Bad impression of IM and FP

[HiddenTruth]

I started outpatient clinic about a year ago and I just had my first rotation in FP. I am so startled by the way things work in medicine. It seems like everything is ran by pharamcotherapy and labs. Honestly, I think if someone knew a little bit pf physiology and pharmacology they can run the show. It was just a big turn off seeing that everything in IM at our hospital is a consult to the subspecialty and/or "run this lab, run that lab, put 'em on this drug, bla bla" It seems like they have no idea what they're no doing, no problem solving at all. I was just soo turned off by Medicine in general--

I need tangible results for what I do. I need to see my hard earned education and training put to use rather than just being able to write scripts or request this lab or that.

Anyone else have this experience or feel this way. I don't know if a lot of IM or medicine in general is like this or it's my institution and the way medicine is practiced here. Any comments would be great--thanks.

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[Mike59]

Maybe I'm not clear with what you're saying in your post, but I believe you're expressing your disappointment with the lack of clinical skills and non-pharm. treatments being implemented in these clinics... It's been my experience in every field so far (specialties and primary care alike) that medicine relies heavily on drugs and labs and you'd be hard pressed to find many doctors that don't practice in that way. My guess is that it's partly due to the need to cover their ass in terms of potential legal consequences and also the accumulation of bad habits.

Observing such practice doesn't necessarily turn me off of outpatient primary care, I would say it motivates me to be a more thoughtful and hands-on physician when I'm done with training. Also, I'm sure as you do more rotations you'll meet some great FPs that will serve as good role models.

 

[MustafaMond]

Sounds like your clinic sucks.
You should wait until your inpatient rotation. Maybe you will find that more rewarding.

 

[pikachu]

I started outpatient clinic about a year ago and I just had my first rotation in FP. I am so startled by the way things work in medicine. It seems like everything is ran by pharamcotherapy and labs. Honestly, I think if someone knew a little bit pf physiology and pharmacology they can run the show. It was just a big turn off seeing that everything in IM at our hospital is a consult to the subspecialty and/or "run this lab, run that lab, put 'em on this drug, bla bla" It seems like they have no idea what they're no doing, no problem solving at all. I was just soo turned off by Medicine in general--

I need tangible results for what I do. I need to see my hard earned education and training put to use rather than just being able to write scripts or request this lab or that.

Anyone else have this experience or feel this way. I don't know if a lot of IM or medicine in general is like this or it's my institution and the way medicine is practiced here. Any comments would be great--thanks.

Are you complaining about internal medicine, or just about the way that the family practitioners are managing medical problems? you will find those are two very different things! internists are often willing to manage medical problems that the FP's will turf to subspecialty. you are right that most standard outpatient preventive medicine is boring as hell. so maybe it's not for you; there are lots of other fields you will experience and you will probably like something else better. exactly what rotation is this that you've been doing it for a whole year???

 

[tom_jones]

I started outpatient clinic about a year ago and I just had my first rotation in FP. I am so startled by the way things work in medicine. It seems like everything is ran by pharamcotherapy and labs. Honestly, I think if someone knew a little bit pf physiology and pharmacology they can run the show. It was just a big turn off seeing that everything in IM at our hospital is a consult to the subspecialty and/or "run this lab, run that lab, put 'em on this drug, bla bla" It seems like they have no idea what they're no doing, no problem solving at all. I was just soo turned off by Medicine in general--

I need tangible results for what I do. I need to see my hard earned education and training put to use rather than just being able to write scripts or request this lab or that.

Anyone else have this experience or feel this way. I don't know if a lot of IM or medicine in general is like this or it's my institution and the way medicine is practiced here. Any comments would be great--thanks.

Every time someone says IM sucks, a surgeons gets his scalpel

 

[imtiaz]

hahahahahah! awesome.

 

[Willamette]

I started outpatient clinic about a year ago and I just had my first rotation in FP. I am so startled by the way things work in medicine. It seems like everything is ran by pharamcotherapy and labs. Honestly, I think if someone knew a little bit pf physiology and pharmacology they can run the show. It was just a big turn off seeing that everything in IM at our hospital is a consult to the subspecialty and/or "run this lab, run that lab, put 'em on this drug, bla bla" It seems like they have no idea what they're no doing, no problem solving at all. I was just soo turned off by Medicine in general--

I need tangible results for what I do. I need to see my hard earned education and training put to use rather than just being able to write scripts or request this lab or that.

Anyone else have this experience or feel this way. I don't know if a lot of IM or medicine in general is like this or it's my institution and the way medicine is practiced here. Any comments would be great--thanks.

In this regard, things vary widely from place to place, and physician to physician. I too had a disappointing experience when first exposed to FP during medical school. I felt like the FP I was precepting with was a referral-monkey and meds adjuster disguised as a physician. Thankfully, I come from a part of the country where FPs basically run the show, and I knew that they were NOT all like the one I had the misfortune of learning from during the formative years of my med school education. With this idea in mind, I had to look no further than (literally) down the hall to find a "full-spectrum FP" that practiced in a way that jived with my pre-medschool-conceived notions. I have since come to realize that one of the "strengths" of FP is that it allows the practitioner to do as much or as little as they so desire. If FP is something you think you might like to do, I would encourage you to find someone who practices "full-spectrum FP" to get a feel for the real breadth of the specialty.

