Decline of Family Medicine

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navdoc47

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A friend of mine, who recently graduated from FP, is struggling to make ends meet as he establishes his own private practice in Las Vegas. To give an example of how watered down reimbursements are for primary care, he is reimbursed approx 60% of medicare by blue cross for your typical office visit. This translates to roughly $40 for a 30 minute visit (including copay). It's even funnier when follow-up visit reimbursements are smaller than the copay. Add to your costs your medical assistant and/or secretary, rent, 6% fee for your biller, malpractice insurance, and it's no surprise that you have to work like a slave to make a decent living.

One of the reasons why primary care gets screwed is they have little means of negotiating contracts since there are so many primary care providers (to include PAs, NPs).

The advantage to specialty care is simply the fact that specialists, given their fewer numbers, can group together and form greater leverage to negotiate for appropriate reimbursement.

The AMA has little power, else it would have fixed the malpractice issue years ago. Ironically, the interest groups representing hospitals are much more powerful, given that they were able to pass legislation quickly to give "the Match" immunity to monopoly rules. This allows earnings to continue to be depressed for the roughly 100,000 strong resident work force. The political picture for primary care remains bleak - there will be no overnight fix to the problem since nobody outside of primary care seems to care.

I just want to forewarn people going into family medicine that they are entering an arena where they will be expected to often work for free in private practice or to simply be an employee.

An amusing link on physician family doc reimbursements:
http://home.austin.rr.com/austintxmd/Pages/intro.html

A link that discusses the overall picture on the decline of family medicine:
http://www.policyreview.org/apr04/alper.html
 
navdoc47 said:
A friend of mine, who recently graduated from FP, is struggling to make ends meet as he establishes his own private practice in Las Vegas. To give an example of how watered down reimbursements are for primary care, he is reimbursed approx 60% of medicare by blue cross for your typical office visit. This translates to roughly $40 for a 30 minute visit (including copay). It's even funnier when follow-up visit reimbursements are smaller than the copay. Add to your costs your medical assistant and/or secretary, rent, 6% fee for your biller, malpractice insurance, and it's no surprise that you have to work like a slave to make a decent living.

One of the reasons why primary care gets screwed is they have little means of negotiating contracts since there are so many primary care providers (to include PAs, NPs).

The advantage to specialty care is simply the fact that specialists, given their fewer numbers, can group together and form greater leverage to negotiate for appropriate reimbursement.

The AMA has little power, else it would have fixed the malpractice issue years ago. Ironically, the interest groups representing hospitals are much more powerful, given that they were able to pass legislation quickly to give "the Match" immunity to monopoly rules. This allows earnings to continue to be depressed for the roughly 100,000 strong resident work force. The political picture for primary care remains bleak - there will be no overnight fix to the problem since nobody outside of primary care seems to care.

I just want to forewarn people going into family medicine that they are entering an arena where they will be expected to often work for free in private practice or to simply be an employee.

An amusing link on physician family doc reimbursements:
http://home.austin.rr.com/austintxmd/Pages/intro.html

A link that discusses the overall picture on the decline of family medicine:
http://www.policyreview.org/apr04/alper.html
Click to expand...

I hate to say it but your friend should just move... Big cities can be too much competition for family medicine... they got all the specialists readily available and it may be hard to build a patient base... In a less populated city, it is easier to get patients... Las Vegas I would think is a bad place for an FM doc.
 
navdoc47 said:
he is reimbursed approx 60% of medicare by blue cross for your typical office visit.
Click to expand...

Anyone who accepts a commercial insurance contract that reimburses less than Medicare is an idiot, sorry. He's getting what he's asking for.

I just want to forewarn people going into family medicine that they are entering an arena where they will be expected to often work for free in private practice or to simply be an employee.
Click to expand...

Those aren't the only options.

An amusing link on physician family doc reimbursements
Click to expand...

That site hasn't been updated since 1998.

A link that discusses the overall picture on the decline of family medicine
Click to expand...

Actually, it talks about the state of primary care, with an emphasis on managed care and internal medicine (although family medicine is certainly involved). It's a good article, though not entirely the "doom and gloom" piece that you're making it out to be.
 
McDoctor said:
Thanks for the article. Now if you'll excuse me, I'm going to seal all the windows in my house and turn the gas on.
Click to expand...

Keep in mind that many of the issues that are discussed related to primary care in this country do not necessarily have a negative impact on individual physicians. Quite the opposite, in fact...primary care physicians are finding themselves more in demand than ever, and are increasingly able to find higher-paying jobs, negotiate better reimbursement with insurance carriers (payors are often highly motivated to establish a referral base for their in-network specialists), and even cherry-pick their patients.

