Posted on residencyandfellowship.com (not by me)
Panda Bear keep the faith and as my pathology teacher always said "Don't let the bastards get you down"
Posted: Fri Nov 11, 2005 11:56 pm Post subject:
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I understand perfectly that some clinics need to be fast-paced. Out-patient surgery clinics, for example, are incredibly focused and it is not unusual for one resident to see twenty patients in a long moring. I did that as an intern last year almost effortlessly. This is because a surgery clinic is ruthlessly "problem-focused" with one chief complaint. The history and physical exam needed to formulate a surgical plan is concise but brief. Not to mention things like routine wound checks which take five minutes.
Family medcine is not surgery. The patients are generally more involved in their work-ups and even if they are not, this is where the concept of health maintenance rears its ugly head. In other words, not only do we have to elicit a chief complaint and formulate a plan for that but at every visit we are expected to address every single health maintenance issue that applies to the patient. If someone comes in for a sprained wrist it is not enough that we get an xray and treat it (by sending it to ortho, ha ha) but we have to make sure the patient is up to date on their cholesterol, colon cancer screening, pap smears, prostate, vaccinations, mammograms and every other applicable screening. And we have to offer smoking cessation, harangue them about their weight, and make disapproving noises over their drinking.
Not too complicated on a 23-year-old healthy male but very time-consuming on a typical older patient.
Thus, there is no such thing as a simple visit. Nor do we dictate simple SOAP notes but must fit our note into a incredibly cumbersome template.
In a way, however, this is a problem for all of family medicine, that is, squeezing a comprehensive visit into the time only sufficient for a focused visit. It's just that at Duke you start out rushing and only learn to rush, not how to be efficient.
I just want to mention didactics or rather the lack of didactics. The conferences are incredibly weak and are usually on some completely useless subject like anger management or self esteem. Either that or some topic on community medicine which is often taught by a social worker or someone who's medical knowldge is irrelevent to their career.
Even when on a medical topic, a rare event, because the conference includes PAs, NPs, social workers, and nurses the content is either irrelevant to physicians in any but an incidental way or sufficiently dumbed down for the benefit of those without medical degrees.
In short, very few didactic sessions are worth attending.
It has been proposed by quite a few people that we need to have a protected block of time carved out every week (like they do in Emergency Medicine) which is to be used for grown-up education. The PAs and NPs can sit at the kiddy table if they like.
The resistance to this idea is intense. Of course it would be hard ot schedule but not impossible. Surely Duke will not lock its doors if a couple of FP interns are off the wardss fro three hours on a Tuesday afternoon.
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Posted: Sat Nov 12, 2005 10:33 am Post subject: cont'd
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You future interns also have to understand that six residents per class is not enuogh to run a primary care specialty program at a large insitution like Duke. Maybe it is at a small unopposed program but there are many service requirements at Duke which siphon off residents from things like an Inpatient Family Medicine Service which we no longer have.
Not ot mention that the reason the didactics suck is that we can seldom, it seems, get enough residents together to make a good showing for a guest lecturer.
Medicine grand rounds, on the other hand, are well attended and the conference center is usually packed. If you are a high-powered academic, where would you want to give a talk? To a standing-room-only crowd of residents and attendings or two a couple of bored FP residents and a bunch of PAs and LPNs who probably don't even understand what you are talking about.
Consequently, the conferences we do have are pretty thin gruel. I absolutely refuse now to go to any conference presented by a social worker, a midwife, a lactation consultant, or any other "physician extender" because there is nothing important in them that couldn't be jotted down on a business card and handed out in lieu of wasting an hour of my life.
Thin gruel. That pretty much sums up the whole community medicine experience. I don't see why it requires specialized training in a residency to learn how to pass out condoms at high schools, nag the poor to quit drinking, and agitate for even more social welfare. These are things which, if you believe in them you can pick up in about five minutes which is why the academic barriers to being a social worker are so low.
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