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This is something that's been getting a little more steam in the past couple of years; what are your thoughts about increasing the current GME to four years? (Personally, I think it's way overdue.)
Four-year residency
- Thread starter hidradenitis
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hidradenitis said:
It is an absolutely atrocious idea. We as physicians are pricing (and educating) ourselves out of the market. It makes absolutely no sense that the POST graduate component of a PHYSICIAN training program in family medicine should be YEARS longer than that of mid-level providers who can do exactly the same thing. Also what does it say about med school -- it is such a waste of time that no one who attends can practice any sort of medicine without 4 years of additional training??
It is ludicous that a nurse or PA can train into general practice faster than a surgeon. This would make it even harder?!? This sort of thing will be the nail in the coffin for physician participation in primary care.
Terrible idea. We should be doing the opposite. We have to recognize what the allied providers have already figured out: on the job training and learning is not such a bad thing...
eddieberetta said:
I agree. I think "adding years" is nuts, personally. My gradfather trained in the '40's, did a traditional "hands-on" internship (qualifying him for any GP work), and then completed his pathology residency in two more. He was one of the most highly regarded (med director of the path lab serving most of south texas) and extraordinarily well-educated doctors I have ever known.
What might be a good idea would be accredited 1 year fellowships for FP's in surgery and procedures, ob, etc., that would hopefully make it easier to get appropriate procedural priviledges and insurance coverage.
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Personally, I wouldn't mind adding another year to FP. Considering the breadth of patients you see, it wouldn't hurt to have additional time learning. If I do FP, I will want to do a fellowship. Not that it really matters to those in the US, but in the UK GPs can spend 5 years or more preparing for practice (in fact, in the UK they have much longer post-grad training schemes than the US grad ever dream of). And as for the mid-level folks, don't they have to work under the supervision of a doctor (i.e. they can't just hang up a shingle and start practicing)? If you are assuming responsibility for what they are doing, then you probably ought to be trained better/longer than they are. Maybe that's heretical.
Personally, I think if I were too dumb to learn how to perform basic general practice in five years of tough clinical experience, then I really shouldn't be a doctor. One can't really mature in any skilled field until one is practicing independently and has to take responsibility for his or her own education.
(It's possible that in the UK, FP's do more surgery, if so, I see where you're coming from--but only a tiny minority here do anything major.)
I'm hostile to the notion of "adding years" because I can't see any vaid purpose for doing so (is there an issue of FP's being incompetent or insufficiently trained?), and because I can see a lot of negative results from such an action.
Family Physicians (along with peds) are the lowest-paid doctors in the U.S. A required four year residency (and more delay in paying back student loans) is a pretty strong invitation to go into a better paying field (GS-five years--anyone?). FP's are already swimming against the current at many medical schools, yet provide excellent care and unlike other doctors, frequently choose to work in underserved areas. This idea seems to be yet another way to make medicine in the US even more useless, specialized, and irrelevant for those who need doctors the most.
(It's possible that in the UK, FP's do more surgery, if so, I see where you're coming from--but only a tiny minority here do anything major.)
I'm hostile to the notion of "adding years" because I can't see any vaid purpose for doing so (is there an issue of FP's being incompetent or insufficiently trained?), and because I can see a lot of negative results from such an action.
Family Physicians (along with peds) are the lowest-paid doctors in the U.S. A required four year residency (and more delay in paying back student loans) is a pretty strong invitation to go into a better paying field (GS-five years--anyone?). FP's are already swimming against the current at many medical schools, yet provide excellent care and unlike other doctors, frequently choose to work in underserved areas. This idea seems to be yet another way to make medicine in the US even more useless, specialized, and irrelevant for those who need doctors the most.
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If you can't do sneezes and sniffles, recognize oh-**** situations, say "diet and exercise" 30-40 times per day, and do a well-baby-woman-man-sports physical, you did not pay attention during med school. You are one of those Family-Medicine-As-Back-Up people who fell off the keg-wagon during med school or got rejected from General Surgery because you did not apply yourself. It's true, if middle level providers can do it in two, then you the MDeity should be able to do it in 4+3. Worse yet, how about the 1st year pathology resident who's moonlighting in YOUR clinic? Give me a break. Please... let the specialists do specialist work, and let the generalist do generalist work. It makes me so mad when specialists try to do primary care and when generalists try to do specialist work... no one does it right.
What is there to gain in yet 1 more year of supervised training that you couldn't get 1 year out? Procedures seem to be the only reasonable reason to do 1 more year of training... and even then, if you plan on being in 1-town-1-doc town, but personally, I wouldn't do it. Procedures get outdated fast. I would rather do 1 month a year training for the next 12 years in CME on how to do procedures/imaging than to do 12 months in 1 year. Technology will leave you behind if you don't keep up anyways. Why lose a year?
What is there to gain in yet 1 more year of supervised training that you couldn't get 1 year out? Procedures seem to be the only reasonable reason to do 1 more year of training... and even then, if you plan on being in 1-town-1-doc town, but personally, I wouldn't do it. Procedures get outdated fast. I would rather do 1 month a year training for the next 12 years in CME on how to do procedures/imaging than to do 12 months in 1 year. Technology will leave you behind if you don't keep up anyways. Why lose a year?
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Wow, I'm surprised at the response; I thought more folks would've been for the concept. 
Family medicine is at a crossroads (that's the buzz since the Future of Family Medicine report, anyways). Diverse approaches to 'tweaking the system' are being discussed, an extension of the residency being one of them. Before going into the reasons in favor of this, consider the following items considered among the 'big' problems with specialty: lack of prestige, current students not interested, ever-limited scope of practice, encroachment by midlevel providers, poor reimbursement by HMO's, etc, etc, etc. In response, some have argued that we need to redefine our specialty before it's done for us.