Yes, there are problems in American health care that need fixing. However, if you desire a career as a family physician or general internist, you need to realize that there is tremendous opportunity, as well.
 
It's my opinion that PCP in EVERY city need to gather up to community meetings each year. I think PCP should come together and flat out deny all types of insurance in a 'strike' effort.... if every PCP in the city decided to no longer accept insurance and to take simple 'set' cash payments upfront on all visits then we'd start seeing a serious improvement.

I think the set amount can be calculated and set regardless of how difficult the visit is but modified according to procedures done though needs to be broadened up.

I am saying this because this is how small businesses work... All the shell gas stations and mobile and the rest of the grtocery stores in one area meet and discuss their numbers. PCP need to realize that they are not isolated and that they should discuss between themselves what they will accept and what they will not accept.

If all the docs in a city... say like Orlando for example... met and decided... we want to raise our copay by $20 they can do that and insurance cant stop them. It becomes like a union.

It needs an initiative from a big/moderate organization/group. The problem is that they might turn out to be like Kaiser.. I think that group started out similar...

Also there will be people who just out right refuse to join the flow of the main stream.
 
Faebinder said:
It's my opinion that PCP in EVERY city need to gather up to community meetings each year. I think PCP should come together and flat out deny all types of insurance in a 'strike' effort.... if every PCP in the city decided to no longer accept insurance and to take simple 'set' cash payments upfront on all visits then we'd start seeing a serious improvement.
Click to expand...

That would be flagrantly illegal. Collusion and price-fixing carry severe penalties, including jail time. Unless you fancy the idea of being somebody's "girlfriend," I'd keep the revolutionary rhetoric confined to forums like this one. 😉

All the shell gas stations and mobile and the rest of the grtocery stores in one area meet and discuss their numbers.
Click to expand...

Oil companies are not regulated by the same laws that govern medicine in this country. Incidentally, if you want to know what's really wrong with the United States of America, look at "big oil" (but I digress.)
 
navdoc47 said:
A friend of mine, who recently graduated from FP, is struggling to make ends meet as he establishes his own private practice in Las Vegas. To give an example of how watered down reimbursements are for primary care, he is reimbursed approx 60% of medicare by blue cross for your typical office visit. This translates to roughly $40 for a 30 minute visit (including copay). It's even funnier when follow-up visit reimbursements are smaller than the copay. Add to your costs your medical assistant and/or secretary, rent, 6% fee for your biller, malpractice insurance, and it's no surprise that you have to work like a slave to make a decent living.

One of the reasons why primary care gets screwed is they have little means of negotiating contracts since there are so many primary care providers (to include PAs, NPs).

The advantage to specialty care is simply the fact that specialists, given their fewer numbers, can group together and form greater leverage to negotiate for appropriate reimbursement.

The AMA has little power, else it would have fixed the malpractice issue years ago. Ironically, the interest groups representing hospitals are much more powerful, given that they were able to pass legislation quickly to give "the Match" immunity to monopoly rules. This allows earnings to continue to be depressed for the roughly 100,000 strong resident work force. The political picture for primary care remains bleak - there will be no overnight fix to the problem since nobody outside of primary care seems to care.

I just want to forewarn people going into family medicine that they are entering an arena where they will be expected to often work for free in private practice or to simply be an employee.

An amusing link on physician family doc reimbursements:
http://home.austin.rr.com/austintxmd/Pages/intro.html

A link that discusses the overall picture on the decline of family medicine:
http://www.policyreview.org/apr04/alper.html
Click to expand...


all i know is that i have a lot of friends who are FM docs, in the southeast and some in Midwest, some newly graduated and some older, and they are all doing very well.. so i can't comment on your friend, but maybe he/she should talk to some regional docs for advice..

medicine is a constantly changing field and you have to adapt but if there was a decline in FM( there isnt), there would be a decline in other specialties as well, everything is connected in medicine if you havent realized it.
 
navdoc47 said:
A friend of mine, who recently graduated from FP, is struggling to make ends meet as he establishes his own private practice in Las Vegas.
Click to expand...

Not to sound like a broken record here, but Las Vegas is one of the fastest growing cities in the US. There is absolutely no reason why anyone with good training in FM and **some** business sense shouldn't be making a very nice living there.

My cousin is also a recent FM graduate who started a practice with one other doc, who is also practicing in one of the fastest growing cities in the midwest. He filled up his practice within 2 years and is now opening a satellite clinic and hiring 3 new docs. He's doing very well financially.
 
Location, location, location. That is what it's all about in any business.

BUT, in medicine you also have to deal with the insurance crap.

In big cities, and even Vegas, Most primary care docs make around 160 to 170K. This is if all they do is general primary care. some make more if they work more hours.

In rural areas, some FPs are making like 300K. NO they are not working to death. Payments are higher in rural areas even by medicare.