Willamette

 

[Mumpu]

It's very hard to come out of FP residency as a competent physician because you get a little bit of everything but no proper education in any given area (lessee... if it takes 3 years to make an internist, 3 years to make a pediatrician and 3 years to make an ob/gyn doc, how can you make someone good at everything in just 3 years?). IMHO FP residencies should be completely scrapped and replaced with med/peds programs.

 

[Willamette]

It's very hard to come out of FP residency as a competent physician because you get a little bit of everything but no proper education in any given area (lessee... if it takes 3 years to make an internist, 3 years to make a pediatrician and 3 years to make an ob/gyn doc, how can you make someone good at everything in just 3 years?). IMHO FP residencies should be completely scrapped and replaced with med/peds programs.

How do you figure that it's "no proper education?" My guess is that the governing bodies know what they're doing with regard to required years of residency. Besides, medicine is a profession in which the good practicioner NEVER STOPS LEARNING. Do you propose "lifelong residencies" too?

BTW, ob/gyn is 4 years...


Willamette

 

[Mumpu]

This is based largely on personal experience, both as a patient and as a student. Most FPs I've met come across as either undereducated, overworked, or just plain uncomfortable with making medical decisions, and either a) forward everyone to specialists or b) don't refer people that need to be referred, sometimes resulting in horrible M&M (missed blatant cancers and heart defects, frequently seen patients with blood pressure in 200's and sugars in 400's, taking 10 years to diagnose Graves' disease because they never bothered to check TSH, patients in fulminant heart failure on piddly doses of lasix and nothing else, etc. etc. etc.).

Not to say that every FP is a bad doctor (I know a few who are excellent, all high-ranking teaching faculty), but med/peds would produce much better physicians. Someone who is board certified in adult and pediatric medicine will be a better doctor for the whole family than a jack-of-all-trades-master-of-none FP.

 

[doc05]

the bottom line is that IM and all its subspecialties are like this. be a surgeon and get things done.

 

[MustafaMond]

Edited:

 

[Winged Scapula]

Kiss my ass.
Your mom can get things done.

Please play nicely folks.

 

[Willamette]

This is based largely on personal experience, both as a patient and as a student. Most FPs I've met come across as either undereducated, overworked, or just plain uncomfortable with making medical decisions, and either a) forward everyone to specialists or b) don't refer people that need to be referred, sometimes resulting in horrible M&M (missed blatant cancers and heart defects, frequently seen patients with blood pressure in 200's and sugars in 400's, taking 10 years to diagnose Graves' disease because they never bothered to check TSH, patients in fulminant heart failure on piddly doses of lasix and nothing else, etc. etc. etc.).

Not to say that every FP is a bad doctor (I know a few who are excellent, all high-ranking teaching faculty), but med/peds would produce much better physicians. Someone who is board certified in adult and pediatric medicine will be a better doctor for the whole family than a jack-of-all-trades-master-of-none FP.

I?m really sorry to hear that your impression of FP in general is so bad. Contrarily, FPs who are solid clinicians is the norm where I am from (Oregon). The idea that meds/peds docs would be better for the whole family just doesn?t hold true as they have relatively little experience with both ob/gyn and orthopaedics. I think it?s important to remember that common things happen commonly, and each of the dx that your anecdotes speak of is indeed common. Thus, ANY good primary care doc should be able to diagnose and treat (or refer, as appropriate) them effectively.

Additionally, I would argue against the ?master-of-none? moniker. Aside from the opportunity for each physician to cultivate their skill in any particular area, I am of the opinion that primary care docs (FPs included) strive to be masters in the art/science of diagnosis and treatment of the common diseases that afflict their patient populations.

Willamette

 

[Mumpu]

Willamette, you make very good points. I think FP should be one of the most difficult residencies because of the sheer amount of medicine in which you have to be proficient. Instead, in many places it's one of the easiest and least rigorous ones.

I have no bone to pick with FP as a specialty. I just think they are undereducated for what they are expected to do.

 

[Harrie]

Willamette, you make very good points. I think FP should be one of the most difficult residencies because of the sheer amount of medicine in which you have to be proficient. Instead, in many places it's one of the easiest and least rigorous ones.

I have no bone to pick with FP as a specialty. I just think they are undereducated for what they are expected to do.

Exactly! It never really made sense to me...

Medicine residency = 3 years
Pediatrics residency = 3 years
OB-Gyn residency = 4 years

FP residency = 3 years? Althought FPs claim to be medicine/peds/ob/gyn all in one, shouldn't that require 10 years of training??? (minus a few for overlap I guess) Not that I think that there is no place for FPs, but I don't know how they are supposed to be the all around doctor yet still have only a three year residency.

 

[Mike59]

Exactly! It never really made sense to me...

