full scope family medicine in Texas

[wlf87]

Hi, I will really appreciate any input from people with experience in this matter.

I would very much like to be in FM if there are opportunities to do full scope FM. Is this possible to do in Texas? I really do not mind practicing in rural underserved areas. I would also really like to devote 20% of my time to international humanitarian missions like MSF, so I think the primary care skillset will help me there.

what is the future in doing any obgyn or complicated procedures by the time I graduate, given how everything is being driven towards specialization? http://www.aafp.org/about/the-aafp/family-medicine-facts/table-12.html . Also there seem to be issues of lack of malprac insurance, hospital privileges, turf battles with obgyn/peds. So with that in mind, can I still hope to do any procedures or will it be simple outpatient clinic stuff? I would like to do just enough procedures (*scopes, ob, minor surg procedures?!) to satisfy the urge of doing something worthwhile w/ my hands, and I’m not good w/ my hands and definitely not cut out for surgery.

Also, I wonder why would women go see FM instead of obgyn or not take their kids to a ped instead? And minus the obgyn/ped, IM then looks more attractive over FM because of the training to do deep differential dx. Sadly, the trend of moving the procedures to the specialists seems to be true for IM also -- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855006/

Bottomline: what kind of procedures can I reasonably expect most likely to be doing in FM vs IM in a rural setting? Which TX residencies are geared towards full scope practice?

Thank you

Edits: Added linebreaks.

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[JustPlainBill]

First off -- take a deep breath, in through the nose, out through the mouth for 4 seconds each cycle for about 2 minutes to slow your heart rate and give the adrenaline time to wear off ---- Your post makes you sound like a gerbil on Benzedrine -- do not "gush" -- it's unseemly ;-0

So - full scope in Texas -- Texas is nice since the TMB gives you enough rope to hang yourself with -- with a Texas License (DO/MD degree + intern year) you can do whatever you want to do -- including appendectomies, ICU, OB/Gyn, whatever....the question is will your malpractice/hospital let you? given the amount of money you can borrow now -- if you had to, you could equip a small surgical center and procedure away to your hearts content with self-coverage for malpractice since tort reform allows $250K max for pain and suffering ----

Now, realistically -- yes, you'll be in the boonies, likely with a critical access hospital where you can do anything/everything your CEO will let you do -- including full ICU, scopes, deliveries, etc. You can run everything from peds to geri, depending on your comfort level.

Places to get that kind of training as an FM? In Texas - JPS, Waco, Tyler, not necessarily in that order ---

JPS is the big boy on the block -- huge residency but tends to leave it's residents without adult supervision.
Waco's great and I've had a few colleagues go there and then out to the boonies.
Tyler -- Think JPS light -- class sizes are smaller but just a strong a program -- used to have a dual certified FM/Ob-Gyn attending that could get you the number of CSections you needed to get signed off.

Problem with this? Reimbursement and liability -- For OB, you're on the hook until they're 18; And remember, you're not going to be held to the standard of "FM guy trained in this procedure, we'll cut him some slack" but to "FM guy doing a colonoscopy who upgefucht -- would an IM trained gastroenterologist or general surgeon made this mistake?" level.

So -- I too was once like you, wanting to be "the man" out in the boonies -- learned my lesson the hard way --

If you're single, pursue what you really want and don't settle -- I was 42 when I went to med school and am out 1 year in practice -- the whole "I'm doing this cuz I'm too old" is nonsense -- it's very common for physician's to be in their 80s and keep their hand in ---

 

[Mad Jack]

Hi, I will really appreciate any input from people with experience in this matter, and esp those who’ve graduated or doing residency through the FMAT program at Lubbock. I am an older non-trad switching to medicine and going in primary care is probably my only practical and feasible option. This is good because I am interested in it (except 5% of the times when I think I want to do something esoteric like hemeonc). I would very much like to be in FM if there are opportunities to do full scope FM. Is this possible to do in Texas? I really do not mind practicing in rural underserved areas as I am single and don’t foresee having kids, and I do not have any family issues that would prevent me from moving anywhere. I would also really like to devote 20% of my time to international humanitarian missions like MSF, so I think the primary care skillset will help me there. The biggest issue I have with FM is what is the future in doing any obgyn or complicated procedures by the time I graduate, given how everything is being driven towards specialization? http://www.aafp.org/about/the-aafp/family-medicine-facts/table-12.html . Also there seem to be issues of lack of malprac insurance, hospital privileges, turf battles with obgyn/peds. So with that in mind, can I still hope to do any procedures or will it be simple outpatient clinic stuff? I would like to do just enough procedures (*scopes, ob, minor surg procedures?!) to satisfy the urge of doing something worthwhile w/ my hands, and I’m not good w/ my hands and definitely not cut out for surgery. Also, after seeing many bad primary care docs, I now routinely see specialists directly instead of wasting my time and prolonging my suffering, so I wonder why would women go see FM instead of obgyn or not take their kids to a ped instead? And minus the obgyn/ped, IM then looks more attractive over FM because of the training to do deep differential dx. Sadly, the trend of moving the procedures to the specialists seems to be true for IM also -- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855006/ Bottomline: what kind of procedures can I reasonably expect most likely to be doing in FM vs IM in a rural setting? Which TX residencies are geared towards full scope practice?