But the problem with FP goes deeper than location. It has to do with the fact that even though the FP supply is going to be either short or maldistributed (as it is getting to be now), the salaries are not going much higher.

This is because unlike radiology or anesthesiology, primary care is allowing PAs and NPs (I know CRNAs are midlevels but they don't do many of the procedures that anesthesiologist do) to take over their jobs even though these midlevel providers are not as well trained. If the insurance companies have a choice, they will go with the cheaper one.
 
careful...you are summoning MacGyver...he's probably getting a whiff of a distant midlevel debate as we speak.

We've been over and over and over the midlevel thing. 😴

No one has yet been able to convince me with hard evidence that the increase in PAs and NPs working in primary care over the past 20 years has had a direct effect on MD/DO reimbursements or availability of patients. And if it hasn't happened yet, I'm really not worried about the bottom falling out during my career.
 
sophiejane said:
careful...you are summoning MacGyver...he's probably getting a whiff of a distant midlevel debate as we speak.

We've been over and over and over the midlevel thing. 😴

No one has yet been able to convince me with hard evidence that the increase in PAs and NPs working in primary care has had a direct effect on MD/DO reimbursements or availability of patients.
Click to expand...

While I am not a fanatic like MacGyver.. I do disagree with you Soph. When it's cheaper to get a mid level, they will get a mid level and not an FP. Hospitals care about money.

It's all good from a different angle... Finally FM is going to be forced to make sure it is a specialty and not a 'general clinical practice'. Unfortunately, I think a lot of old school FM are still stuck in the old school mentality.🙁 The scope of the practice needs to be better defined.

This is the first step of the specialty defining itself since the change of the name from FP to FM.
 
One more..

This is from the Annals of Family Medicine... check out the comments too.. tells you what the old school is thinking.
 
"From the outset family medicine has struggled between the polarities of wanting to be similar to most, if not all, of the other allopathic disciplines (specialties) and wanting to pursue a distinct voice as a generalist discipline rooted in a keen social conscience. This dynamic underlies the distinction between wanting to be part of the mainstream American biomedical culture and wanting to be a counterculture. This undercurrent permeates the models held by family physicians about their discipline."


That's the trouble right there, especially at a program I will call "Earl" to avoid offending anyone. If you asked the many residents who left the program, the "social conscience" was getting in the way of medical science.

At the risk of offending, I also want to point out that in medicine, there is no such thing as a family and thus it cannot be the "organ system" around which a specialty practices. We treat patient's one at a time, not collectively.
 
"The development and maintenance of internal cultural continuity and a reliable cultural boundary are made difficult under the circumstances of continuous change that often become perceived as threat, attack, and intrusion. Consider the common experience of family medicine interns. Although they are formally known as family medicine interns, they generally spend little time in the family medicine department or on its clinical services. Instead, they rotate for 1 month (sometimes 2) on a sequence of medical services: surgery, emergency medicine, obstetrics, neonatal intensive care unit, pediatrics, and so on. Each service comes with new cultural and identity demands, in addition to the clinical skills, rules, and roles to learn, every first day of the month. Interns have the common feeling of being like a fish out of water, of being in places "where they need you for their ‘scut work,’ but they don’t want you." No sooner have the interns learned the culture of the specialty service on which they are rotating, than they have to start all over again as a stranger at the beginning of the next month".

The author has it exactly right.
 
Panda Bear said:
"The development and maintenance of internal cultural continuity and a reliable cultural boundary are made difficult under the circumstances of continuous change that often become perceived as threat, attack, and intrusion. Consider the common experience of family medicine interns. Although they are formally known as family medicine interns, they generally spend little time in the family medicine department or on its clinical services. Instead, they rotate for 1 month (sometimes 2) on a sequence of medical services: surgery, emergency medicine, obstetrics, neonatal intensive care unit, pediatrics, and so on. Each service comes with new cultural and identity demands, in addition to the clinical skills, rules, and roles to learn, every first day of the month. Interns have the common feeling of being like a fish out of water, of being in places "where they need you for their ‘scut work,' but they don't want you." No sooner have the interns learned the culture of the specialty service on which they are rotating, than they have to start all over again as a stranger at the beginning of the next month".

The author has it exactly right.
Click to expand...

Acutally, in my experience, the author has it exactly wrong, but then, I'm only interviewing and rotating at unopposed community programs. I've seen a very different picture than the one he paints.

The author refers to an outdated and apparently opposed model, at least at the programs I am ranking. My #1 program spends 4 months on inpatient family medicine in 1st year, 2 in 2nd, and 2 in 3rd. They admit and follow everything from newborns to ICU patients. There is absolutely no scut, and there is plenty of personal responsibility and continuity of care.

