Why so much training in the inpatient setting?

[curvyintern]

Why do fm residents mainly train in the inpatient setting when they will only see out patients after residency?

Ped clinic would be very educational for a fm resident but ped inpatient???

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[DIce3]

IMHO there is not inpatient medicine and outpatient medicine, but rather a continuum of care along a spectrum. The inpatient teaching ward is a more efficient vehicle to learn to care for sick patients as many outpatients are less sick. Some diseases only present frequently in the outpatient setting, hence outpatient teaching months. It has only been in the last ten years that physicians sadly stopped seeing their own patients in the hospital. This is not a good thing IMHO.

 

[curvyintern]

yeah, understand that you also has to do some training in the inpatient setting to see cases you otherwise wouldn´t see. But don´t think you need to practice inpatient medicine. ICU for example is an almost total waste of time compared to for example derm.

The ratio inpatient vs outpatient seems to be like 80:20 today, something like 20:80 would be better, no?

 

[brats800]

As was already mentioned, you learn different things on inpatient and outpatient. You also take care of different acuity. If I mistreat someone's acne as an outpatient, they call or come back in a couple weeks and we try something else. If I mistreat the septic patient I have currently in the ICU, who is on abx with a PICC + significant IV fluids to keep his pressures up and may need pressor support, if I mistreat that patient - he dies. Short of splitting FM into multiple tracks (OB heavy or light, Inpatient heavy or light, etc) and just transferring care of your inpatient / sick patients to the specialists, you need to learn your inpatient and you need to learn it well. It takes time to learn to care for really sick people.

 

[curvyintern]

As was already mentioned, you learn different things on inpatient and outpatient. You also take care of different acuity. If I mistreat someone's acne as an outpatient, they call or come back in a couple weeks and we try something else. If I mistreat the septic patient I have currently in the ICU, who is on abx with a PICC + significant IV fluids to keep his pressures up and may need pressor support, if I mistreat that patient - he dies. Short of splitting FM into multiple tracks (OB heavy or light, Inpatient heavy or light, etc) and just transferring care of your inpatient / sick patients to the specialists, you need to learn your inpatient and you need to learn it well. It takes time to learn to care for really sick people.

I do understand that. I fully understand that it is challenging to care for a septic patient. My point was that as a FM doc you don´t have to know it! If you get a septic pt to your office the important thing is to recognize it and then start fluids and oxygen and send to closest hospital. Since you cant know everything I would much rather know more about acne than learning about different pressors.

 

[deleted87716]

Why do fm residents mainly train in the inpatient setting when they will only see out patients after residency?

Not sure where you got that idea. Nearly 70% of FPs have hospital privileges.

Source: http://www.aafp.org/online/en/home/aboutus/specialty/facts/15.html

 

[VA Hopeful Dr]

I do understand that. I fully understand that it is challenging to care for a septic patient. My point was that as a FM doc you don´t have to know it! If you get a septic pt to your office the important thing is to recognize it and then start fluids and oxygen and send to closest hospital. Since you cant know everything I would much rather know more about acne than learning about different pressors.

You can't know everything about everything, but you can know a fair bit about most everything.

 

[rachmoninov3]

I do understand that. I fully understand that it is challenging to care for a septic patient. My point was that as a FM doc you don´t have to know it! If you get a septic pt to your office the important thing is to recognize it and then start fluids and oxygen and send to closest hospital. Since you cant know everything I would much rather know more about acne than learning about different pressors.

An IM dose of rocephin would be more helpful, so it looks like you do need more in patient and ICU. (OK, so that was a cheap shot) However, as my previous threads have lamented the shrinking scope of practice of FM, in part because of hospitalists. There are some physician who still prefer to do full scope family medicine, not just outpatient. Likewise, there are some that only want to do outpatient. It's a balance to provide the right education for everyone. In your PGY-2 and PGY-3 you can skip the ICU rotation and pad your electives with things like derm.

In the mean time, please take your inpatient requirements as a chance to learn as much as you can and don't go jumping on the "FM is an outpatient only specialty" bandwagon thereby threatening the education of your crazier fellow residents who want to practice full scope family medicine.