Thank you

A lot of people have trouble reading text walls. You might get more responses if you break up your writing into paragraphs.

 

[CrileDO]

So -- I too was once like you, wanting to be "the man" out in the boonies -- learned my lesson the hard way --

Sorry to derail the thread, but can you go into any additional detail about this? As someone about to start residency with a "rural guy who does everything" mindset, what are the pitfalls (if you'd be comfortable sharing any details)?

 

[wlf87]

Now, realistically -- yes, you'll be in the boonies, likely with a critical access hospital where you can do anything/everything your CEO will let you do -- including full ICU, scopes, deliveries, etc. You can run everything from peds to geri, depending on your comfort level.

Places to get that kind of training as an FM? In Texas - JPS, Waco, Tyler, not necessarily in that order ---

JPS is the big boy on the block -- huge residency but tends to leave it's residents without adult supervision.
Waco's great and I've had a few colleagues go there and then out to the boonies.
Tyler -- Think JPS light -- class sizes are smaller but just a strong a program -- used to have a dual certified FM/Ob-Gyn attending that could get you the number of CSections you needed to get signed off.

Problem with this? Reimbursement and liability -- For OB, you're on the hook until they're 18; And remember, you're not going to be held to the standard of "FM guy trained in this procedure, we'll cut him some slack" but to "FM guy doing a colonoscopy who upgefucht -- would an IM trained gastroenterologist or general surgeon made this mistake?" level.

So -- I too was once like you, wanting to be "the man" out in the boonies -- learned my lesson the hard way --

---

First, thank you for all this information! I could not get sufficient physician shadowing experience (everyone was citing privacy regulations) so most my information is from what I'm reading from the internet.

I did read that OB has the one of highest rate of malpractice insurance or lawsuits (forget which one exactly) just after neurosurgery and that FM gets reimbursed at lower rates for the same procedures than specialists. But money is not the reason I want to switch to medicine now. What I really like about FM is being in a position to solve problems across age, gender, and disease spectrum, unlike a specialist who sees a specific set of problems. Plus, I will have more opportunities to practice in under-served areas as a generalist than as a specialist.

So notwithstanding that, do you think it's possible to get sufficient experience to get competent in these high risk procedures, maybe not all, but at least a few of them? Competent enough that I don't have to worry about malpractice. For ex, I read this about an FM residency "start the day as the primary surgeon for a high risk c-section... intubate and start a subclavian line on a surgery patient... examine/diagnose/treat/educate patients in clinic... place an umbilical artery catheter in a neonate, " I don't know hard/realistic it is to do at least some of these when one is a FM physician on one's own, outside of residency training, but it's worthwhile if it's possible.

Also, would appreciate an opinion about IM vs FM? From what I read, the procedures are not much different. Can one do some procedures as a hospitalist and do outpatient primary medicine as an internist in a rural setting? Primary care is very important and meaningful to me, so I am hoping the procedures would keep it from being monotonous.

If you're single, pursue what you really want and don't settle -- I was 42 when I went to med school and am out 1 year in practice -- the whole "I'm doing this cuz I'm too old" is nonsense -- it's very common for physician's to be in their 80s and keep their hand in---

This is so inspiring! Thank you!

 

[cabinbuilder]

I will chime in since I work exclusively in rural/frontier settings.

Competent enough that I don't have to worry about malpractice. You always have to worry about malpractice. That is the nature of what the world is. The public sees you as doctor=money=target. Medicine today is about customer service and keeping the complaints down.

You can learn all that they will teach you in residency but reality is you may not get to keep up your skills. Every residency is different and you may be disappointed at the lack of teaching. I never delivered a baby or followed a pregnant patient in residency. What I know is what I experienced myself being pregnant. Most rural places are getting away from delivering at that site. When I was in SE Alaska, all women at 37 weeks went to Juneau to deliver due to lack of services and weather being a huge factor in access to help.

I learned central lines and ICU management in residency - have never done a line since. Patient's who are sick enough to need a line generally are shipped. Most rural hospitals don't have an ICU and definitely don't have the nursing staff who know how to take care of that sick a patient.