Medicine residency = 3 years
Pediatrics residency = 3 years
OB-Gyn residency = 4 years

FP residency = 3 years? Althought FPs claim to be medicine/peds/ob/gyn all in one, shouldn't that require 10 years of training??? (minus a few for overlap I guess) Not that I think that there is no place for FPs, but I don't know how they are supposed to be the all around doctor yet still have only a three year residency.

First, FPs don't "claim to be medicine/peds/ob/gyn all in one". The bread and butter of FP is common outpatient complaints and management. This easily explains why a 3 year residency is suficient. It's not about mastering everything in all fields of medicine, it's about having enough of a background to address patient needs for non-emergent/non-complex diseases and if necessary, recognize serious disease patterns and refer patients to the right source for such ailments. 90% of an FP's day is spent managing diabetes/back pn/URIs/well child visits etc. To argue that they require 10 years of training to do this is nothing short of absurd. OBGyns and Peds train for 4+ years because of they are required to master the subtleties of managing the zebras that FPs are only required to recognize warning signs of.

 

[HiddenTruth]

Are you complaining about internal medicine, or just about the way that the family practitioners are managing medical problems? you will find those are two very different things! internists are often willing to manage medical problems that the FP's will turf to subspecialty. you are right that most standard outpatient preventive medicine is boring as hell. so maybe it's not for you; there are lots of other fields you will experience and you will probably like something else better. exactly what rotation is this that you've been doing it for a whole year???

Well the school I go to emphasizes on primary care medicine--we have outpatient medicine clinic starting our 2nd semester of med school which lasts the entire four years, once/wk. Additionally, we have 6 months of IM rotations (2 mos each for the last 3 years).

I am complaining mainly about IM and FP (primary care medicine specialties) because from what I see we don't do a whole lot for the patient and it just doesn't seem right. I mean seriously, if I knew pharm I could run the show in clinics. All we do for people with mutiple medical problems is increase their dosage or let's put u on this medication, let's get BMP, FLP or actually let's refer u to ophtho for blurry vision, let's refer u to OMFS cuz u have a buccal cyst--I mean come on!! A good internist should be able to figure out a lot of stuff. And it just seems like a big turn off. I would like to see my hard work lead to some tangible results. I wanted to go into medicine first but now I think sutgery maybe something that I am interested for the sake reason of "DOING SOMETHING." If you're an orthopedist, you literally fix people--broken bone, you fix it, child can run now. It just seems that with medicine we're really not doing much, especally if people have complex multiple medical problems. I just feel like in the long run--10 years from now, I won't be satisfied w what I do cuz I don't feel like my education and training are being put to it's full use. Plus, being a partial perfectionist I don't think I can be fully satisfied with IM unless I am a really good internist and that is very difficult, and I don't think the training at our school provides those. What do you guys think?

 

[MustafaMond]

Plus, being a partial perfectionist I don't think I can be fully satisfied with IM unless I am a really good internist and that is very difficult, and I don't think the training at our school provides those.

THere's your reason.
Insecurity of being a good physician.

 

[DrQuinn]

Well the school I go to emphasizes on primary care medicine--we have outpatient medicine clinic starting our 2nd semester of med school which lasts the entire four years, once/wk. Additionally, we have 6 months of IM rotations (2 mos each for the last 3 years).

I am complaining mainly about IM and FP (primary care medicine specialties) because from what I see we don't do a whole lot for the patient and it just doesn't seem right. I mean seriously, if I knew pharm I could run the show in clinics. All we do for people with mutiple medical problems is increase their dosage or let's put u on this medication, let's get BMP, FLP or actually let's refer u to ophtho for blurry vision, let's refer u to OMFS cuz u have a buccal cyst--I mean come on!! A good internist should be able to figure out a lot of stuff. And it just seems like a big turn off. I would like to see my hard work lead to some tangible results. I wanted to go into medicine first but now I think sutgery maybe something that I am interested for the sake reason of "DOING SOMETHING." If you're an orthopedist, you literally fix people--broken bone, you fix it, child can run now. It just seems that with medicine we're really not doing much, especally if people have complex multiple medical problems. I just feel like in the long run--10 years from now, I won't be satisfied w what I do cuz I don't feel like my education and training are being put to it's full use. Plus, being a partial perfectionist I don't think I can be fully satisfied with IM unless I am a really good internist and that is very difficult, and I don't think the training at our school provides those. What do you guys think?

How about Emergency Medicine?

You'll get the "Doing Something" feeling a few times each shift! You'll reduce a fracture, run a code, suture a lac, Dx pneumonia, blah blah. Of course you have to deal with a lot of non medicine stuff, too... but I think it should be something you look into. I couldn't stand FP or IM... well, come to think of it, I couldn't stand anything besides EM and Psych. Diff'rent Strokes for Diff'rent Folks... some people love to be in the OR (KC), some people hate it (Q). Some people love the outpatient FP setting, some hate it. Its obvious you don't like the outpatient FP setting.