 

[smq123]

yeah, understand that you also has to do some training in the inpatient setting to see cases you otherwise wouldn´t see. But don´t think you need to practice inpatient medicine. ICU for example is an almost total waste of time compared to for example derm.

The ratio inpatient vs outpatient seems to be like 80:20 today, something like 20:80 would be better, no?

It's a waste of time if you let it be a waste of time.

ICU (and its close relative, CCU) can really hammer home the physiology that you use when treating patients every day. Plus, it prepares you for the tough conversations with patients you'll have.

 

[cabinbuilder]

I do understand that. I fully understand that it is challenging to care for a septic patient. My point was that as a FM doc you don´t have to know it! If you get a septic pt to your office the important thing is to recognize it and then start fluids and oxygen and send to closest hospital. Since you cant know everything I would much rather know more about acne than learning about different pressors.

This is the biggest farce I have heard in a long long time. There are those of us who work rural medicine who do the inpatient, ER, and outpatient jobs siumultaneously. I have been places recently where I had a septic patient who I was trying to medevac to the nearest facility but couldn't because the plane was grounded due to weather - I was THE ONLY DOCTOR IN TOWN. So, I can't just say. "I"m sorry, I'm an FP and I don't really need to know how to take care of you even though there is no one else." Ain't never gonna happen. Bottom line is you never know where your career will take you and there may be a time where you need to be up on your inpatient medicine because if you aren't, the patient will die waiting for someone who knows what to do.

My last assignment if I got a patient like that in the clinic, I walked them across the hall into the hospital, put them in a bed and wrote orders to get the nurses started and went back to clinic to finish the day while seeing ER patients inbetween.

 

[survivordo]

I would also add that a big part of an FP's job is knowing when a patient is sick sick and needs to be hospitalized and when they are just sick and can run the course at home. This, of course, comes with experience but I also think see the course of an illness throughout a hospital stay is beneficial.

Survivor DO

 

[survivordo]

I would also add that a big part of an FP's job is knowing when a patient is sick sick and needs to be hospitalized and when they are just sick and can run the course at home. This, of course, comes with experience but I also think see the course of an illness throughout a hospital stay is beneficial.

Survivor DO

 

[smq123]

I do understand that. I fully understand that it is challenging to care for a septic patient. My point was that as a FM doc you don´t have to know it! If you get a septic pt to your office the important thing is to recognize it and then start fluids and oxygen and send to closest hospital. Since you cant know everything I would much rather know more about acne than learning about different pressors.

Wait a minute.

Why do you care about Family Medicine training? According to your previous posts, you're an IM resident who has remediation issues. So why do you know, or care, what our training entails and why?

 

[surrender903]

Wait a minute.

Why do you care about Family Medicine training? According to your previous posts, you're an IM resident who has remediation issues. So why do you know, or care, what our training entails and why?

zing!

 

[drcrispmd]

There are many FP that admit and follow their patients in the hospital. They go to the hospital and round on their patients before their office opens. In places where the ICU is open, they can admit and follow patients there too. Also, there are a good number of FP docs becoming hospitalist as well. Especially in rural hospitals because they can admit minor peds in the rural hospitals.

 

[KnuxNole]

Please don't be the FP resident who scoffs and rolls their eyes at the thought of inpatient rotations. It's a part of training, which makes a lot of sense. You can't know what patients who need admission present like if you don't see them right? And where do really sick patients go to? The ICU and medicine floors! Like others said, inpatient/outpatient shouldn't be seen as a separate entity. After all, where do you see septic patients the most? In the hospital. Sure they might present in the clinic or in an urgent care center, but why would you ever be satisfied knowing basic stuff in the early years of your training? You're a doctor, not a triage nurse haha. If you only train in clinic for 3 years, you'll be a "weak" physician, as best explained by a previous poster in another topic with this same discussion. Which to be honest OP, your posts sound familiar to the OP of the topic "good opposed programs".


Remember, you are in residency to learn as MUCH as you can, never to get by with learning the minimum necessary.

 

[MedicineDoc]

Inpatient is the same as outpatient. It's a continuum and there are a ton if FM docs who take care of their sickest patients while they are in the hospital. Also their are a lot of FM hospitalist like myself. I beleive my FM inpatient training and my outpatient training were both very good and I didn't feel even slightly uncomfortable transitioning to hospitalist after completion of my residency.

