Procedures

[mustangsally65]

What kinds of procedures do rural physicians do that their bigger-city counterparts would refer to a specialist?

My family doctor has removed both my toenails before, and I've read about some rural FM docs who do sigmoidoscopies, deliver babies, and even perform the occasional appendectomy if a general surgeon isn't available.

What have those of you in rural medicine encountered that have seemed a bit out of the ordinary for your specialty?

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[skypilot]

What kinds of procedures do rural physicians do that their bigger-city counterparts would refer to a specialist?

My family doctor has removed both my toenails before, and I've read about some rural FM docs who do sigmoidoscopies, deliver babies, and even perform the occasional appendectomy if a general surgeon isn't available.

What have those of you in rural medicine encountered that have seemed a bit out of the ordinary for your specialty?

Not out of the ordinary but I know FPs in New Hampshire only an hour and a half out of Boston that are doing vasectomies.

 

[deleted6669]

Not out of the ordinary but I know FPs in New Hampshire only an hour and a half out of Boston that are doing vasectomies.

This is fairly common. I know fp's in los angeles (which has no lack of urologists) doing these as well.
sigs/treadmills/derm procedures/c-sections/joint injections are fairly common as well.

 

[mustangsally65]

So are these skills picked up during residency?

 

[deleted6669]

So are these skills picked up during residency?

at the right residency, yes.
best bet is to shoot for unopposed programs with lots of ob and em exposure....I work at a facility with an fp residency. they learn all of these procedures and more.

 

[BACMEDIC]

at the right residency, yes.
best bet is to shoot for unopposed programs with lots of ob and em exposure....I work at a facility with an fp residency. they learn all of these procedures and more.

Are the right residencies at rural locations or all those with FP spots?

 

[sophiejane]

Are the right residencies at rural locations or all those with FP spots?

It totally depends on the residency. In general, I think that an urban program that is unopposed will give you the best exposure to pathology while also giving you the chance to do procedures and deliveries that you don't have to "share" with other residents like you would in an opposed program.

It's pretty common for rural FPs in my part of the country to do colonoscopy, colposcopy, vasectomies, OB, minor surgeries like mole removal, and ultrasound in their offices.

Some of them are making a tidy sum doing all that. And to the naysayers, they do these procedures often enough to be quite proficient.

 

[shemozart]

I totally agree with the above....if you want to do any of the following, there are places you can learn this stuff. As well, if you don't pick it up in residency, don't worry, you can always do a CME course, apprentice with someone in your clinic who does do it, do a fellowship.....there is always a way! As far as appys, I know there's a couple programs (isn't is called "frontier medicine" or something - like Pocatello ID?) where you still get training, but that's fading a bit. But still, if you want it, and want to get good at it, you can do pretty much anything if you find a way to get training and get privileges to do it in practice. Most people pick a few procedures and get really good, others do more, some don't do any.

You don't have to be practicing in a small town to do most of this either, but it GREATLY facilitates it! Any questions about procedures, just yell out a few and those of us on the board can let you know which are included as part of every FP residency (normal vaginal deliveries, minor office procedures), and which you might get in residency, might not (i.e., colonoscopies).

 

[mustangsally65]

What's the difference between opposed and unopposed?

 

[sophiejane]

Opposed means that there are other residency programs at the same hospital in addition to family medicine, like internal medicine, OBGYN, surgery. This is the model for the larger, university based programs. Good if you want to go into academics, but not good for much else, at least for FP. FM residents are usually the red-headed stepchildren, as it were. They get the least respect and often have to wait in line beind medicine, OBGYn, and surgery to get deliveries and procedures. They have lots of outpatient and not as much (or as good) inpatient experience as the medicine residents.

Unopposed means that the FP residents run the hospital. There are no other residents--they do all services, from surgery to OB to medicine to outpatient to peds. This happens at smaller community-based hospitals, most of which are not associated with medical schools. There are some larger hospitals with unopposed programs (JPS in Ft. Worth is the largest in the country, I believe. They have around 22-24 residents in a class and a 450-bed county hospital), but most are not that big.