 

[Lonestar]

Dude,
you should look into the "ROAD" specialties (Radiology, Opthamology, Anesthesiology, Dermatology). The irony is inorder to get into one of these you have to do well in primary care (IM, FP). I came from a med school that was very primary care driven (curriculum similar to yours) and didn't have much exposure to the specialties. I got much of my exposure during the latter half of my third year and 4th year. Definitely try out these specialties, the physicians in these specialties are very happy in general. ER is also a good option since it is more acute and has good lifestyle associated with it. Surgery is just hell, unless you like optho or ENT. But, the best four in my opinion are ROAD specialties. So, go follow some of these docs in your off time in the 3rd year. The earlier the better.

 

[Willamette]

How about Emergency Medicine?

You'll get the "Doing Something" feeling a few times each shift! You'll reduce a fracture, run a code, suture a lac, Dx pneumonia, blah blah. Of course you have to deal with a lot of non medicine stuff, too... but I think it should be something you look into. I couldn't stand FP or IM... well, come to think of it, I couldn't stand anything besides EM and Psych. Diff'rent Strokes for Diff'rent Folks... some people love to be in the OR (KC), some people hate it (Q). Some people love the outpatient FP setting, some hate it. Its obvious you don't like the outpatient FP setting.

Let me start by saying that I think EM is really cool (probably the only specialty that has a shot at tearing me away from Rural FP), and I DO NOT believe that "Rural-Track FPs" are trained to manage a busy ED like the EM trained guys/gals. This being said, they ARE trained and ARE EXPECTED to be able to do each of the things Quinn mentioned ( You'll reduce a fracture, run a code, suture a lac, Dx pneumonia, blah blah) for their rural patients. What I'm trying to get at is that FP is not ALL run-of-the-mill outpatient medicine in much of the country. However, much of it IS R.O.T.M OtPt. Medicine, and you are probably unlikely to enjoy FP if you don't like ambulatory medicine. Also, try and remember that there's more to being a good doctor than knowing and applying the science of medicine. How you relate to your patients (even when they're just in to see you for a meds adjustment) goes a long way toward helping them keep healthy.

Willamette

 

[fourthyearmed]

Exactly! It never really made sense to me...

Medicine residency = 3 years
Pediatrics residency = 3 years
OB-Gyn residency = 4 years

FP residency = 3 years? Althought FPs claim to be medicine/peds/ob/gyn all in one, shouldn't that require 10 years of training??? (minus a few for overlap I guess) Not that I think that there is no place for FPs, but I don't know how they are supposed to be the all around doctor yet still have only a three year residency.

That's exactly how I feel. I enjoyed my FP rotation in a rural setting but I do not feel that the residency is enough training for all they are expected to know therefore I never even considered it as being the specialty for me. I want to feel comfortable that my training was complete enough for everything I will see.

 

[PACtoDOC]

For those of you who have never practiced real medicine, hold your judgement of FP's because realize that your patient's normally come from them when you are a specialist. First let me tell you that FP is actually a wonderful profession that can be extremely lucrative, and fulfilling. You are kidding yourself if you think it requires a GI doc to do every routine scope, an OB to do every routine or even C-section delivery, a cardiologist to do every stress test, an orthopedist to set every fracture, a dermatologist to do every skin biopsy...etc.... What you guys don't want to hear is that it really doesn't even require a physician to do most of these things well. As a PA, before I came to medical school I was doing most of these things scrap the OB and stress test, but what you are forgetting is that these tests are only a small part of what make a specialist. FP's only do the critically necessary procedures to help people who otherwise would never have easy access to these specialists. I mean come on, most people that want to go into FP start becoming an FP the day they begin medical school. Because medical school is basically a well rounded education in all the same things you need to be a primary care doc (FP). So most people that go into FP get 4 years of medical school, plus 3 years of residency to learn their trade. And most FP's don't do every single procedure possible. Most learn one or two higher level procedures to offer their patient's better care. No one is arguing that FP's should be doing these procedures routinely if they are in an area where specialists are a dime a dozen. But the vast majority of healthcare is provided outside of cities of 100,000 or less. And there are more FP's in those places than any other specialty. I for instance will be doing routine FP with OB and surgical OB. I will probably get as much surgical OB as most OB residents in the OB strong program I attend, so I am not worried in the slightest. There is simply nothing more fulfilling than being able to get to know your town, and your patients as an FP doc. Its ashame more of you "vastly experienced rookies" cannot see that. Lets get real here, who do you think was providing care for rural America back before the 1950's? Well, I'll tell you...they were called GP's, who had 2-3 years less training than today's FP's, but somehow the care was provided in a safe manner and today millions of American's appreciate and prefer to have an FP.

 

[Mumpu]

PAC, you did a great job describing what attracts many people to FP. I wish every FP had the same attitude as you.

Training is not about procedures -- it's about learning to recognize and manage diseases. At the end of a 3-year residency, a general internist is better trained than FP in adult medicine, a pediatrician is better at peds, and an OB doc is better at OB. Thus, I would prefer an IM doc for myself, a pediatrician for my kids, and an OB/Gyn for my pregnant wife. If I wanted a single doctor, I would go to a double-boarded Med/Peds. No offense to FPs but more rigorous training counts. Remember, if you don't recognize a disease as a primary care provider, it goes undiagnosed. That's a huge responsibility, IMHO, and I would want as much training as possible.