 

[cabinbuilder]

. After all, where do you see septic patients the most? In the hospital. Sure they might present in the clinic or in an urgent care center, but why would you ever be satisfied knowing basic stuff in the early years of your training? .

Just need to chime in and vent a little bit. I am currently working urgent care and had a patient present with "swelling of leg" for 7 days. 83 years old multiple co-morbidities, wife mentally disabled and doesn't drive. US of leg shows extensive clot in common femoral and superficial femoral veins. His edema is from the toes to the top of iliac crest. This is friday afternoon.

So I called the hospitalist (who is also locums) at a rural site (40 bed hospital) to admit this patient. He stops me mid sentence and says "we don't admit for DVT anymore" just set up for the wife to give lovenox twice a day with coumadin and f/u on Monday. WTF is that? Is it just me or is that unacceptable care to anyone else out there? What happened to humanity?

Anyhow, one of the senior doctors who was looking at the patient with me in the clinic says "he needs to be admitted" and called the hospitalist and got the patient admitted.

 

[VenturaResident]

Why do fm residents mainly train in the inpatient setting when they will only see out patients after residency?

Ped clinic would be very educational for a fm resident but ped inpatient???

Troll much?

From reviewing your other posts on SDN, I wonder if perhaps you might consider focusing on learning and performing well in your own residency program and specialty field rather than wasting time making fairly ignorant comments about other people's choices.

 

[VA Hopeful Dr]

Just need to chime in and vent a little bit. I am currently working urgent care and had a patient present with "swelling of leg" for 7 days. 83 years old multiple co-morbidities, wife mentally disabled and doesn't drive. US of leg shows extensive clot in common femoral and superficial femoral veins. His edema is from the toes to the top of iliac crest. This is friday afternoon.

So I called the hospitalist (who is also locums) at a rural site (40 bed hospital) to admit this patient. He stops me mid sentence and says "we don't admit for DVT anymore" just set up for the wife to give lovenox twice a day with coumadin and f/u on Monday. WTF is that? Is it just me or is that unacceptable care to anyone else out there? What happened to humanity?

Anyhow, one of the senior doctors who was looking at the patient with me in the clinic says "he needs to be admitted" and called the hospitalist and got the patient admitted.

If the patient and/or caregiver is capable, I think outpatient lovenox works well. In this instance, I'm with you that a night or two in house was probably the right call.

 

[MedicineDoc]

If the patient and/or caregiver is capable, I think outpatient lovenox works well. In this instance, I'm with you that a night or two in house was probably the right call.

We mainly observe them until social work can confirm they have drug coverage for lovenox and nursing can teach them how to give themselves shots. I have also seen them sent home on xarellto with given the first dose as long as they have drug coverage. I personally don't like the idea of not being able to reverse xarellto in the event of a bleed and haven't pushed it much although i disclose it is available and offer it with telling them the risk benefits. I guess if these 2 things could be accomplished in the ER and no other signs or symptoms would be okay to let them go home as they would be fully anticoagulated.

 

[rachmoninov3]

Inpatient is the same as outpatient. It's a continuum and there are a ton if FM docs who take care of their sickest patients while they are in the hospital. Also their are a lot of FM hospitalist like myself. I beleive my FM inpatient training and my outpatient training were both very good and I didn't feel even slightly uncomfortable transitioning to hospitalist after completion of my residency.

Just curious, I'm looking at doing some part-time hospitalist work after residency, but the director of the employed physicians said that the hospitalist group may not want an FM doc right out of residency. Is this common? At my hospital we have two hospitalists that start working there right after graduating.

 

[cabinbuilder]

If the patient and/or caregiver is capable, I think outpatient lovenox works well. In this instance, I'm with you that a night or two in house was probably the right call.

I totally agree. I would have done the outpatient route if:
1) the patient was younger,
2) the wife was more mentally aware,
3) it wasn't 4pm on a friday when there really isn't home assistance available
4) (the biggie) the clot was in the lower leg, not in the two main veins in the thigh and was into the pelvis. Just a recipe for disaster.

Thanks for letting me vent. I just hate having to beg to get a patient in the hospital. I would rather have privileges and do it myself.