Subspecialty rotations are done one-on-one with specialists, and again there is no scut--they see patients in the clinic, and do consults as they would if they were a resident in that specialty.

The interesting thing about this program (and why I'm ranking it #1) is that the culture of the program is positive, energetic, and there is a high level of intellectual exchange among residents and faculty. Faculty are experienced, many graduated AOA, and didactics are excellent. This is reflected in their 3rd years, who are some of the smartest and best residents I've met at any program in any specialty.

People who rank programs like the one described in the above article are in for an unpleasant surprise next year, and frankly, they deserve what they get. This is a very important decision, and making it based on a medical school's big name alone is a huge mistake.
 
Panda Bear said:
The author has it exactly right.
Click to expand...

The only problem is that he just described intern year in practically every specialty, yet he made it sound as if only FP interns do rotations like that. 👎

It probably sounds a lot like your EM internship, doesn't it? That's what I've gathered from some of your recent posts, anyway.

If you're really keen to avoid that off-service feeling, you don't want to go to a big academic medical center for residency. I'm sure we agree on that.

Meanwhile, may I recommend the Dixie Chicks' song, "Goodbye Earl?" 😉
 
KentW said:
The only problem is that he just described intern year in practically every specialty, yet he made it sound as if only FP interns do rotations like that. 👎

It probably sounds a lot like your EM internship, doesn't it? That's what I've gathered from some of your recent posts, anyway.

If you're really keen to avoid that off-service feeling, you don't want to go to a big academic medical center for residency. I'm sure we agree on that.

Meanwhile, may I recommend the Dixie Chicks' song, "Goodbye Earl?" 😉
Click to expand...

No. We do four critical care months and two EM months in first year. EM seniors cover the ICUs when we rotate there and most if not all of the residents are EM. I think critical care is highly relevant to EM.

Then we do cardiolo"gy, medcine, and a smattering of other stuff but none of it is "fluff."

I don't know how it is at unopposed programs but at "Earl," FM was just a source of scut-oxen the other services. It was obvious.
 
Panda Bear said:
At the risk of offending, I also want to point out that in medicine, there is no such thing as a family and thus it cannot be the "organ system" around which a specialty practices. We treat patient's one at a time, not collectively.
Click to expand...

You're not offending, you're just not making sense. 😉

This idea that doctors need to "practice around an organ system" is relatively new, and the quoted article bemoans the passage of the "Days of the Giants" when this wasn't the case.

Much of one's well-being, and by extension, one's health, relates to lifestyle issues and interpersonal dynamics that most specialists who practice within the "disease model" dismiss as irrelevant. Many of these have their roots in the family. Family physicians are trained to treat patients as people, not organ systems with diseases. Many specialists scratch their head and wonder, "What's the point?" However, good primary care is one of those things that tends to be taken for granted, and isn't viewed as important until it's not there.

So, which "organ system" do you guys in the ED practice around? Don't even try to tell me you don't do any primary care; you do tons of it...you just don't do it very efficiently or effectively. 😉
 
Panda Bear said:
We do four critical care months and two EM months in first year. EM seniors cover the ICUs when we rotate there and most if not all of the residents are EM. I think critical care is highly relevant to EM.

Then we do cardiolo"gy, medcine, and a smattering of other stuff but none of it is "fluff."
Click to expand...

Here's the list of internship rotations at my old residency:

Inpatient Medicine - 2 Months
Inpatient Pediatrics - 2 Months
Obstetrics - 2 Months
General Surgery - 2 Months
ER - 1 Month
ICU - 1 Month
FM Office - 2 Months

We were unopposed on all services, except OB and peds. Where's the "fluff?"

Panda Bear said:
I don't know how it is at unopposed programs
Click to expand...

No, you don't...clearly.
 
Faebinder said:
One more..

This is from the Annals of Family Medicine... check out the comments too.. tells you what the old school is thinking.
Click to expand...

That was an interesting article. I'm amazed at the similarities between the struggle for "identity" and "purpose" of the specialty of family medicine compared with the struggle for identity of osteopathic medicine.

This sucks...now I'm going to struggle to explain my existence both as a DO and as a family physician! 😱
 
Shinken said:
I'm going to struggle to explain my existence both as a DO and as a family physician! 😱
Click to expand...

Be glad you're not a general internist...IMO, they've struggled with their identity even more than FM. Say "internist" to most people, and they think you're talking about a new trainee. 🙄
 
Shinken said:
This sucks...now I'm going to struggle to explain my existence both as a DO and as a family physician! 😱
Click to expand...

No you won't. Nobody cares if you are a DO or an MD in family medicine, nobody asks you to explain. Likewise, the people who appreciate family docs are the ones who choose to be their patients, so it's unlikely you will have to explain your existence to anyone. Just do your job well.
 