 

[PACtoDOC]

I respect the fact that you may want an IM doc for yourself, or a Ped for Peds, but what you have to understand Mum is that very few people in this country have that same option available to them. I came into medicine to be able to do as many things as humanly possible, and provide the absolute best care to underserved areas that I can. So let me ask you this Mumpu, can you argue that there is any better doctor for rural America than an FP? I think not. Would you want that IM doc treating your kid, or that OB doc treating your rash, or the surgeon doing your prostate exam? Put up a map of the US, cover up every single city of 100,000 or greater, then step back 7 feet with 3 darts, and I bet it will take you 100 throws to hit 5 areas that are "specialist heavy". On the other side of that statement, you will probably hit "FP" dominated areas thr majority of throws. No doubt, it would make much more sense and you would have no argument from me if there were enough IM, surgeons, peds, and OB's to provide even the most basic care in these areas. But since we are more likely to see FP's doing CABG's in urban teaching hospitals before this happens, I suggest you attempt to realize that few people have the options available to you Mumpu. And for the record, I would way sooner send my kid or wife to an excellent FP over a Med/Peds doc because these guys are purely hospital trained and tend to be way undertrained in the everyday clinical setting where "zebras tend not to roam". See, you can be an expert zebra spotter, but what the hell do you do when a horse goes by?

 

[Trisomy13]

It's very hard to come out of FP residency as a competent physician because you get a little bit of everything but no proper education in any given area (lessee... if it takes 3 years to make an internist, 3 years to make a pediatrician and 3 years to make an ob/gyn doc, how can you make someone good at everything in just 3 years?). IMHO FP residencies should be completely scrapped and replaced with med/peds programs.

I'm currently doing a rotation where the FP residency is taken very seriously (I think it might have been one of the first in the nation) and when it works, it really works. I've learned a lot in my first 2 weeks, even as a third year student. I'm not sure FP is for me, but I feel lucky to be able to see a good program so that I don't just write it off like so many people are quick to do.

 

[pikachu]

I respect the fact that you may want an IM doc for yourself, or a Ped for Peds, but what you have to understand Mum is that very few people in this country have that same option available to them.

So what you're saying is, if the specialist coverage in a certain area is subpar, then the average Joe Schmuck should just settle for it?

As a PA, I guess you are used to overstepping your own credentials, but this is a bit extreme. Most Americans live in urban areas and therefore should have access to an internist, a pediatrician, and an Ob-Gyn. (At least this is true since the 1920's, when medical knowledge was limited enough that a family practitioner might have been able to master enough medicine, pediatrics, obstetrics, and gynecology to practice in all 4 fields. Of course, this was also before the advent of antibiotics.) So all Americans should (have the right to) take advantage of a practitioner who is well trained in one field, rather than doing a half-assed job in four different fields.

 

[PACtoDOC]

You really believe that most Americans live in urban centers? There are nearly 300 million people in this country, and if what you are eluding to is correct, then there should be an average of 300 cities with 1 million people or more right? Since last time I checked there are only 20-30 cities that fit this criteria, your theory is bogus. Maybe you have grown up where concrete is the common soil type and where the roadside plastic bag is the main flower, but most Americans do not live in urban centers and are happy to have whatever care they can get. And trust me when I tell you this. Most rural Americans are plenty happy with their small town GP or FP, and they wouldn't want some city IM doc coming in and providing their care. You have a lot to learn about the world of medicine my friend.

 

[pikachu]

You really believe that most Americans live in urban centers?

In fact, I do, according to the US Census:

http://www.census.gov/Press-Release/www/1999/cb99-238.html

Scroll down a little ways, and you'll find another fact that I guess you didn't learn in FP residency.

 

[PACtoDOC]

Listen, just because you show some governmental document stating that 75% of people live in urban centers, you still provide no definition of urban. There are plenty of places where there are towns of 30-50K people and where FP's still are basically the dominant physician type. You have to quantify what you mean by urban, because it certainly is not meaning only large cities. But even if you were correct and only 25% of Americans live in rural America, in your ideal world, 1 in 4 Americans would have no healthcare since you believe FP's to be worthless. Nothing like a city specialist questioning the legitimacy of small town medicine when they have never spent a day one as a rural American.

 

[MustafaMond]

As a PA, I guess you are used to overstepping your own credentials, but this is a bit extreme..

damn!!!!!!

 

[pikachu]

Listen, just because you show some governmental document stating that 75% of people live in urban centers, you still provide no definition of urban.

I don't need to, the Census does:
http://www.census.gov/geo/www/ua/ua_2k.html
Maybe if you would do actual research before shooting off your post, you wouldn't look so uninformed.

There are plenty of places where there are towns of 30-50K people and where FP's still are basically the dominant physician type.

Where is your proof of this, Dr. Documentation?

...get your a$$ off the FP forum...

Last time I checked, this was the clinical rotations forum...