I learned how to do scopes in residency too. But what happens if you perforate someone's bowel? They get shipped to the surgeon. Anymore, those types of exams that can have fatal complications are only done in a facility where help is readily available.

Many times in the rural setting it's not a matter of you knowing what to do, it's a matter of hospital politics allowing it, malpractice, equipment availability, and staffing.

 

[cabinbuilder]

Sorry to derail the thread, but can you go into any additional detail about this? As someone about to start residency with a "rural guy who does everything" mindset, what are the pitfalls (if you'd be comfortable sharing any details)?

The pitfalls are administration. You are alone in a 10 bed hospital and you ship the patient in DKA where there is an ICU so that person has a chance to live and the administrators come to you and chew you out for not keeping admissions in their hospital and you are costing them money. Who cares that you did what's in the best interest of the patient when the number crunchers run your life. But, on the flip side of that, you keep a patient with a pneumonia or try to manage SVT with monitoring and drugs and that person dies, admin comes to you for causing a Sentinal event in their hospital and now their JACHO accreditation is under scrutiny. You are then deemed a "liability" to the system and they make your life miserable until you resign.

Like Bill, I have had my share of ugliness in the wilderness and it certainly wasn't from some grizzly chasing me. I have have been forced out/bullied/hated/taunted/disrespected/ etc. and have resigned 5 permanent jobs in the past 5 years. The longest one lasted 3 months, the shortest 2 weeks. There is a reason I do locums exclusively because I have become so untrusting of "the man" that I vowed I would never give up my freedom again and take care of the patients how I feel they should be. If they don't like my services or give me grief, I am out the door.

 

[NurWollen]

I will chime in since I work exclusively in rural/frontier settings.

Competent enough that I don't have to worry about malpractice. You always have to worry about malpractice. That is the nature of what the world is. The public sees you as doctor=money=target. Medicine today is about customer service and keeping the complaints down.

You can learn all that they will teach you in residency but reality is you may not get to keep up your skills. Every residency is different and you may be disappointed at the lack of teaching. I never delivered a baby or followed a pregnant patient in residency. What I know is what I experienced myself being pregnant. Most rural places are getting away from delivering at that site. When I was in SE Alaska, all women at 37 weeks went to Juneau to deliver due to lack of services and weather being a huge factor in access to help.

I learned central lines and ICU management in residency - have never done a line since. Patient's who are sick enough to need a line generally are shipped. Most rural hospitals don't have an ICU and definitely don't have the nursing staff who know how to take care of that sick a patient.

I learned how to do scopes in residency too. But what happens if you perforate someone's bowel? They get shipped to the surgeon. Anymore, those types of exams that can have fatal complications are only done in a facility where help is readily available.

Many times in the rural setting it's not a matter of you knowing what to do, it's a matter of hospital politics allowing it, malpractice, equipment availability, and staffing.

I hate bean counters.... I hate corporate politics. I guess it's a reality everywhere though. I might as well deal with it in the context of a field I enjoy (medicine) than in some field where I don't even like what I do (my last job before starting med school.)

What do you tell the bean counters in these situations? How do they respond when you tell them you did something because it was a matter or survival/good outcome for the patient? I imagine a comment like, "I'm sorry I screwed up your numbers, I should have let the patient die" wouldn't go over well.

 

[cabinbuilder]

I hate bean counters.... I hate corporate politics. I guess it's a reality everywhere though. I might as well deal with it in the context of a field I enjoy (medicine) than in some field where I don't even like what I do (my last job before starting med school.)

What do you tell the bean counters in these situations? How do they respond when you tell them you did something because it was a matter or survival/good outcome for the patient? I imagine a comment like, "I'm sorry I screwed up your numbers, I should have let the patient die" wouldn't go over well.

The problem is that these people telling you to keep patients are not doctors, they don't understand that not every diagnosis can be managed in a small town hospital. There is no reply. You will never win the argument. My general statement has become, "If you don't like my care, I will be happy to work elsewhere." That usually shuts them up since it's a huge hassle to find a replacement.

 

[CrileDO]

The pitfalls are administration. You are alone in a 10 bed hospital and you ship the patient in DKA where there is an ICU so that person has a chance to live and the administrators come to you and chew you out for not keeping admissions in their hospital and you are costing them money. Who cares that you did what's in the best interest of the patient when the number crunchers run your life. But, on the flip side of that, you keep a patient with a pneumonia or try to manage SVT with monitoring and drugs and that person dies, admin comes to you for causing a Sentinal event in their hospital and now their JACHO accreditation is under scrutiny. You are then deemed a "liability" to the system and they make your life miserable until you resign.

