rural/full scope/"cowboy" programs

[DrMidlife]

Draft protocol for evaluating the degree of full spectrumness at an FM program. I'm PGY1, and my experience is mid-Atlantic coast and west coast, so those from the midwest, NE, Texas, FL etc, and those who have strong contrasting opinions, please pipe up.

1. Learn how to find FM residencies. From aafp.org, find the residency directory. Find FREIDA. Maybe find the directory on aacom.org. Maybe find the searchable tables on ACGME. There's no such thing as an unlisted FM residency, and if there is, so what? You have plenty of work to do.
2. Make friends with the need to build and maintain a good list. If you're borderline and expecting to need to apply to 100+ programs, you're going to need to look at maybe 150 to get a decent 100. Just accept that you won't end up getting full value for every last keystroke you invest in your list. Start with state, town, program name and add info as you go. When you find out something interesting that opens your eyes about what to value, go back and run your list again. Keep track of things you love about a program (near a good surfing beach) and things that make you nervous (new EM residency is starting during your PGY2 year).
3. Pick a handful of programs to get started, such as some of the classic full spectrum programs (JPS, Ventura, Klamath Falls, Alaska, Lancaster, lots more discussed in this subforum). Find each program's website. There may be more than one official website. There may be only one sucky website. The website may not be recently updated. Look at it anyway. See if there's anything in wikipedia. See if there is any useful content in SDN posts (rare).
4. You need to know: how many major training sites? is all of inpatient peds at a separate facility, for instance, and if so, are you willing to dilute your peds training? are you farmed out to the VA to see old people (pros/cons)? is the off-site training substantial enough that there's no point in trying to have continuity patients?
5. You need to know: what's the trauma level at the main site? if there's no helipad, you're not getting much trauma or peds EM. Maybe that's accounted for elsewhere in the curriculum.
6. You need to know: are there other residencies at a major training site? find each facility's GME page and see for yourself. Also, the NRMP match data includes data at the site level, which instantly tells you if there's another residency.
7. You need to know: are there fellows? Such as OB fellows between you and all the high risk births? Such as sports med? Trauma/CC? ED? Hospitalist? Are new fellowships in the works?
8. You need to know: is the main hospital a safety net? or will you have patients you're not allowed to see because private providers don't want residents? the more Medicaid/uninsured in the mix, the more they need your labor, and the more you'll get to do. sometimes wikipedia is a better source of basic info on a hospital than the hospital's website.
9. You need to know: are electives baked into the schedule? this allows you to cover a few holes in your training if necessary, and maybe forgive a curriculum hole.
10. Compare to Alaska. I am going to big fat claim that Alaska is the de facto standard for full spectrum unopposed, no foolin around, you betcha you're ready for anything after 3 years, rigorous FM training. AKFMR is the only residency in the whole state. 95% of docs in Alaska are FM, many in sites only accessible by boat or plane. Residents get multiple remote assignments where you basically get dropped from a plane to deliver babies and remove harpoons (I'm kidding but just barely). (Full disclosure: I interviewed there and ranked it high but it's not where I landed.)
11. Don't take any blanket statements about whether a program is "good" or "bad" from your classmates or fellow interviewees. You don't know how they got that info. You don't know if their top priority is cush hours etc.

A note on what "cowboy" means: that's the label a program gets when residents aren't supervised and are teaching themselves. Generally it's hard to stay accredited by allowing such. For every individual who celebrates how much freedom he/she had to do lines & intubations alone in the ED in the middle of the night back in '87, there are maybe 5 individuals who had major gaps in their training that negated the point of choosing full spectrum. Generally when somebody not affiliated with a reputable full spectrum program describes that program as "cowboy" they are objecting to the whole concept of full spectrum. There are FM/other docs who think FM docs shouldn't do c sections, shouldn't do lines, shouldn't be hospitalists etc. There are specialists who honestly don't see the point of primary care at all. So you have to be the grownup about what matters to you.

The cheapest choice is to apply, so go ahead and be flat out wrong at this stage. It's more expensive to interview, so be more sure before you accept & travel. And then it's a very big life-changing deal to choose to rank or not rank a program - it's not until this point that you need ALL the info you can get your hands on to make a great choice.

Some questions for full spectrum PDs (not in front of other interviewees):

1. What are the weaknesses of your program? (If they say there are no weaknesses, they are full of crap.)
2. If I'm interested in X, would I need to use elective time to get good training? (Where X might be sports med or c-sections or Peds EM or family planning etc.)
3. If I'm interested in X, am I ready to do X after residency or would you expect me to do a fellowship?
4. What do you do when you have a specialist who isn't supporting your trainees? (The answer doesn't really matter, they just have to have an answer.)
5. Are recent graduates giving you any feedback about their training that you'll be trying to address?

Best of luck to you.

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[DrMidlife]

Here's a big fat one I left out: go to the AAFP conference in late July. Kansas City. Spend the money. http://www.aafp.org/events/national-conference.html

I didn't go because my targets were already solid. Which was stupid - there's a ton of info & networking that only happen at the conference.

 

[cabinbuilder]

Compare to Alaska. I am going to big fat claim that Alaska is the de facto standard for full spectrum unopposed, no foolin around, you betcha you're ready for anything after 3 years, rigorous FM training. AKFMR is the only residency in the whole state. 95% of docs in Alaska are FM, many in sites only accessible by boat or plane. Residents get multiple remote assignments where you basically get dropped from a plane to deliver babies and remove harpoons (I'm kidding but just barely).

I will second this since I have worked in remote Alaska where I am THE ONLY DOCTOR on an Island and the next one is 6 hours by ferry or 1 hour by plane. My colleague actually delivered high risk twins on a medvac plane in a snowstorm flying out of Barrow to Anchorage - the babies and mom lived. Is is also true that most doctors are IM or FP and get to do a heck of a lot more procedures because there just isn't anyone else to do them.