 

[skypilot]

Opposed means the hospital hosts other residency programs which may compete with FP for procedures. It might be tough to get any experience doing appys as a FP resident if their are surgical residents who want to do them. Or to do OB procedures if there are OB residents who want a chance to do them.

 

[Pyroclast]

What kinds of procedures do rural physicians do that their bigger-city counterparts would refer to a specialist?

My family doctor has removed both my toenails before, and I've read about some rural FM docs who do sigmoidoscopies, deliver babies, and even perform the occasional appendectomy if a general surgeon isn't available.

What have those of you in rural medicine encountered that have seemed a bit out of the ordinary for your specialty?

You only had two toenails???

 

[lilnoelle]

Any other surgeries a rural FP might be able to do that aren't listed above?

 

[lilnoelle]

Also, how do you find out which programs are unopposed? I'm guessing most of the rural track programs are unopposed, but those wouldn't be large enough to get a lot of procedural experience.

 

[sophiejane]

Also, how do you find out which programs are unopposed? I'm guessing most of the rural track programs are unopposed, but those wouldn't be large enough to get a lot of procedural experience.

It's generally by program. Yout just have to go to the website or call and find out. They won't necessarily mention the word "unopposed" but if they are a community program, they are unopposed usually. There are a few that are unaffilliated with a university medical school that are not unopposed, but it seems to be rare.

Not that you can't get good training at opposed programs, certainly there are some that provide excellent training in academic settings. The thing is, when you are IT at a hospital, you are IT. No turf battles, no question about who does the ICU care, the deliveries, the procedures.

I LOVE my unopposed program and can't imagine that I'm missing out on much by not being at an academic or opposed program.

 

[lilnoelle]

It's generally by program. Yout just have to go to the website or call and find out. They won't necessarily mention the word "unopposed" but if they are a community program, they are unopposed usually. There are a few that are unaffilliated with a university medical school that are not unopposed, but it seems to be rare.

Not that you can't get good training at opposed programs, certainly there are some that provide excellent training in academic settings. The thing is, when you are IT at a hospital, you are IT. No turf battles, no question about who does the ICU care, the deliveries, the procedures.

I LOVE my unopposed program and can't imagine that I'm missing out on much by not being at an academic or opposed program.

Would this size of a hospital be decent as far as getting experience with procedures? Its a "rural track" program and is in a city close to my hometown.
http://www.ama-assn.org/vapp/freida/inst/0,1238,188003,00.html

Thanks for your help!

 

[sophiejane]

Would this size of a hospital be decent as far as getting experience with procedures? Its a "rural track" program and is in a city close to my hometown.
http://www.ama-assn.org/vapp/freida/inst/0,1238,188003,00.html

Thanks for your help!

2 ICU beds and 337 deliveries a year? Ouch. Sounds pretty quiet.

Seriously, if you want to do rural, train urban. Trust me on this. There is no way on earth you are going to see what you need to see and get the kind of volume you need to be well trained for full spectrum family medicine in a teeny tiny hospital like that. This is my opinion and I'm sure there will be some who will disagree, but I did a lot of research on programs and talked to a lot of people before applying.

 

[lilnoelle]

2 ICU beds and 337 deliveries a year? Ouch. Sounds pretty quiet.

Seriously, if you want to do rural, train urban. Trust me on this. There is no way on earth you are going to see what you need to see and get the kind of volume you need to be well trained for full spectrum family medicine in a teeny tiny hospital like that. This is my opinion and I'm sure there will be some who will disagree, but I did a lot of research on programs and talked to a lot of people before applying.

Good to know. I've got a while before I'm applying (I'm a 2nd year student) but I did find a few programs that described training for a bunch of procedures. I'm guessing theres no point in doing a bunch of research because things can change before I apply anyway.

 

[Doowai]

An opposed program in Milwaukee I interviewed at did a lot of procedures, vasectomies, colonoscopies, LEEP, treadmills. The guy who taught vasectomies did alot of them in his private practice in Milwaukee.

Many Fp's in Phoenix do minor procedures like toenail removals.