 

[Green912]

I have to agree with PactoDoc about the relative degrees of urban vs. rural areas in the country. For the most part I've lived in the more populated areas of five states and have traveled cross-country by car/bus many times. And every time I leave my familiar concrete jungle, I'm always amazed at how quickly the buildings disappear in 30-45 minutes, leaving you with hours of open country and small towns.

 

[Willamette]

So what you're saying is, if the specialist coverage in a certain area is subpar, then the average Joe Schmuck should just settle for it?

As a PA, I guess you are used to overstepping your own credentials, but this is a bit extreme. Most Americans live in urban areas and therefore should have access to an internist, a pediatrician, and an Ob-Gyn. (At least this is true since the 1920's, when medical knowledge was limited enough that a family practitioner might have been able to master enough medicine, pediatrics, obstetrics, and gynecology to practice in all 4 fields. Of course, this was also before the advent of antibiotics.) So all Americans should (have the right to) take advantage of a practitioner who is well trained in one field, rather than doing a half-assed job in four different fields.

First of all, take it easy on the personal attacks dude. Secondly, It's becoming increasingly obvious that people from big cities don't seem to understand the immense value that an FP can potentially bring to their community. This is sad because nearly all of our pre-residency training is destined to take place in those same large cities where specialists and super-specialists have the luxury of spending their entire career in one little corner of medicine, while looking down on other specialties (and even figuratively spitting on the 21st century generalists). The simple fact is that most of what can ail a person happens to be quite common, and a well-educated generalist can deal with most of them. The key is to provide good, kind, and compassionate care for those who ail in a way that you are familiar with, and to be exquisitely aware of the limits of your knowledge so that you can make thoughful and timely referrals when the situation arises.

Willamette

 

[Mumpu]

A well-educated generalist is a double-boarded med-peds with education in both adult and pediatric medicine. Many schools offer primary care tracks in internal medicine and peds residencies for this exact purpose. I don't understand how you can argue that an FP is better at EITHER adult or pediatric medicine than someone who is specifically educated and certified in it. Every rural med-peds I've talked to said their practices are blooming for this exact reason. When given the choice between an FP and a med-peds, people go to med-peds because they want an adult specialist for themselves and a peds specialist for their kids.

My point is that family medicine needs to be seriously reworked to become at least what med-peds is right now (i.e. 4 years of rigorous adult and pediatric training, not 3 years of what looks like my 3rd year medical school curriculum).

Also, the fact that FPs still dominate in many parts of the country is not necessarily a good thing. There is A LOT of bad medicine being practiced in the US. With rigorous testing, a good 50% of rural doctors would (rightfully) lose their medical licenses because they lack the knowledge to safely take care of people. Just look at the recent scourge of hyperkalemias with spironolactone. I'm certain that the vast majority of guilty physicians are not urban IM docs but rather rural FPs who heard about spironolactone on the evening news.

 

[HiddenTruth]

My point is that family medicine needs to be seriously reworked to become at least what med-peds is right now (i.e. 4 years of rigorous adult and pediatric training, not 3 years of what looks like my 3rd year medical school curriculum).

Just look at the recent scourge of hyperkalemias with spironolactone. QUOTE]


TRU DAT!!--

 

[MustafaMond]

Just look at the recent scourge of hyperkalemias with spironolactone. I'm certain that the vast majority of guilty physicians are not urban IM docs but rather rural FPs who heard about spironolactone on the evening news.

This is pretty harsh, and unfair post.

The NEJM study that showed the increasing rate of spironolactone scrips, was compiled from the state database of Ontario.

The population of ontario is VASTLY more urban than rural.
So Please STFU about family medicine.

Based on the studies, you can blame canadian physicians, but you shouldn't make accusations like that about an entire field.

At least people read the RALES trial and started getting more pt's on spironolactone. It is an excellent medicine that we are still learning about. I find it awesome

Its funny how you can criticize physicians in general as "*******es"

Where were you with your intelligent opinion before you saw Tom Brokaw talk about the NEJM study?

IMHO, if you have a pt. w/o contraindications who is class IV heart failure, and normal K+ levels, and is NOT on spironolactone, YOU are the one who is a *******.

 

[Willamette]

Mumpu,

I'm starting to feel like a broken record here...the meds-peds program DOES NOT provide enough breadth (being deficient in OB and Ortho for starters) to provide BETTER OVERALL coverage for a small community than FP. I AM IN NO WAY denigrating the meds-peds specialty, as I think that the training provides an excellent opportunity for a physician to become an excellent clinician. However, I'll fight tooth-and-nail the notion that FPs are somehow inherently inferior physicians. Is three years enough time to know everything about everything? Of course it isn't, but neither is 5, 10, or even 50 years. The FP specialty was the first to realize that practitioners of medicine ought to make lifetime learning a part of their practices, requiring periodic recertification. The first seven years (4 med school, 3 residency) is just a start...

Willamette

 

[PACtoDOC]

Also, the fact that FPs still dominate in many parts of the country is not necessarily a good thing. There is A LOT of bad medicine being practiced in the US. With rigorous testing, a good 50% of rural doctors would (rightfully) lose their medical licenses because they lack the knowledge to safely take care of people.