Like Bill, I have had my share of ugliness in the wilderness and it certainly wasn't from some grizzly chasing me. I have have been forced out/bullied/hated/taunted/disrespected/ etc. and have resigned 5 permanent jobs in the past 5 years. The longest one lasted 3 months, the shortest 2 weeks. There is a reason I do locums exclusively because I have become so untrusting of "the man" that I vowed I would never give up my freedom again and take care of the patients how I feel they should be. If they don't like my services or give me grief, I am out the door.

Thank you very much for taking the time to respond to my post. When you were doing rural practice, were you from the area that you practiced in? Also, can you tell me about any procedures you did that you got burned (i.e. doing scopes or OB)?

 

[cabinbuilder]

Thank you very much for taking the time to respond to my post. When you were doing rural practice, were you from the area that you practiced in? Also, can you tell me about any procedures you did that you got burned (i.e. doing scopes or OB)?

I still do rural locums. I am never from the area as I grew up in Interior Alaska. I have never been burned. I don't do OB, I don't do prenatal or neonatal care. I learned scopes but have never done one in practice. I learned stress tests and have never done one. I learned central lines and have never done one in practice (if I were to miss and cause a pneumothorax I have never put in a chest tube). I do lots of casting, splinting, sutures, skin lesion removals, abscess. I do TONS of OMT. Nothing like having someone walk out of the office pain free and back to living.

 

[CrileDO]

I still do rural locums. I am never from the area as I grew up in Interior Alaska. I have never been burned. I don't do OB, I don't do prenatal or neonatal care. I learned scopes but have never done one in practice. I learned stress tests and have never done one. I learned central lines and have never done one in practice (if I were to miss and cause a pneumothorax I have never put in a chest tube). I do lots of casting, splinting, sutures, skin lesion removals, abscess. I do TONS of OMT. Nothing like having someone walk out of the office pain free and back to living.

Thanks again for your response. I just worry that even if I go to a rural program where I get good training in scopes, lines, and chest tubes that I won't be able to do them in practice because of the liability and the unwillingness of people to help if something goes wrong with the procedure because I'm a family doc.

Again, sorry to derail, OP.

 

[cabinbuilder]

Thanks again for your response. I just worry that even if I go to a rural program where I get good training in scopes, lines, and chest tubes that I won't be able to do them in practice because of the liability and the unwillingness of people to help if something goes wrong with the procedure because I'm a family doc.

Again, sorry to derail, OP.

You are not "getting it". You don't do a lot of these high risk procedures in rural area because many times YOU ARE THE ONLY DOCTOR without backup. You don't do anything that may potentially harm a patient when there is not another doctor there to help you if something does go wrong. That is the nature of rural medicine. If you want to be doing lines, etc all the time then be a hospitalist in an ICU at a bigger hospital. It comes down to a matter of staffing and safety.

 

[SuckySurgeon7]

I

I learned scopes but have never done one in practice. I learned stress tests and have never done one. I learned central lines and have never done one in practice (if I were to miss and cause a pneumothorax I have never put in a chest tube). I do lots of casting, splinting, sutures, skin lesion removals, abscess. I do TONS of OMT. Nothing like having someone walk out of the office pain free and back to living.

Thanks for the great insight, CB.

I seem to remember you working in urgent cares, but do you ever find yourself working in an emergent situation where you don't have the procedural skills (chest tubes, etc.) to save a person's life? I am imagining working in a rural E.R. and having someone die on me because I don't know how to do x, y, z. Could that person's family put the blame on you in a court of law? Now let's say the we change the setting: you have a patient walk into your family practice clinic, the only one for miles around, and they die because you don't perform the chest tube placement. Could you still be sued? I imagine the answers are yes to the first and no to the second, but I'm asking because you seem to know some of the subtleties after being in the field a while.

 

[wlf87]

I will chime in since I work exclusively in rural/frontier settings.
Many times in the rural setting it's not a matter of you knowing what to do, it's a matter of hospital politics allowing it, malpractice, equipment availability, and staffing.

Thank you for all the real-world insights. I guess the AHCAA is not going to fix this anytime soon. I have great respect for those in the trenches and not much tolerance for bureaucrats, so it will be a steep learning curve.

Given all the real world limitations you mentioned, I see not much difference between IM and FM if one wants to practice in primary care. Looks like the obgyn/ped stuff for a FM would be more like a triage kind of situation whereas a 3 year IM fellowship would be more indepth knowledge-wise than a 2 month IM rotation in FM, so I think could be more helpful in resolving patient problems ...but then FM knowledge would be useful in a global health context where there would not be as many trained professionals around...
this is hard to decide on.