 

[fc1000]

I would like to throw in a different perspective on rural training. I am a resident in a 1-2 rural training track and I looked hard at a lot of great programs, both rural and urban (but all unopposed). I think some of the RTT's have a lot to offer. For many of them you spend the first year working in a higher volume city hospital for your inpatient rotations. Then you move to a rural hospital/clinic for the next 2 years when the years are more clinic based with a longitudinal inpatient practice. Out of the graduates from my program all do OB and inpatient medicine, some do colonscopy/EGDs, 1 did c-sections (but no longer does), and all were trained to do the run of the mill outpatient stuff (colpos, IUDs, vasectomy, stress tests, lumps/bumps, etc).

I can't speak for all RTT's but a major advantage of some of them is the quality of the outpatient clinic experience. Since the residents make up a small proportion of a well functioning rural practice (ideally), we have a smaller proportion of the patients who seem to plague lots of resident only clinics: narcotics seekers, chronic pain patients, and the mentally ill (we still have our share, but it is more like a real-life rural practice).

I also think that once clinical volume crosses a certain threshold the quality of the experience is much more important than the quantity. I would rather have 10 great experiences treating someone with a CHF exacerbation (working side by side with an experienced rural FP who I know well), then 100 experiences treating the same kind of patient when I am too tired to see straight, and too busy to read about what I am seeing/doing.

In many RTT's you can get good procedural/inpatient experience because everyone in town knows that you want to be called for good cases. That is the way to get a higher-volume experience without doing 100s-1000s of admissions for CHF/COPD/cellulitis/RO MI/RSV/OD/EtOH.

The bottom line is that I think some RTTs combine the benefits of both urban and rural training. They aren't for everyone -- the major drawbacks are having to move between the 1st and 2nd year, and having a smaller peer group to hang out with. I think they are at least worth a close look for people who are preparing for rural practice.

 

[HarveyCushing]

I would like to throw in a different perspective on rural training. I am a resident in a 1-2 rural training track and I looked hard at a lot of great programs, both rural and urban (but all unopposed). I think some of the RTT's have a lot to offer. For many of them you spend the first year working in a higher volume city hospital for your inpatient rotations. Then you move to a rural hospital/clinic for the next 2 years when the years are more clinic based with a longitudinal inpatient practice. Out of the graduates from my program all do OB and inpatient medicine, some do colonscopy/EGDs, 1 did c-sections (but no longer does), and all were trained to do the run of the mill outpatient stuff (colpos, IUDs, vasectomy, stress tests, lumps/bumps, etc).

I can't speak for all RTT's but a major advantage of some of them is the quality of the outpatient clinic experience. Since the residents make up a small proportion of a well functioning rural practice (ideally), we have a smaller proportion of the patients who seem to plague lots of resident only clinics: narcotics seekers, chronic pain patients, and the mentally ill (we still have our share, but it is more like a real-life rural practice).

I also think that once clinical volume crosses a certain threshold the quality of the experience is much more important than the quantity. I would rather have 10 great experiences treating someone with a CHF exacerbation (working side by side with an experienced rural FP who I know well), then 100 experiences treating the same kind of patient when I am too tired to see straight, and too busy to read about what I am seeing/doing.

In many RTT's you can get good procedural/inpatient experience because everyone in town knows that you want to be called for good cases. That is the way to get a higher-volume experience without doing 100s-1000s of admissions for CHF/COPD/cellulitis/RO MI/RSV/OD/EtOH.

The bottom line is that I think some RTTs combine the benefits of both urban and rural training. They aren't for everyone -- the major drawbacks are having to move between the 1st and 2nd year, and having a smaller peer group to hang out with. I think they are at least worth a close look for people who are preparing for rural practice.

Thanks for the great post. That is one reason why I am looking at going into a rural oriented unopposed FP program. From my research and talking to those who do rural FP, a program with a rural track is probably one of the best ways to prepare for rural medicine and why those programs have such a large success putting their graduates into rural areas. Nothing wrong with wanting to do an urban training, but I think you will end up depending on resources in certain cases that you might not have out in a rural setting. Thanks for sharing your opinion.