 

[cabinbuilder]

We mainly observe them until social work can confirm they have drug coverage for lovenox and nursing can teach them how to give themselves shots. I have also seen them sent home on xarellto with given the first dose as long as they have drug coverage. I personally don't like the idea of not being able to reverse xarellto in the event of a bleed and haven't pushed it much although i disclose it is available and offer it with telling them the risk benefits. I guess if these 2 things could be accomplished in the ER and no other signs or symptoms would be okay to let them go home as they would be fully anticoagulated.

The whole xarelto thing scares me. The drug before that (the name escapes me currently) I had two patients who had severe bleeds. One in the brain and one in the bladder. I don't trust it, won't use it. The inability to reverse is just a bad deal.

 

[cabinbuilder]

Just curious, I'm looking at doing some part-time hospitalist work after residency, but the director of the employed physicians said that the hospitalist group may not want an FM doc right out of residency. Is this common? At my hospital we have two hospitalists that start working there right after graduating.

Just depends on the company and how big the hospital is. Whether you do ICU/Lines? Situations like this I would hope you have kept good patient logs in residency (I have had to prove this myself for a job) that show you have managed plenty of inpatients.

 

[DIce3]

Just curious, I'm looking at doing some part-time hospitalist work after residency, but the director of the employed physicians said that the hospitalist group may not want an FM doc right out of residency. Is this common? At my hospital we have two hospitalists that start working there right after graduating.

An adult hospitalist practices internal medicine

internal medicine residency= 3 years of internal medicine training
family medicine residency= 8 months of internal medicine training

 

[MedicineDoc]

An adult hospitalist practices internal medicine

internal medicine residency= 3 years of internal medicine training
family medicine residency= 8 months of internal medicine training

I haven't calculated up the amount of time I spent in the hospital but it was MOST of the time. There was hospital call even after outpatient clinic. There were patients in the hospital including the ICU that had to be rounded on in the morning. I believe the idea that IM gets almost no outpatient training is actually a negative for ability to treat hospitalized pts ie admitting BPPV and ordering thousand dollar MRIs for BPPV. I got more than enough inpatient AND OUTPATIENT training to be completely comfortable in the hospital. Maybe the real question should be did you get enough outpatient training to even no what can be treated outpatient or learn much specialty medicine such as Ortho, ENT, Opthalmology etc. We also had pulmonology acd critcal care rotations in addition to seeing ICU pts daily. Of course these specialists goal was to educate on the most important topics and what needs to be done including whether they require hospitalization and/or specialty consult. Outpatient is not a different species and you should stop suggesting it has no value in taling care of patients regardless of what setting your pt us in. You should be able to accomplish goals that are core measures in hospitalist medicine that bleed directly into outpatient where your patient is going after discharge not the planet Mars. Hospital medicine is the same medicine just with more resource such as and nursing monitoring/ respiratory therapy and ability to monitor labs, tele, and vitals and supllement oxygen by various means. There are more FM docs seeing their pts in the hospital than there are total hospitalists and there have been for YEARS. The society of hospitalist medicine recognizes FM doctors as trained in hospital medicine and there is a pathway for hospitalist certification just as there is in IM. Also your definition of internal medicine as some separate entity from the knowledge base of FM is laughable.

 

[DIce3]

My above post only serves to answer rachmoninov3's question as to why many hospitalist groups only employ BC/BE internal medicine and not BC/BE family medicine physicians right after residency.

 

[KnuxNole]

Just depends on the company and how big the hospital is. Whether you do ICU/Lines? Situations like this I would hope you have kept good patient logs in residency (I have had to prove this myself for a job) that show you have managed plenty of inpatients.

Just curious, what counts as patient logs for ICU patients? Does that mean admitting a patient to the ICU, and taking care of them until they go to the floor and ultimately discharged? Or does it mean patients you take care of solely on an ICU rotation?

 

[MedicineDoc]

Just curious, what counts as patient logs for ICU patients? Does that mean admitting a patient to the ICU, and taking care of them until they go to the floor and ultimately discharged? Or does it mean patients you take care of solely on an ICU rotation?

There are plenty of hospitalists that don't do procedures both IM and FM.

 

[VA Hopeful Dr]

Just curious, what counts as patient logs for ICU patients? Does that mean admitting a patient to the ICU, and taking care of them until they go to the floor and ultimately discharged? Or does it mean patients you take care of solely on an ICU rotation?