 

[wlf87]

Again, sorry to derail, OP.

No problem, this is all enlightening and will eventually help me to a decision.

 

[cabinbuilder]

I


Thanks for the great insight, CB.

I seem to remember you working in urgent cares, but do you ever find yourself working in an emergent situation where you don't have the procedural skills (chest tubes, etc.) to save a person's life? I am imagining working in a rural E.R. and having someone die on me because I don't know how to do x, y, z. Could that person's family put the blame on you in a court of law? Now let's say the we change the setting: you have a patient walk into your family practice clinic, the only one for miles around, and they die because you don't perform the chest tube placement. Could you still be sued? I imagine the answers are yes to the first and no to the second, but I'm asking because you seem to know some of the subtleties after being in the field a while.

I have never been sued, nor have I ever been threatened to be sued.

I will say that rural people have a different view on life and understand the limitations of care they have living in a rural area. That is understood and most are grateful for whatever skills you bring to their area and no one has ever faulted me for trying. We all have limitations in our training but fortunately in our age now you can just about learn anything from youtube in a 5 minute tutor session. I have used that before and many times it's not a matter of announcing your short comings about a procedure but doing a quick study and having confidence in silence. Of course you first do no harm and I would be the last person to put someone in danger. I have many specialist friends who are always available to me by phone and if I get in a pinch they know I will call.

Yes, I work urgent care but I have also worked in ER in the Frontier setting: on an island in Southeast Alaska, Central Nevada, Northern Montana, Central Colorado. Yes, I have had a few situations where I was scared the person would die (I had a guy with a 3/4 amputation of his arm) with only 4 units of blood on the island and the best we could do was all hold pressure and pray the plane got there soon enough. That man lived but he did lose his arm.

I do hold the record in Tonopah, NV for the most medevac's in a 12 hour shift - 10. 4 of those were MI's. All of those people lived another day but anyone could have died there in the ER. People die and sometimes you can intervene and sometimes you can't. That is life and you have to accept that you can only do your best but you cannot save everyone. That is not practical.

Trust me that in an emergency you tend to do things that you wouldn't otherwise. In small towns the EMT's are a valuable resource and always help. Not sure the chest tube thing in an office would even be feasible as I don't know many offices who would even have a kit available. Of course you could try a needle decompression and get them to the nearest ER.

 

[CrileDO]

You are not "getting it". You don't do a lot of these high risk procedures in rural area because many times YOU ARE THE ONLY DOCTOR without backup. You don't do anything that may potentially harm a patient when there is not another doctor there to help you if something does go wrong. That is the nature of rural medicine. If you want to be doing lines, etc all the time then be a hospitalist in an ICU at a bigger hospital. It comes down to a matter of staffing and safety.

Fair enough. I apologize if I am frustrating you. I was just asking your perspective on the matter because I have seen docs who were in rural places (but still 30 mins - 1 hour from a place with back up) do things like scopes, lines, and intubations in practice. I could see how you wouldn't want to do that if you were 2+ hours away from the nearest surgeon or ICU.

 

[cabinbuilder]

Fair enough. I apologize if I am frustrating you. I was just asking your perspective on the matter because I have seen docs who were in rural places (but still 30 mins - 1 hour from a place with back up) do things like scopes, lines, and intubations in practice. I could see how you wouldn't want to do that if you were 2+ hours away from the nearest surgeon or ICU.

Herein lies the difference in your definition of rural and mine. Southeast Alaska the nearest surgeon was 1 hr by plane, 6 hours by ferry. Central NV is 4 hrs by car, 1 hr by plane. Yes, an hr away by vehicle to help is a huge difference and you may be given privileges for procedures as long as there is a back plan in place for that facility.

What "rural" area are you talking about?

For example: when I had issues in Nevada, all I had to do was let the call center know in Vegas I was sending a patient. I didn't have to beg another doctor to accept or give a long report, etc. It was already in agreement if our facility put in the call, the patient was accepted, I called the plane.

Now in Alaska when I had an issue I had to spend a huge amount of time begging UoW or Juneau or Anchorage or Ketchikan to find an accepting physician. Of course I would have intubated or done a chest tube or other procedure if that person was going to die without but I surely wasn't going to put into practice those things that can go wrong quickly with the knowledge of getting them sent somewhere else was a huge ordeal.

As far as intubations usually the EMT or RT person is more practiced than me and I gladly let them do those.

 

[CrileDO]

Herein lies the difference in your definition of rural and mine. Southeast Alaska the nearest surgeon was 1 hr by plane, 6 hours by ferry. Central NV is 4 hrs by car, 1 hr by plane. Yes, an hr away by vehicle to help is a huge difference and you may be given privileges for procedures as long as there is a back plan in place for that facility.