That quite frankly shows your utter ignorance about the FP profession, and your utter ignorance in general. Talk about condescending? So do you think that FP wannabe's are less intelligent as well? How about we all show our real stats...where will you stack up? Don't generalize because you will find yourself surrounded!! Could I stay in the big city and do IM/Ophtho/Derm? Damn straight I could, but you better hope I don't, because it will mean one less spot for you!!

 

[Mumpu]

Mustafa, FYI spironolactone has been around since 1960's. My point was that there are a lot of physicians who are so incompetent that they don't understand the need to monitor K levels in spironolactone patients.

Williamette, yes FP's have more exposure to OB and ortho. My point was that 3 years is not enough training to be competent at all of that (e.g. med-peds takes 4 years to give just adult and peds proficiency, no OB or ortho each of which take 3-5 years to attain proficiency in).

Pac, you are obviously insecure that being an FP will make you less of a doctor. I never suggested FPs were less intelligent, just that they need better training that they currently get. That's a problem with the accrediting agencies, not with people who go into the profession. Most of the problem physicians who need to be sacked are "good ol' docs" who haven't cracked open a book since 1927. However, there is no system to do real-time assessments of physician competency in any profession. I'd love to see something that launches an investigation every time an 8-year-old is found to have a congenital heart defect, a patient with NYHA IV walks in on 12.5 of HCTZ and nothing else because ALLHAT said so, a teenager with HOCM falls down dead a week after PCP signed the permission to play sports, etc.

 

[MustafaMond]

Mustafa, FYI spironolactone has been around since 1960's. My point was that there are a lot of physicians who are so incompetent that they don't understand the need to monitor K levels in spironolactone patients.

..........................
I'd love to see something that launches an investigation every time an 8-year-old is found to have a congenital heart defect, a patient with NYHA IV walks in on 12.5 of HCTZ and nothing else because ALLHAT said so, a teenager with HOCM falls down dead a week after PCP signed the permission to play sports, etc.

You turnip.
I know a lot more about spironolactone than you do.
You obviously are ignorant of The Canadian NEJM study, and RALES trial.
As I suspected, your info on spironolactone was gleaned from Tom Brokaw.

As far as your second statement. I don't know if you are working in the ****tiest hospital in the USA, or whether you watch too much "ER".

 

[Mumpu]

Mustafa, that was really mature, especially for an R3 in IM... So much for teaching, being a positive role model, etc. You will make a smashing private practice physician. Would you be so kind as to substantiate anything you said in your post? You are also welcome to point out (with supporting evidence, por favor) factual errors in my posts. I'm always open to learning.

All three examples I mentioned are (a small fraction of) the actual patients I've seen coming in from the community. I wish it wasn't true because defending the honor of some unknown pediatrician who never learned basic auscultation from a furious mother who cannot believe that her little girl has had a fist-sized ASD (with classical exam and ECG changes, no less) for the past decade is not fun.

 

[pikachu]

I'm starting to feel like a broken record here...the meds-peds program DOES NOT provide enough breadth (being deficient in OB and Ortho for starters) to provide BETTER OVERALL coverage for a small community than FP.

You're missing Mumpu's whole point. He is saying that FP is
too broad as it is already. Rather than addressing that criticism, you're now adding TWO MORE fields that FP's need to be able to practice in. Let's not forget about the fact that FP residents, as one of the "lifestyle" specialties who spend most of their time in clinics, probably get fewer hours of training per week than medicine and peds residents (except on outpatient rotations), and certainly fewer hours per week than Ob-Gyn and Ortho residents. More knowledge required, less time to acquire it - doesn't add up. Don't try to snow everyone with these "Lifetime Learning" platitudes either; obviously every good physician strives to keep up to date on the current standards of care in his/her specialty. However, we all know that residency is where the vast majority of your knowledge base in your field is gained.

Your straw man arguments that FP's are not "inherently inferior physicians" (no one is claiming this; the only question is with the TRAINING) do not address the question Mumpu, I, and others are posing: How can three years of (mostly) outpatient training be sufficient to do anything more than skim the surface of Internal Medicine, Gynecology, Obstetrics, Pediatrics, and Ortho? If you care so much about rural Americans, shouldn't you want to be trained in more depth in order to provide better care? Look, maybe this training was enough for you personally, and you learned a ton of medicine, and you're a GREAT FP who knows when to refer to specialists, and you read all the major journals in all the fields you're dealing with, etc., but many other family doctors do NOT. And they cause a lot of train wrecks. This is not to say that there are no incompetent IM/Peds/Ob-Gyn either, but at least their training is not a setup for this to happen.

"He who knows not, and knows not he knows not, is a fool; shun him."

 

[Willamette]

Listen, everyone knows that almost all hospital-based specialties spend at least the first year of residency as glorified scut-monkeys. FPs, on the other hand (at least in the unopposed programs), are nurtured and taught from day one how to be GOOD primary care docs. Take a look at the contents of the journal "American Family Physician" and you'll see that, over the course of a year or two, they hit MANY MAJOR areas of concern for the population at large. You guys really need to realize the fact that "COMMON things occur COMMONLY," and that most problems don't require a specialist for proper management.

