome. I figure for cost purposes, practices like that are pretty much required to be partially staffed by mid-levels? Also, does malpractice significantly increased depending on how many procedures you incorporate in your practice?



I guess I'm still trying to figure that out. I've basically been stuck between FM and peds, so I'd definitely like to see kids. On top of bread and butter stuff, I like the idea of sports medicine (simple fractures, splints, casts, joint injections), ultrasound, basic psych stuff, prenatal care (probably not deliveries, but don't have enough exposure).. There's so many things I like and get excited about in primary care. I shadowed in allergy awhile ago and I think some of those basic skills and knowledge are well within reach of an FP, but don't see many doing it.

So midlevels are physician extenders -- they allow us to serve more patients -- the key is finding the ones that know their limitations and know when to come talk to you --

Malpractice will change depending on whether you're doing inpatient or not; it also changes based on what procedures you do outside the "normal" FM practice -- if you're delivering babies, you can bet your malpractice goes up -- if you're doing standard FM stuff -- it's really not that bad;

In FM you can do as little or as much as you want -- all of the stuff you described is completely within the realm of FM -- truly, most people don't need a specialist, they just want to feel important by saying their problem requires the care of a "specialist" for some exotic disease or they're quick to hire a lawyer when things go wrong (through either non-adherence or bad physiology/genetics) and try to sue -- I've actually had family members try to play "stump the doctor" by trying to have me guess what they have by giving one or 2 symptoms and what they thought were "dead giveaway" clues -- they looked a little despondent when I told them we didn't refer to diseases in that manner --- I considered telling them it sounded like they had a rare form of mountain carabiner's disease which would cause their ears and nose to rot off and was highly contagious to anyone living in their household and the first sign it was happening was a sudden urge to urinate after drinking water 3 hours prior (this was at a family picnic) -- but I had mercy and just nodded and smiled (must be getting soft) ----

 

[HipsterLorax]

It's great to hear that the sort of training you get at unopposed residencies isn't only applicable to super rural "cowboy" practices. I'd really like to work with underserved people, so I can see it being a huge asset not having to refer them to specialists since they likely won't be able to afford it.

 

[FiveRivers]

Is it possible to continue doing prenatal care, but not the actual deliveries, after residency?
If so, how does that work?

 

[VA Hopeful Dr]

Is it possible to continue doing prenatal care, but not the actual deliveries, after residency?
If so, how does that work?

I'm sure its possible, but I'd be hard pressed to see how outside of essentially being an OB/GYNs office employee. You'd be getting the easy part and leaving the delivering doctor the high liability/long-hours part. Few would want to take on that role.

 

[HipsterLorax]

I know an NP that does prenatal care (among other things) through our mobile health program. But yeah, that's kind of specific.

 

[deleted87716]

Is it possible to continue doing prenatal care, but not the actual deliveries, after residency?
If so, how does that work?

It wouldn't. Pregnancy care is reimbursed as a global fee, which means the physician (or practice) gets paid one lump sum for everything, from prenatal care through postpartum. And, before you ask, fee-splitting is illegal.

 

[witzelsucht]

It wouldn't. Pregnancy care is reimbursed as a global fee, which means the physician (or practice) gets paid one lump sum for everything, from prenatal care through postpartum. And, before you ask, fee-splitting is illegal.

how does this work if someone moves cross country during a pregnancy? or MFM is needed?

 

[linguistafeliz]

Actually, I have heard of some FM doctors (in North Carolina, specifically) doing only prenatal care but not deliveries. Some OBs (and FMs) get sick of all the prenatal office visits and are happy to work with FM doctors who take care of all the prenatal care up until delivery. I think it would depend on who you're working with, logistics, etc. but definitely is being done in some places. Don't know how feasible/common it is in practice.

 

[HipsterLorax]

Actually, I have heard of some FM doctors (in North Carolina, specifically) doing only prenatal care but not deliveries. Some OBs (and FMs) get sick of all the prenatal office visits and are happy to work with FM doctors who take care of all the prenatal care up until delivery. I think it would depend on who you're working with, logistics, etc. but definitely is being done in some places. Don't know how feasible/common it is in practice.

Seems like, according to Blue Dog, that they'd have to be a part of the same practice or system. I , too, know of a couple of these unique situations so I'm guessing that's how it happens without "fee splitting"

 

[deleted87716]

Seems like, according to Blue Dog, that they'd have to be a part of the same practice or system. I , too, know of a couple of these unique situations so I'm guessing that's how it happens without "fee splitting"

Yes, if you're under the same tax ID number, the revenue can be divided up however you want.

 

[deleted87716]

how does this work if someone moves cross country during a pregnancy? or MFM is needed?

The one who delivers gets to bill. The first doc gets nothing.

Most OBs refer high-risk patients to MFM early on. There's no point in continuing to see a patient you aren't going to deliver.

 

[deleted87716]

Actually, I have heard of some FM doctors (in North Carolina, specifically) doing only prenatal care but not deliveries. Some OBs (and FMs) get sick of all the prenatal office visits and are happy to work with FM doctors who take care of all the prenatal care up until delivery.

They're probably part of the same group, in which case it would be no different than having a nurse-midwife providing pre-natal care.

How they get reimbursed isn't clear. Most nurse-midwives are salaried.

 

[JustPlainBill]

And lest you think it's all goodness and light, sunshine and daffodils with butterflies doing their thing and puppies playfully chewing on their tails and chasing each other -- first shot out of the bag this morning -- 50+ y/o patient who had been seen by an ENT for ear/nose complaints presents with 1 week of cough, has self discontinued abx prescribed by ent and determined that the cough slightly exacerbated by eating and lying down has no GERD component and wants a "shot" as it always resolves issues faster and then wants to know why the abx shot works faster --- as I attempted to explain what I likely thought was going on, including a brief physiology lesson regarding GERD associated cough and/or reactive airway cough, I kept getting interrupted -- so I politely quit explaining, did my PE and ..... covered for possible infectious cough and reactive airway cough and treated the symptoms with my favorite -- tessalon ----and did I mention a syncophant family member repeating everything anyone in the room said with the added,"Oh, yesss" and deep sigh to punctuate sentences/thoughts ----

Some days, it's just not worth gnawing through the restraints ----

 

[HipsterLorax]

I thought this was an interesting read related to expectations of scope of practice and how they change..

http://www.ncbi.nlm.nih.gov/pubmed/26647258