What "rural" area are you talking about?

For example: when I had issues in Nevada, all I had to do was let the call center know in Vegas I was sending a patient. I didn't have to beg another doctor to accept or give a long report, etc. It was already in agreement if our facility put in the call, the patient was accepted, I called the plane.

Now in Alaska when I had an issue I had to spend a huge amount of time begging UoW or Juneau or Anchorage or Ketchikan to find an accepting physician. Of course I would have intubated or done a chest tube or other procedure if that person was going to die without but I surely wasn't going to put into practice those things that can go wrong quickly with the knowledge of getting them sent somewhere else was a huge ordeal.

As far as intubations usually the EMT or RT person is more practiced than me and I gladly let them do those.

Yes, I think we are on different pages in terms of how we define "rural". I am speaking of the Southeastern US. The state I'm in is terribly underserved and rural, but definitely not anywhere near being 4+ hours by car ride to back up. These places are, at most, 2 hours from back-up at a larger hospital, but are still considered very rural.

 

[galactus]

There are plenty of residencies in Texas that will prepare you for this "full scope" that you speak of, including surgical OB training. We had 5 FM attendings that do c-sections and there is always 1-2 residents graduating every year doing full scope + OB.
There are tons of procedures to be learned in residency. Would you get more inpatient procedures in IM? Sure, but I did my fair share and comfortable doing lines and intubations, and circs. What about outpatient procedures (colpo, IUDs, Nexplanon, casting/splinting, occipital nerve blocks, toenail removal, joint injections, etc)? These I learned with during FM residency.

To each their own, but what you're asking for does exist. I know people in Texas who practice what you're looking for, because I graduated with them!

 

[styphon]

Where I practice, it is considered rural - but we are about 60-90 minutes by car from a major hospital, different from the situations cabinbuilder is talking about..

I work for a Native American tribe and currently do clinic work only. I see peds, OB, and adult. I do GYN outpt procedures along with joint injections/skin biopsies. If I so desired - I could add on nursing home rounding (seeing only Native Americans) to my job, and/or inpt rounding (again, only on Native patients).

 

[primadonna22274]

I'm not in TX but I am in a rural SE program where we are trained in just about every primary care procedure. We don't do c-sections except as first assist but since I really strongly dislike OB doesn't matter to me. We treat patients in all parts of the hospital except for the NICU and we can follow the neonatologists there if we are interested (I'm not--I'm a closet internist and gerontologist). We do EGDs and colonoscopies and flex sigs. We are trained in bedside US and will sound anything and put a needle or line in anything including central lines (R IJ) and a-lines. We admit every other unassigned patient alternating with the hospitalist team and our own FM center patients to a 500-bed hospital and follow them in all the ICUs and step down units. My census the last week included half a dozen train wreck geriatrics with multisystem disease in various levels of decompensation with a smattering of "younger" and arguably "healthier" patients with shorter stays. Our service is busy and we are constantly stretched but when I get out of here I will be able to work anywhere--and that's why I chose this program. I did all of the procedures Cabin does as a PA prior to going to med school, except for OMT which I learned in med school but sadly don't use as much as I would like--there just isn't time or enough mentoring to keep up skills. What I wanted was strong inpatient training and I had no trouble finding it. Now translating this to practice after residency remains to be seen but I am likely to work somewhere rural or semi-rural as that's what I enjoy the most. I certainly don't expect to have the same career as a physician that I had as a PA (although I often did enjoy working as a PA and was blessed with many great opportunities).
I swore when I went back to med school I would not do a FM residency. Famous last words lol. Truthfully the broad training and the ability to tailor my practice to my talents after residency is what led me to rank my FM program among many strong categorical IM programs--and the ability to more easily cover the ED or hospital service when I wanted to. YMMV.

 

[cabinbuilder]

Again, what you do in residency and what you do in real world situation are 2 different things. I learned all those scopes, lines, and other procedures in residency too where you always had back-up with surgery etc if you caused a perforation or pneumothorax, etc. Learning in a 500 bed hospital with all the specialists at your disposal is a heck of lot different than working in a 10 bed hospital where you are alone.

 

[NurWollen]

Again, what you do in residency and what you do in real world situation are 2 different things. I learned all those scopes, lines, and other procedures in residency too where you always had back-up with surgery etc if you caused a perforation or pneumothorax, etc. Learning in a 500 bed hospital with all the specialists at your disposal is a heck of lot different than working in a 10 bed hospital where you are alone.