Usually any time you are responsible for the care of an ICU patient, whether admitting or as primary.

 

[VA Hopeful Dr]

There are plenty of hospitalists that don't do procedures both IM and FM.

My wife is applying for a job here where we live (IM hospitalist) and was told that the general hospitalists don't do lines, chest tubes, or run codes.

 

[cabinbuilder]

Just curious, what counts as patient logs for ICU patients? Does that mean admitting a patient to the ICU, and taking care of them until they go to the floor and ultimately discharged? Or does it mean patients you take care of solely on an ICU rotation?

For me I count any patient who I have admitted to ICU and taken care of. I got into the habit of keeping patient logs as a locums provider as many sites that I go to include inpatient service as part of the job and I have had to submit my logs to show what types of patients I have taken care of. Many times it gave me the job over someone else. I never had a separate ICU rotation since our ICU was about 12 beds where I trained. It was just part of the medicine service as our attending did both.

 

[Bostonredsox]

My wife is applying for a job here where we live (IM hospitalist) and was told that the general hospitalists don't do lines, chest tubes, or run codes.

Sounds like the worst job ever to me

And to all of your earlier points on bleeds, the data on xarelto is actually favorable compared with warfarin. There are fewer bleeds, and a massive amount less intracranial bleeds with xarelto than warfarin. Yes, warfarin is theoretically reversible.....but >9 times out of 10, when a gomer comes in with an ICH on warfarin, they're dead. Unless they present immediately to a tertiary care neurosurg center, they get shipped and by the time they arrive the cerebral edema is so massive its lights out and onto comfort measures. Now, non fatal GI bleeding is what we see most often with xarelto. Ill take a higher chance of non reversible non fatal GI bleeding than a much higher chance of reversible intracranial hemorrhage. The former lives, the latter dies. Warfarin is a terrible drug. Endless interactions both with diet and other meds, difficulty with compliance, and most studies show pts remain in the therapeutic range only 55% or so of the time. Nearly 1/2 the time they are not effectively preventing stroke or PE, or are supratherapitic and at high risk for bleed, most notably ICH.

Just this week had an 72 y/o on VKA for a dvt for 4 months. Came in after a fall down his stairs at home. INR was 14. Hemorrhaged everywhere except luckily his brain. Will be lucky to come off the vent. Warfarin is a nasty drug.

 

[VA Hopeful Dr]

Sounds like the worst job ever to me

And to all of your earlier points on bleeds, the data on xarelto is actually favorable compared with warfarin. There are fewer bleeds, and a massive amount less intracranial bleeds with xarelto than warfarin. Yes, warfarin is theoretically reversible.....but >9 times out of 10, when a gomer comes in with an ICH on warfarin, they're dead. Unless they present immediately to a tertiary care neurosurg center, they get shipped and by the time they arrive the cerebral edema is so massive its lights out and onto comfort measures. Now, non fatal GI bleeding is what we see most often with xarelto. Ill take a higher chance of non reversible non fatal GI bleeding than a much higher chance of reversible intracranial hemorrhage. The former lives, the latter dies. Warfarin is a terrible drug. Endless interactions both with diet and other meds, difficulty with compliance, and most studies show pts remain in the therapeutic range only 55% or so of the time. Nearly 1/2 the time they are not effectively preventing stroke or PE, or are supratherapitic and at high risk for bleed, most notably ICH.

Just this week had an 72 y/o on VKA for a dvt for 4 months. Came in after a fall down his stairs at home. INR was 14. Hemorrhaged everywhere except luckily his brain. Will be lucky to come off the vent. Warfarin is a nasty drug.

Yeah but you love CC, my wife loathes it.

I agree with the rest of your post. I even had an attending in residency (IM-CC who "retired" to general hospitalist/teaching) who liked to point out that even with FFP coumadin reversal isn't instant and with bleeding in the brain an hour is too long. Plus, as you say, the newer agents tend to be heavier on the GI end of things which can always be fixed by more blood while waiting for the drug to wear off.

I'm still somewhat ticked off that the 110mg Pradaxa, which worked as well as coumadin but with significantly less bleeding, didn't get FDA approval.