Panda Bear said:
I think critical care is highly relevant to EM.
Click to expand...

:laugh:

Seriously? What kind of management skills for seriously ill patients are you going to need in the ED? Planning on managing lots of patients on vents down there? Tweaking those electrolytes? Fine tuning abx regiments? Managing glucose?

Anyone sick enough to need that kind of management doesn't spend long in the ED.
 
sophiejane said:
:laugh:

Seriously? What kind of management skills for seriously ill patients are you going to need in the ED? Planning on managing lots of patients on vents down there? Tweaking those electrolytes? Fine tuning abx regiments? Managing glucose?

Anyone sick enough to need that kind of management doesn't spend long in the ED.
Click to expand...

Critical Care is as important to EM as EM is important to IM. Everyone wants to increase their turf.... Fact is EM wont go up to the critical care unit and manage the critically ill for days... it's just not what they were supposed to be all about... Just like you can claim the IM are not supposed to come down to the EM and manage the emergencies... it's not what they are trained to be.

I happen to think surgery is important for OBGYN but you wont see me saying OBGYN should be trained to do appendectomies.

This is going off topic... Unlike all other specialties... FM has a little of everything and I think that's what's hurting it. I'd like to see one of the two things happen. Either:

1) Change the name from Family Medicine to General Medicine (I hate to see this happen but it's true).

or...

2) Put the family back in Family Medicine by somehow only taking families. Payments would be done to the doctor to manage families not indivisuals. This would be a lot closer to the Boutique medicine style, which I believe can save family medicine.

Converting family medicine to general medicine will destroy it. People will always think... I wanna go see a specialist not a generalist.
 
sophiejane said:
No you won't. Nobody cares if you are a DO or an MD in family medicine, nobody asks you to explain. Likewise, the people who appreciate family docs are the ones who choose to be their patients, so it's unlikely you will have to explain your existence to anyone. Just do your job well.
Click to expand...

I know...I was just being facetious. The article made it seem like FM has the same struggle for identity and respect that osteopathic medicine is facing nowadays.

Luckily, no matter how much academicians sit and think about it and no matter what slogans are used, FM is here to stay and so is osteopathic medicine. I'm happy and proud I'll belong to both groups.
 
sophiejane said:
Acutally, in my experience, the author has it exactly wrong, but then, I'm only interviewing and rotating at unopposed community programs. I've seen a very different picture than the one he paints.

The author refers to an outdated and apparently opposed model, at least at the programs I am ranking. My #1 program spends 4 months on inpatient family medicine in 1st year, 2 in 2nd, and 2 in 3rd. They admit and follow everything from newborns to ICU patients. There is absolutely no scut, and there is plenty of personal responsibility and continuity of care.

Subspecialty rotations are done one-on-one with specialists, and again there is no scut--they see patients in the clinic, and do consults as they would if they were a resident in that specialty.

The interesting thing about this program (and why I'm ranking it #1) is that the culture of the program is positive, energetic, and there is a high level of intellectual exchange among residents and faculty. Faculty are experienced, many graduated AOA, and didactics are excellent. This is reflected in their 3rd years, who are some of the smartest and best residents I've met at any program in any specialty.

People who rank programs like the one described in the above article are in for an unpleasant surprise next year, and frankly, they deserve what they get. This is a very important decision, and making it based on a medical school's big name alone is a huge mistake.
Click to expand...

Do you guys and gals think that part of the problem is the apparently varying quality of the FM programs out there? Do you think this aspect detracts from the image that medical students have of family medicine? I know that this is true for even IM but at least IM seems to garner more support at the big academic centers and can therefore as a whole present itself in a better light.

I've also notice a lot of discussions about having to choose your programs very carefully in FM. Shouldn't programs be more uniform? As an EM applicant, it is rare for me to find a 'bad' program. PD's and attendings on the interview trail reiterate this as they consistently tell me that I will get great training just about everywhere because of the EM RRC standards. The point is, does anyone think that tightening up the quality of FM programs out there will make a difference in attracting medical students to the specialty? Shouldn't all FM programs be unopposed (or at least close to being entirely unopposed)?
 
Faebinder said:
1) Change the name from Family Medicine to General Medicine (I hate to see this happen but it's true).
Click to expand...

How about changing the name to Primary Care Medicine?
 
KentW said:
The only problem is that he just described intern year in practically every specialty, yet he made it sound as if only FP interns do rotations like that. 👎
Click to expand...

You are so right, Kent.

The author must be referring to FM Interns at opposed programs because every residency program rotates and the issue of scut and repressed identity is more obvious at opposed programs. I agree, however, that when you rotate "off-service" (off-FM) that you do lose the FM perspective.