Although you can argue if any general field can be considered a specialty, there are multiple areas within the field that in real life FP subspecialties: ambulatory med, urgent care, doc-in-the-sticks, not to mention the board-certified fellowships, like Sports Med or Geriatrics. The idea isn't that you do another year of 'more of the same'; it's that you spend another year on something more germaine to what your practice will be like. Read this section from the FFM report on GME (and read the comments on the same too, found at www.annfammed.org.)
Anyways, there are other arguments for it, but I'm too tired to write them now.
By the way, one of the posters mentioned the added year as being a factor that would scare people from the specialty. That may be true. On the other hand, you could argue that with a 40% US match rate and among the lowest reimbursed fields (as well as one of the least prestigious), pretty much anyone who would be scared off already is.
And as far as our "doing as well as a mid-level", my response is: I'm not a mid-level and don't provide mid-level care. Maybe it is heretical to think we should be better trained and provide more to the patient than the PA's we supervise and the med students we train.
The GP's of the past were the backbone of American and maybe that day will come again, but until then, FP as a specialty is going have to adapt to the times or continue to struggle.
Is there a currently practicing, boarded FP that could chip in with their opinion?
Family medicine is at a crossroads (that's the buzz since the Future of Family Medicine report, anyways). Diverse approaches to 'tweaking the system' are being discussed, an extension of the residency being one of them. Before going into the reasons in favor of this, consider the following items considered among the 'big' problems with specialty: lack of prestige, current students not interested, ever-limited scope of practice, encroachment by midlevel providers, poor reimbursement by HMO's, etc, etc, etc. In response, some have argued that we need to redefine our specialty before it's done for us.
Although you can argue if any general field can be considered a specialty, there are multiple areas within the field that in real life FP subspecialties: ambulatory med, urgent care, doc-in-the-sticks, not to mention the board-certified fellowships, like Sports Med or Geriatrics. The idea isn't that you do another year of 'more of the same'; it's that you spend another year on something more germaine to what your practice will be like. Read this section from the FFM report on GME (and read the comments on the same too, found at www.annfammed.org.)
Anyways, there are other arguments for it, but I'm too tired to write them now.
By the way, one of the posters mentioned the added year as being a factor that would scare people from the specialty. That may be true. On the other hand, you could argue that with a 40% US match rate and among the lowest reimbursed fields (as well as one of the least prestigious), pretty much anyone who would be scared off already is.
And as far as our "doing as well as a mid-level", my response is: I'm not a mid-level and don't provide mid-level care. Maybe it is heretical to think we should be better trained and provide more to the patient than the PA's we supervise and the med students we train.
The GP's of the past were the backbone of American and maybe that day will come again, but until then, FP as a specialty is going have to adapt to the times or continue to struggle.
Is there a currently practicing, boarded FP that could chip in with their opinion?
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Four year Family Medicine residency? Bad idea. In Canada, FM is a two year residency and still consistently can't attract residency applicants. A four year residency would just about completely kill off FM as a specialty; it can only make it even more unpopular than it already is.
Flankstripe said:
I guess I simply cannot grasp the logic behind adding another year. FP's do fine with three--if they want additional training in some area of interest--that's what fellowships are for. I would much rather have a three year residency with a "Family Practice Surgery" CAQ or Sports Medicine CAQ than just waste a year on the supposition that I'm too dumb to learn FP in five.
I don't see any reason to suppose that "more required electives" (which is all I see in this proposal) will correspond to better medicine, greater reimbusement, or more respect. FP practices vary enormously, and FP's are unlikely to know if or what additional training might be helpful to them until they have been in practice for a while. As I mentioned, that's what CME and fellowships are for.
In short, I think this proposal was designed by someone who has an FP inferiority complex, and wrongly believes that by making FP training longer FP will look more like a "specialty," and hence be worthwhile (The insulting subtext being that FP's are just wanna-be specialists).
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sdude said:
I have to admit this is probably the most realistic option out there. Even so, the fellowship opportunities available to FP's could stand some improvements. The Sports Med and Geriatric CAQs are well and good; why not standardize the OB and EM/Urgent Care fellowships? Or a 'FP Surgery' or Rural Care CAQ? What about a two year EM fellowship that gives you ABEM certification? Seems there's a lot that could be done to increase options.
hidradenitis said:
I think these are great ideas. I also am really annoyed that there aren't more fellowship opportunities in FP. If you check the surveys on the NAFP (sp?) very few FP's do major invasive procedures. Those who do have taken responsibilty for their own training in order to earn coverage/privileges (and by all accounts do a good job).
It would would be great if high quality, competitive, and accredited training was available that would enhance the insurability/practice scope of FP's with special skills. I think it would improve the image of the entire field.
In Canada, there's such a thing as a GP-surgeon. I've read that the health officials are getting upset because few people are going into this dual specialty. Apparently this specialty has an excellent reputation for good primary care/surgical outcomes (more limited surgical practice than a GS, of course), and there is a shortage in many rural areas that can't support a full-time surgeon.
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I think the best idea would be to improve FP fellowship programs. Like has already been said, if someone wants to be more specialized, they can just do a fellowship. However, if someone wants to remain very general, then 3 years is plenty. The major difference between the 3 and 4 yrs plans outlined by the FFM report is the "attainment of in-depth expertise in 1 or 2 domains of family medicine." To me, that sounds like the perfect description of a fellowship.
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Extending FP residency training by another year is a very bad idea. That tells me just how out of touch with reality the leaders in this specialty are. Most of the FFM report seems to be unrealistic. This is just my humble opinion.
CambieMD
CambieMD