 

[HarveyCushing]

Seriously, if you want to do rural, train urban. Trust me on this. There is no way on earth you are going to see what you need to see and get the kind of volume you need to be well trained for full spectrum family medicine in a teeny tiny hospital like that. This is my opinion and I'm sure there will be some who will disagree, but I did a lot of research on programs and talked to a lot of people before applying.

Not sure I completely agree with you on this one. To say that those who train at a smaller community setting (<50-100,000) get an inferior training is just plain wrong. Training has a lot to do with more than just the number of cases. If one is planning on doing rural medicine, then it makes perfect sense to do a program that specializes in that, don't you think?

 

[sophiejane]

If one is planning on doing rural medicine, then it makes perfect sense to do a program that specializes in that, don't you think?

Nope.

It's okay to agree to disagree, but I did a whole lotta research and talking to people and reading about this, and it's my conclusion that you CAN have volume (patient and procedure) as well as academic substance in a program AND great clinic experience, and that the combination (for me) is the best way to train to be a rural doc.

Think about it, how is pneumonia any different in a small town versus a big city? Right, it's not. Okay, now how are you going to get to see as much as you can possibly see of the weirdness and the variety if you don't have volume? Seeing more patients and doing more procedures on more patients = more chances to practice and learn. It's not enough for me to fill in the gaps with reading, I need to put my hands on the patient and see it with my own eyes.

But we all learn differently, so do what's best for you.

I do know that some rural programs like to market themselves that way, i.e. if you want to practice rural, you have to train rural. But I would argue that the programs turning out some of the best trained rural docs are in urban settings, simply because they have seen and done a ton.

There ARE fantastic unopposed FM programs in urban settings where you are the only show in town and you do EVERYTHING and also get great volume. Ask them where their grads practice and you are going to get a litany of little towns rattled off.

 

[sophiejane]

You may want to check out this thread for a discussion on how idyllic clinic can be in a rural training program. See post by Dirtridindoc (A Casper, WY resident):

http://forums.studentdoctor.net/showthread.php?t=489653

 

[HarveyCushing]

There ARE fantastic unopposed FM programs in urban settings where you are the only show in town and you do EVERYTHING and also get great volume. Ask them where their grads practice and you are going to get a litany of little towns rattled off.

While you might have more volume at an urban program, you also have more residents in the program. So whether you see 100,000 patients a year with 30 residents, or 50,000 patients with 15 residents I don't see how volume necessarily equates with a better education? Ultimately I think one has to take each program on a case by case basis. Some programs in a rural are big on procedures, others aren't. The same for urban programs. Ultimately I think one has to take each program and see what they have to offer and how they will fit into your goals for training. Also in an urban area you are competing with other medical centers for patients, whereas if you are the only medical center in an area of 100,000 pop. you might have dibs on basically everything. Just a thought, but I appreciate your comments sophie. So thanks for making me think more about this .

 

[EdibleEgg]

There are two sides to the coin. I trained in an urban program for the same reasons Sophie mentions. I think she is right on most accounts. However, the way you manage a STEMI in a big urban hospital is much different from the way you manage a STEMI when there are no cardiologists around and the nearest hospital with a cath lab is four hours away. The same goes for several other conditions.

 

[sophiejane]

While you might have more volume at an urban program, you also have more residents in the program. So whether you see 100,000 patients a year with 30 residents, or 50,000 patients with 15 residents I don't see how volume necessarily equates with a better education? Ultimately I think one has to take each program on a case by case basis. Some programs in a rural are big on procedures, others aren't. The same for urban programs. Ultimately I think one has to take each program and see what they have to offer and how they will fit into your goals for training. Also in an urban area you are competing with other medical centers for patients, whereas if you are the only medical center in an area of 100,000 pop. you might have dibs on basically everything. Just a thought, but I appreciate your comments sophie. So thanks for making me think more about this .

Very true. But see, I don't think of 100K as rural.