But let me ask you, how else are you going to get good at delivering babies if you don't spend 1, 2, 3 months on L&D delivering babies? Or, concentrated time examining 10, 20 knees a day? Specialty rotations are necessary evils in medical education. The issue here is does the specialist mentality persist *after* residency? Or does it all fall into place?

To me, so what if there's different ideas on what Family Medicine is all about? The family doctor should reflect the needs of their local community, which vary from the rural mountain top to the big city. We shouldn't forget that we need to be as relevant to our patients as we are to biomedicine.
 
KentW said:
So, which "organ system" do you guys in the ED practice around? Don't even try to tell me you don't do any primary care; you do tons of it...you just don't do it very efficiently or effectively. 😉
Click to expand...

Exactly... and radiologists, pathologist, internist, pediatricians...

Pathologists especially. Holy cow, talk about big time generalists...

But then again in the ER, it's Chest Pain-Cardiology, Cough-Pulmonary, Fever-ID, Back Pain-Ortho... a nurse practitioner can do that. Oh wait, many do. (Sorry PB, not knocking your people, I'm just saying we gotta keep an eye out on the big picture, ya' know?)
 
sophiejane said:
:laugh:

Seriously? What kind of management skills for seriously ill patients are you going to need in the ED? Planning on managing lots of patients on vents down there? Tweaking those electrolytes? Fine tuning abx regiments? Managing glucose?

Anyone sick enough to need that kind of management doesn't spend long in the ED.
Click to expand...


Whoa. I am doing a critical care month right now and just last night on call was in six codes and ran two of them. That's a pretty important skill for an EM physician. I also placed an IJ central line, a femoral line, and two radial arterial lines, things we do a lot of in the ED and that need practice.

Although I am against the extraodinary measures we take to keep the warm dead from getting cold, the ICU is also a great place to practice your ACLS skills.

The month before last I did several thoracentesis and almost got to do a peicardiocentesis while on pulmonary.

We get a lot of our intubations in the unit, not to mention learning how to manage the ventilator which is an important skill too, not that we're training to be pulmonologists or respiratory therapists but it is quite possible to practice at a small ED where these specialties are limited or not available and you would still have to at least get people going on life support.

Same with learning to manage acute medications like pressors, sedations, and analgesia which we do a lot of in the ED but really get to learn from the critical care folks.

We do manage sick people in the ED all the time, especially if their are no ICU beds available which is very common. At many small hospitals, the ED physician, whether he is board certified or not, is responsible for whatever ICU arrangement they have. You don't want to be the kind of doctor, like many in family medicine, who avoids learning anything on their MICU rotations because they will never have to do it.

An EM physican probably has more use for critical care training than a FP has for OB-Gyn, something stressed by FP programs but not even part of the scope of practice of many in the specialty.

Our program thinks critical care is so important that we pretty much take over the units with our residents on certain months. Everybody rotating this month at our hospital is EM even though there is FM, IM, Surgery, and other residencies at the hospital. We are not just cheap labor (well, every resident is, but you know what I mean) and most of the attendings appreciate our aggressiveness and tendency to step forward, not back into the shadows, during tough moments.

I hate call with a passion but even yer' uncle Panda like ICU call.
 
KentW said:
...So, which "organ system" do you guys in the ED practice around...
Click to expand...

The ED physician is the real generalist, not the FP. Fortunately we can dispense with the holistic, happy happy stuff.

We even spend more time with our patients (think about it) than almost any other physician.
 
sophiejane said:
:laugh:

Seriously? What kind of management skills for seriously ill patients are you going to need in the ED? Planning on managing lots of patients on vents down there? Tweaking those electrolytes? Fine tuning abx regiments? Managing glucose?

Anyone sick enough to need that kind of management doesn't spend long in the ED.
Click to expand...

Been in an ED lately, especially an overcrowded urban one? Patients admitted to the ED staying there for days, waiting for a bed to become available 'upstairs'? The ED I used to work in routinely had 15-20% of the ED census as long term guests (more than 24 hours on the ED board).
 
Panda Bear said:
The ED physician is the real generalist, not the FP. Fortunately we can dispense with the holistic, happy happy stuff.

We even spend more time with our patients (think about it) than almost any other physician.
Click to expand...

Whatever helps you sleep at night, man. 😉

The "holistic, happy happy stuff" is what's known as the art of medicine. I agree with you, however, that it's largely dispensed with in the ED.
 
flighterdoc said:
Been in an ED lately, especially an overcrowded urban one? Patients admitted to the ED staying there for days, waiting for a bed to become available 'upstairs'? The ED I used to work in routinely had 15-20% of the ED census as long term guests (more than 24 hours on the ED board).
Click to expand...