This makes sense. I know an FM doc who does scopes. He practices in a town of about 25,000 where there is no GI doctor but there are a few general surgeons for back up. IThere are internists but not enough to cover the hospital, so the FM doctors can do all the inpatient they want. There are EM-boarded docs but not enough to cover the ED 24/7. The FM docs there seem to have a nice broad scope of practice.

 

[wlf87]

Thank you all for your kind insights! Your posts have me really pumped about FM. I would not have gained this knowledge even if I were able to shadow a FM doc locally. Thank you!

There are tons of procedures to be learned in residency. Would you get more inpatient procedures in IM? Sure, but I did my fair share and comfortable doing lines and intubations, and circs. What about outpatient procedures (colpo, IUDs, Nexplanon, casting/splinting, occipital nerve blocks, toenail removal, joint injections, etc)? These I learned with during FM residency.

The intubations/central lines were during IM rotation, right? What are some of other inpatient IM procedures that one would not be exposed to in FM? I guess I'm confused what procedures would a primary care IM doc get to do that a FM cannot do. I think IM would be able to dx/manage more complicated diseases, but procedure-wise I thought FM was more diverse.

Also, is it possible to update skillsets later post-residency on a need-to-know basis, through continuing education/short term courses/assisting other docs; how does it work? For ex: It probably might not make sense for a FM to go get training in IM inpatient procedures (as that area would have more hospitalists anyway, or maybe not, as in NurWollen's example), but let's say a rural IM doc has a patient base that would be better served if he could get educated on the FM outpt gyn procedures you mentioned (colpo, IUDs, etc), or a FM doc who has not done any OB after residency as they worked in a urban area, but now wants to do OB and scopes because they are in a rural area? I ask because I think one of the advantages of being in FM or primary care IM would be to move & see different parts of the country & tailor my skillsets to better serve whatever the patient base needs -- is this even practical or just idle fantasy because insurance companies are dictating right down to the medications, tests that a doctor can order for his patients?!

We don't do c-sections except as first assist but since I really strongly dislike OB doesn't matter to me

Why dislike OB? If you don't mind.

I swore when I went back to med school I would not do a FM residency. Famous last words lol. Truthfully the broad training and the ability to tailor my practice to my talents after residency is what led me to rank my FM program among many strong categorical IM programs--and the ability to more easily cover the ED or hospital service when I wanted to. YMMV.

This! It's good to hear you say this with all your background. Makes me think I will be happy with my choice if get there...

 

[cabinbuilder]

Thank you all for your kind insights! Your posts have me really pumped about FM. I would not have gained this knowledge even if I were able to shadow a FM doc locally. Thank you!

The intubations/central lines were during IM rotation, right? What are some of other inpatient IM procedures that one would not be exposed to in FM? I guess I'm confused what procedures would a primary care IM doc get to do that a FM cannot do. I think IM would be able to dx/manage more complicated diseases, but procedure-wise I thought FM was more diverse.

Also, is it possible to update skillsets later post-residency on a need-to-know basis, through continuing education/short term courses/assisting other docs; how does it work? For ex: It probably might not make sense for a FM to go get training in IM inpatient procedures (as that area would have more hospitalists anyway, or maybe not, as in NurWollen's example), but let's say a rural IM doc has a patient base that would be better served if he could get educated on the FM outpt gyn procedures you mentioned (colpo, IUDs, etc), or a FM doc who has not done any OB after residency as they worked in a urban area, but now wants to do OB and scopes because they are in a rural area? I ask because I think one of the advantages of being in FM or primary care IM would be to move & see different parts of the country & tailor my skillsets to better serve whatever the patient base needs -- is this even practical or just idle fantasy because insurance companies are dictating right down to the medications, tests that a doctor can order for his patients?! Why dislike OB? If you don't mind.
This! It's good to hear you say this with all your background. Makes me think I will be happy with my choice if get there...

I think you need to get it out of your head that there are "IM" Procedures and "FP" procedures, it doesn't work that way. I did not have an "IM" rotation in residency, it was a medicine rotation. Generally what I have found is if you didn't learn it in residency you really won't have time to get the numbers you need to be proficient later and you will never get priviliges. I agree that OB is just evil and I am so happy that I never had to do it. Bad enough I did 3 months planned parenthood looking up drippy hoohas all day. No thanks.

 

[primadonna22274]

Lol Cabin. My dislike of OB has more to do with 2 patients in one body...and how quickly things can go bad. Also I have zero interest in being anybody's mother so I never got that "oooohhhh babiessss" appeal.

 

[cabinbuilder]

Lol Cabin. My dislike of OB has more to do with 2 patients in one body...and how quickly things can go bad. Also I have zero interest in being anybody's mother so I never got that "oooohhhh babiessss" appeal.