I just want you to not close your mind to urban and semi-urban programs as great places--not the only places--to train for rural medicine. If you close yourself off this early in the game, you may well miss even looking at your dream program. I almost didn't even interview at the program I ended up at, and I think that would have been a HUGE shame for me, because it ended up being exactly what I wanted.

PM me if you are interested in my program, not that I'm biased (ha!), but it really is everything you seem to be looking for. It combines the volume and pathology of a big city in a medium-sized university town. There are two moderately big medical centers in town, one with a Level 2 Trauma ER, and we work at BOTH of them. No sharing, we've got most of the poor and a huge chunk of the sick already signed up at our 6 different clinics across town, and we admit them all. We have all of the poverty, crime, and chronic illness of a big city--but no traffic! How fabulous is that?!

Though there are days when I wish there was a little MORE sharing, but that's another story.

 

[HarveyCushing]

Very true. But see, I don't think of 100K as rural.

I just want you to not close your mind to urban and semi-urban programs as great places--not the only places--to train for rural medicine. If you close yourself off this early in the game, you may well miss even looking at your dream program. I almost didn't even interview at the program I ended up at, and I think that would have been a HUGE shame for me, because it ended up being exactly what I wanted.

PM me if you are interested in my program, not that I'm biased (ha!), but it really is everything you seem to be looking for. It combines the volume and pathology of a big city in a medium-sized university town. There are two moderately big medical centers in town, one with a Level 2 Trauma ER, and we work at BOTH of them. No sharing, we've got most of the poor and a huge chunk of the sick already signed up at our 6 different clinics across town, and we admit them all. We have all of the poverty, crime, and chronic illness of a big city--but no traffic! How fabulous is that?!

Though there are days when I wish there was a little MORE sharing, but that's another story.

I appreciate your posts since you have a lot of good points and experience. I will definitely do my best to keep an open mind as I look into programs that I am interested in, and that will provide me with the best training for the future. I hope the AAFP meeting this summer in KC will be a good chance for me to explore what different programs have to offer. I will definitely take up your offer and bounce my ideas off you and hear what you have to say. Your program sounds great, I just wish it had a different location. Not sure I'm ready for Texas livin'.

 

[dirtridndoc]

Thanks for quoting me Sophie...I hope what I wrote wasn't too discouraging but it was truthful.

A word on Opposed vs Unopposed. I think unopposed is ideal IF the residency has faculty that are BC in disciplines other than FP. We have had several med students rotate through our program and opt to go elsewhere for residency because they wanted stronger IM, OB and Peds teaching. That's not to say that we don't have a few faculty who are really good and can teach IM, OB and Peds. Even our Hospitalists are not all BC in IM. I think that is a huge drawback when you are assigned to do your Core IM rotation with on our FP inpatient service or with the Hospitalists. You've got to have a solid foundation in medicine - particularly if you are going to head off into the wilds of rural FM. Same deal with EM training in FM residency. You may be the only doc in the rural ER, so you'd better know your stuff. Luckily, our hospital hired two new EM grads this and the difference in their decision making and management is huge. Again, this is not to disparage the FP's who have worked in our ED for years. Some of them are really good, but there is no comparison with the teaching we have received from the new guys.

Good luck to all next July.

 

[sophiejane]

I think unopposed is ideal IF the residency has faculty that are BC in disciplines other than FP.

This is very true. I have learned a lot from our FP faculty about medicine, both inpatient and ambulatory, but I think my learning might have suffered had we not had a fantastic pediatrician and four equally fantastic OBGyns on staff who are always there to answer questions and teach.

These are all questions to ask about potential programs.

Take it from us, dear future interns: DO YOUR HOMEWORK about programs!! Do not be swayed by location alone (as I almost was) or by frills that in the end will mean very little.



SJ

 

[HarveyCushing]

This is very true. I have learned a lot from our FP faculty about medicine, both inpatient and ambulatory, but I think my learning might have suffered had we not had a fantastic pediatrician and four equally fantastic OBGyns on staff who are always there to answer questions and teach.

These are all questions to ask about potential programs.