I'm in one now. Not seeing a lot of ED docs doing ICU-type management of patients. If they need a vent or seriously need an ICU bed, they are not waiting for days in the ED. The folks who wait >24 hours are cellulitis and the occasional rule out chest pain.
 
flighterdoc said:
Been in an ED lately, especially an overcrowded urban one? Patients admitted to the ED staying there for days, waiting for a bed to become available 'upstairs'? The ED I used to work in routinely had 15-20% of the ED census as long term guests (more than 24 hours on the ED board).
Click to expand...

Hey.. you can argue that in Alaska FM docs do some hernia surgeries..... The question is what is the norm? Is the norm of EM medicine to keep a person 3 days in the ER cause the ICU is packed? Answer is no... but it does happen in large urban areas... Just like in some trauma level 1 centers (e.g. Jamaica Medical Hospital NY), the ER is mostly composed of IM docs. It's just situational... Are we gonna claim that IM is best suited for ER? It's all situational.... ER shouldn't handle critical patients in the long term... although the practice is definitely beneficial for them to do line-procedures and learn them.
 
sophiejane said:
I'm in one now. Not seeing a lot of ED docs doing ICU-type management of patients. If they need a vent or seriously need an ICU bed, they are not waiting for days in the ED. The folks who wait >24 hours are cellulitis and the occasional rule out chest pain.
Click to expand...

It's not the management that's important to learn, it's the initial set up, things that are most certainly done at our ED. The management of an ICU is patient is usually pretty easy (but tedious), it's getting them stabilized and sorted out which is the problem.

At our ICU we get unstable patients transferred from the floor almost like the ICU is the inpatient Emergency Department and we do the same things that we do if the patient comes into the department by ambulance.

People do wait for an ICU bed. I have never seen somebody wait a whole day but four to six hours is not uncommon. Sometimes there are no beds (or rather nurses to cover the beds). The problem is only going to get worse, what with all the baby-boomers getting old not to mention the big bolus of over-weight, multiply co-morbid "utes" who should be hitting the system in about ten years.

Like I said, it seems only intuitive that critical care would be a good skill for an EM physician, just for the skill set in dealing with unstable patients with multiple medical problems.

The other thing I think some of you don't realize is that if the ICU is open, even the FP, at least the traditionalist, will be admitting and following ICU patients. You don't want to be "that guy" who doesn't have ICU admission privileges.
 
awdc said:
How about changing the name to Primary Care Medicine?
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Bleh. 👎

For one thing, lots of people would find this terminology indistinguishable from "urgent care medicine."

I'd take "general medicine" over that, although I'm sure the internists would have a cow. 😉
 
KentW said:
Bleh. 👎

For one thing, lots of people would find this terminology indistinguishable from "urgent care medicine."

I'd take "general medicine" over that, although I'm sure the internists would have a cow. 😉
Click to expand...

Didn't know FM cared about their opinion. :laugh:
 
KentW said:
All specialties have programs of varying quality.
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True but I don't think other specialties have as much of an image problem as FM does with med students. And according to this forum, it seems that opposed programs are generally the more undesirable programs that perpetuate the undesirable myths of FM. Why not just have unopposed programs? Sure, programs will still vary in quality but perhaps not as much as the difference between opposed and unopposed programs???
 
awdc said:
I don't think other specialties have as much of an image problem as FM does with med students.
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That's not because of the quality of the training programs, though. It's the same stuff that was going around when I was in med school; just more of it.

Why not just have unopposed programs?
Click to expand...

Well, for starters, because we don't need to be closing training programs left and right in a specialty that has a well-known and oft-reported shortage of physicians. Even Duke has been criticized for shutting down its FM residency, even though the criticism is largely political in nature.

Second, even though academic medical center-based FM training may suffer due to competition for patients on hospital rotations, they may still appeal to certain people. Freedom of choice is good. "One size fits all" is rarely an ideal situation.

Finally, pretty much every med school with a Department of Family and Community Medicine is going to want its own training program(s), and there are sometimes research dollars involved.

Besides, there's no all-powerful government entity with the authority to shut down a residency program.* Even the RRC doesn't have that kind of power. All they can do is pull their certification. If a program is not fulfilling requirements, it will be placed on probation, and continued infractions may result in loss of certification. From a practical standpoint, the program would be doomed at that point, as it would be unable to attract residents.

* Although, since residency training is subsidized by Medicare, the government can "tweak" the number of training slots in various specialties, which could force programs into closure. I can't see them drastically cutting back on primary care positions, however, given the current environment.
 
Panda Bear said:
The ED physician is the real generalist, not the FP. Fortunately we can dispense with the holistic, happy happy stuff.

We even spend more time with our patients (think about it) than almost any other physician.
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Dude, what's up with this pissing contest? It's like 5th grade. We all know there's no do-it-all doc. There is a reason why things are the way they are.
 