Oh, I"m with you Prima, hate everything about it. Hate crying women, hate germy snotty dirty crying babies and toddlers. I don't "goo" over other people's children. My own were fine but it took a lot of soul serching for me to think about wanting to be pregnant and had the first one at 27.

 

[galactus]

The intubations/central lines were during IM rotation, right?

Nope. I did those while I was on inpatient service, which was all FM. We had our own FM inpatient service, and took care of our own ICU patients.
There is no such thing as "FM" and "IM" procedures. Procedures are either inpatient or outpatient and honestly either specialty can learn how to do both.
There are CME workshops if you want to know how to do certain procedures.

 

[wlf87]

Nope. I did those while I was on inpatient service, which was all FM. We had our own FM inpatient service, and took care of our own ICU patients.
There is no such thing as "FM" and "IM" procedures.

IMO, this situation sounds the best of both IM and FM. Is dealing with inpatient/ICU patients quite possible (re. numbers) in FM, probably in less urban areas? For me, the advantage of IM= dealing /w multiple diseases/complicated in-patients (as hospitalist), but while being interesting, it could also perhaps lead to burnout after seeing very sick & most likely intractable cases almost every day; unless it could be combined with having an outpatient primary-care clinic practice. And the advantage of FM is the versatility which is evident from all these different perspectives; the only disadvantage with FM I see from my perspective (as a male) is dealing with more gyn stuff, but perhaps, and with experience, I can see situations where I would be able (comfortable) to help even in these cases. The ob/gyn+peds is also an advantage in underserved areas (most likely the reason why MSF states FM as an “asset” vs being an Internist)…

 

[JustPlainBill]

Sorry to derail the thread, but can you go into any additional detail about this? As someone about to start residency with a "rural guy who does everything" mindset, what are the pitfalls (if you'd be comfortable sharing any details)?

Sorry -- been a bit busy lately --

Pitfalls? Well -- when I get called over the weekend when I am on call and asks if we can move a patient who is in DKA because they're "sitting up, talking with friends" and they're the only one in ICU and we really want to send the nurse and technician home to save money and the patient "looks fine" -- so I go into the technical aspects of DKA/ketonemia/ketonuria and how quickly patients can crash and no, I want her on NS, etc. and at the end of the conversation, I still get asked,"So can we move the patient out of ICU" --- or when I get scolded because I'm not comfortable admitting an 80 year old with bilateral PNA who recently converted out of aFib and has AMS with signs of sepsis (not SIRS) when I have no backup and no specialists and the nearest higher level hospital is 30 minutes away --- Not by other physicians mind you but other "powers that be" --

I don't care for hospital work and have no intention of doing it.....

 

[cabinbuilder]

IMO, this situation sounds the best of both IM and FM. Is dealing with inpatient/ICU patients quite possible (re. numbers) in FM, probably in less urban areas? For me, the advantage of IM= dealing /w multiple diseases/complicated in-patients (as hospitalist), but while being interesting, it could also perhaps lead to burnout after seeing very sick & most likely intractable cases almost every day; unless it could be combined with having an outpatient primary-care clinic practice. And the advantage of FM is the versatility which is evident from all these different perspectives; the only disadvantage with FM I see from my perspective (as a male) is dealing with more gyn stuff, but perhaps, and with experience, I can see situations where I would be able (comfortable) to help even in these cases. The ob/gyn+peds is also an advantage in underserved areas (most likely the reason why MSF states FM as an “asset” vs being an Internist)…

Seeing sick people doesn't lead to burn out, it's the constant bull**** battle you do trying to practice good medicine and taking care of people how they should be taken care of with administration telling you otherwise and making your life miserable. There's a reason I do locums. I don't have to listen to admin and if they don't like how I practice, they are welcome to terminate my contract and I move on.

 

[cabinbuilder]

Sorry -- been a bit busy lately --

Pitfalls? Well -- when I get called over the weekend when I am on call and asks if we can move a patient who is in DKA because they're "sitting up, talking with friends" and they're the only one in ICU and we really want to send the nurse and technician home to save money and the patient "looks fine" -- so I go into the technical aspects of DKA/ketonemia/ketonuria and how quickly patients can crash and no, I want her on NS, etc. and at the end of the conversation, I still get asked,"So can we move the patient out of ICU" --- or when I get scolded because I'm not comfortable admitting an 80 year old with bilateral PNA who recently converted out of aFib and has AMS with signs of sepsis (not SIRS) when I have no backup and no specialists and the nearest higher level hospital is 30 minutes away --- Not by other physicians mind you but other "powers that be" --

I don't care for hospital work and have no intention of doing it.....

Ah, I remember all those late night bitching phone calls about "how the hell do I get out of this job". Glad you are happier now, Bill.