Take it from us, dear future interns: DO YOUR HOMEWORK about programs!! Do not be swayed by location alone (as I almost was) or by frills that in the end will mean very little.



SJ

I have a logistics question: now when you say that a program has pediatrician/OBGyns...etc. on staff, is that on staff for the residency program? I am curious how the whole faculty thing works for an unopposed program, who is suppose to teach in such a setting? Ideally wouldn't the pediatricians still teach you in the hospital even if they aren't "faculty" in the residency program?

 

[sophiejane]

I have a logistics question: now when you say that a program has pediatrician/OBGyns...etc. on staff, is that on staff for the residency program? I am curious how the whole faculty thing works for an unopposed program, who is suppose to teach in such a setting? Ideally wouldn't the pediatricians still teach you in the hospital even if they aren't "faculty" in the residency program?

I can't speak for other programs, but at our program, faculty is faculty. They don't have other jobs. They work for our clinics, are faculty for inpatient and outpatient rotations, and they are available to us by phone, email or in person pretty much all the time, with the exception of vacations, weekends they aren't on call, etc. This includes the pediatrician and the OBGYns. Other non-paid faculty include an AMAZING colorectal surgeon with whom I've done >100 scopes so far on my 2 months of surgery, a team of pulmonologists who are now under our clinic "umbrella" and teach one-on-one on the pulm/ICU rotation, a cardiology group, and various other community specialists. We are fortunate to have an excellent relationship with local specialists, to whom we refer patients, and who return the favor by teaching us.

Great questions. Ask these to every program!

 

[Doowai]

Very small rural residency programs often go to other hospitals for some rotations. I interviewed at a rural FP program in Ohio that was in a town of less than 20,000. But they often went to Cincinnati for certain rotations - for example they did in-patient pediatrics at a nationally top rated pediatric hospial in Cincinnati.

So if you do residency in a small town program, it does not mean you will spend all of your time there.

 

[hotobhaga]

http://findarticles.com/p/articles/mi_m0689/is_/ai_114521517

 

[DrAmpuT]

What kinds of procedures do rural physicians do that their bigger-city counterparts would refer to a specialist?

Does having a pt. call 911 and ending up w/ one of the FD's EMT/EMT-Ps doing the delivery in their house count as referral to a specialist by chance? Especially if it is out here in the middle of nowhere?

 

[DDuncan]

A more pertinent question of the program would be to ask the number of X procedure/cases/etc that their actual residents have done.

I looked closely at rural track programs, but my self chose a 3 year program.

I actually spent 4 months of med school rotations at the hospital linked below. They were just starting their rural track program then. I don't know how it has developed since, but the people there are awesome.

Remember you do have to spend the first year in the larger major hospital, so alot of the ICU/general high volume things you will see there.

I see you are at KU, yet from Iowa??? You should check out Via Christi in Wichita.

You should read what Dr Bowman has written at http://www.ruralmedicaleducation.org/index.htm.
He is a leader in rural health.

Bottom line is you need to find a program that will train you for the practice that you desire. If you want to do a certain set of procedures in your practice, make sure that they are available in the residency. Don't settle for "you can arrange that by special request or elective" Find places where people DO what you want to do.

There may be limitations in the rural setting for training that limit your access. For example I cant imagine a rural community that you could get NICU training, but I really learned a lot in my NICU rotation about newborn triage/stabilization that will prepare me for my rural career - but you could do it in your intern year in the large center if it was scheduled right?

I think that sophiejane is a bit overboard in saying that there is no way you could get the training in the rural site. Remember it is 1/3 in the larger center (maybe more in few RTT programs that send you back to the large center for a month or 2)

You should check out a few of the RTT if you are really interested. Another in the Midwest is the Madison/Baraboo WI program. Jim Damos the PD there started the first ALSO program. I interviewed there, (hit a deer on the way) and really liked it. moving my family twice was the real drawback for me.

good luck!

Would this size of a hospital be decent as far as getting experience with procedures? Its a "rural track" program and is in a city close to my hometown.
http://www.ama-assn.org/vapp/freida/inst/0,1238,188003,00.html

Thanks for your help!