Panda Bear said:
It's not the management that's important to learn, it's the initial set up, things that are most certainly done at our ED. The management of an ICU is patient is usually pretty easy (but tedious), it's getting them stabilized and sorted out which is the problem.
Like I said, it seems only intuitive that critical care would be a good skill for an EM physician, just for the skill set in dealing with unstable patients with multiple medical problems.
...
The other thing I think some of you don't realize is that if the ICU is open, even the FP, at least the traditionalist, will be admitting and following ICU patients. You don't want to be "that guy" who doesn't have ICU admission privileges.
Click to expand...

No crap. That's why FP's train in the ICU also for those very same skills. The article makes a good point that the "I do this" - "I don't do that" practical element affects the specialty's identity because we all do different things. But as you just pointed out, it doesn't make sense for Critical Care to be the sole domain of Pulm/CC because there are things that every doctor needs to know and understand. At our hospital, we have BOTH closed and open ICU, but because Pulm/CC don't follow patients leaving the ICU, the primary remains on board. There's so much of a pissing contest between Cards and Pulm that Cards refuses to admit patients to the closed ICU or even do consults out there anymore. It's awful because everyone thinks that you can divide a conquer a patient's problem list and the patient will get better when in fact the reality is that many organ systems interact.

I don't have a solution, but I will say that much of this comes from arrogance and narrow mindedness.
 
KentW said:
Well, for starters, because we don't need to be closing training programs left and right in a specialty that has a well-known and oft-reported shortage of physicians. Even Duke has been criticized for shutting down its FM residency, even though the criticism is largely political in nature.

Second, even though academic medical center-based FM training may suffer due to competition for patients on hospital rotations, they may still appeal to certain people. Freedom of choice is good. "One size fits all" is rarely an ideal situation.

Finally, pretty much every med school with a Department of Family and Community Medicine is going to want its own training program(s), and there are sometimes research dollars involved.
Click to expand...

I don't get the impression that community FM programs drive research as well as academic FM programs. Part of it, I think, is volume of patients willing to participate. Academic programs have much better infrastructure in terms of support, venues, and patients than community programs. And the culture is much more geared towards research and than at community hospitals.

FM programs need to have a presence in med schools. How else are you going inspire students to go into FP? Google search Harvard FP programs and you'll find newsletters from FP interest groups wishing they had more FP exposure. At my med school, FM professors were the most active in teaching med students both in and out of the classrooms, clinics, hospital, and abroad.

There're always the names of good FP programs floating around this forum, but don't forget that there are very strong academic FP programs. UNC-Chappel Hill and U Washington-Seattle immediately comes to mind. Missouri, UCSD, and UCSF are always up there. Flip open any FP text book and you'll see some of the names... but very seldom do you see community programs listed...
 
KentW said:
Bleh. 👎

For one thing, lots of people would find this terminology indistinguishable from "urgent care medicine."

I'd take "general medicine" over that, although I'm sure the internists would have a cow. 😉
Click to expand...

Actually since IM uses the "Doctors for adults" tag line they might like FM taking on general medicine. Although I think many older adults would liken you to a general practitioner and you may not want that association.
 
RuralMedicine said:
Actually since IM uses the "Doctors for adults" tag line they might like FM taking on general medicine. Although I think many older adults would liken you to a general practitioner and you may not want that association.
Click to expand...

I was being sarcastic. I don't really have a problem with "family medicine." It's better than "family practice," at any rate...even some lawyers and dentists call themselves that. 😉
 
Panda Bear said:
The ED physician is the real generalist, not the FP. Fortunately we can dispense with the holistic, happy happy stuff.

We even spend more time with our patients (think about it) than almost any other physician.
Click to expand...


Before there was ever an EM residency, all the ERs where run by IMs and FPs.

That is a FACT.

It seems everytime we have a good thing going we tend to screw it up in the US healthcare.

I know of several FP who work in a couple of rural ERs. I asked them once what they did if they had a major trauma in there.

Answer: stabalize the patient and send the to the nearest major hospital so the surgeons can fix them. A place where there is a multi-specialty center and an ICU.

I asked the same question from the level one ER in the city I live in. You know what, they told me they just stabalize and call the surgeons.

So got to thinking why the do we need a specialty for the EM? answer: WE DON'T.
Sorry if this offends your egos guys. But EM is just general medicine with truama added in there. In fact when many of the EM guys get burned out they try to practice general medicine.

You can easily add an extra year to the FM residency (as it is being done now) and replace EM docs all together. In fact the quality of care may go up because FM has far more training in Peds and ob/gyn.

I think ER residency is for those who are adreneline junkys that don't want to practice the routine primary care. What happens is that they end of doing it in the ER anyway.
 
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