Willamette

 

[Mumpu]

Thank you Pikachu.

Williamette... What are you talking about? I personally know several FP interns. Their first-year rotations are very similar to IM (in fact, they rotate through IM). Hitting "many major areas of concern" addresses the BREADTH. You are ignoring the point Pikachu and I are raising about the lack of DEPTH.

You are right, common things occur commonly. But there are many not-that-uncommon things that will result in tremendous morbidity and mortality if missed. If you are a rural doctor (or even an urban PCP), it is your job to recognize these uncommon things. To make it worse, most uncommon diseases mimick the common ones and you need DEPTH in your training to be able to differentiate them. For example, ask yourself how you would feel if a 15-year-old girl whom you delivered and took care of all her life suddenly needed a heart-lung transplant because YOU missed an ASD and she now has Eisenmenger's? What's the most common complaint with ASD? Frequent colds. You need a lot of experience to have a high index of suspicion when things like that pop up. The physical exam findings, as I'm sure you know, are pathognomonic but very subtle.

The responsibility carried by a PCP is tremendous because, practicing in the community you have no oversight. If you screw up, the patient is hosed (surgeons are in a similar situation, and they take at least 5 years of training). Given that level of responsibility, I would want as much training as possible.

 

[Willamette]

Thank you Pikachu.

Williamette... What are you talking about? I personally know several FP interns. Their first-year rotations are very similar to IM (in fact, they rotate through IM). Hitting "many major areas of concern" addresses the BREADTH. You are ignoring the point Pikachu and I are raising about the lack of DEPTH.

You are right, common things occur commonly. But there are many not-that-uncommon things that will result in tremendous morbidity and mortality if missed. If you are a rural doctor (or even an urban PCP), it is your job to recognize these uncommon things. To make it worse, most uncommon diseases mimick the common ones and you need DEPTH in your training to be able to differentiate them. For example, ask yourself how you would feel if a 15-year-old girl whom you delivered and took care of all her life suddenly needed a heart-lung transplant because YOU missed an ASD and she now has Eisenmenger's? What's the most common complaint with ASD? Frequent colds. You need a lot of experience to have a high index of suspicion when things like that pop up. The physical exam findings, as I'm sure you know, are pathognomonic but very subtle.

The responsibility carried by a PCP is tremendous because, practicing in the community you have no oversight. If you screw up, the patient is hosed (surgeons are in a similar situation, and they take at least 5 years of training). Given that level of responsibility, I would want as much training as possible.

I find it ironic that you think these things are so "subtle," yet you as a student are keenly aware of them...three years is plenty of time to become a competent FP, and I've said all that I'm going to say about it on this thread.

Willamette

 

[Mumpu]

I put a lot more work into my physical exam skills than most people. I bet many PCPs do not know the exam and ECG findings (do you?).

I would love to see some proof that 3 years is enough time for competent FPs. I've worked with some outstanding FPs but I've also seen a lot of bad disease blatantly missed. I would even argue that 3 years is not always enough for IM or peds because those docs miss much badness as well.

 

[lowbudget]

<yawn> Are we still talking about whether my daddy can beat up your daddy?

If you need 3+3+4 years to do FP, you're not very bright. Or, you're a professional resident with a visa problem.

And I don't even want to hear about how IM/Pedi/ObGyn are the masters of adult, child, and women's medicine. Even these docs run into trouble and need to refer and consult.

Few observations:
1) When GIM has finished running every lab in the world, they call Rheumatology.
2) Gen Pedi can stick their chest out just a little bit only if they know a Neonatologist is trolling in the NICU.
3) I don't even want to hear about how OB/Gyn handle "high-risk" OB patients. Even they defer to Maternal-Fetal Medicine whenever a pregnant woman has complicated medical issues.
4) My favorite during my Psych rotation was listening Psychiatrists bag on FPs. ARE YOU KIDDING ME? Damn, even Psych is bagging on FP's now...
5) What about the General Surgeon? Are they as good as CT surgeons or Vascular surgeons or ENT or Ortho or Ophtho or Uro? No.

Point is: generalism is generalism and there are times when referrals and consults are appropriate and sometimes when it is not. Does Pedi call Derm everytime they see a rash? No.

And at the same time, specialists need to practice their specialty and not do primary care.

If you really want to talk dirty, here's my take:
1) GIM should stick to their Zebra Safari and stay out of the business of preventive care. AND they need to call the marketing department, because no one knows what the hell an "Internist" does.
2) Gen Pedi should take care of normal newborns, kids too young to get pregnant, and kids with jacked up faces and extremities and abnormal size brains. All others, even a 4th year med student can handle.
3) Ob/Gyn should figure out whether or not they want to be OB or Gyn and start acting like a specialist, focus on doing their own business well for their malpractice premium's sake, and leave the business of primary care to family doctors. AND they need to call the recruiting department because nobody wants to live their life in this 5th circle of Hell.
4) Psych needs to shut the f&ck up, unless they want to get into a USMLE showdown.
5) General Surgeons should leave the Who's the Better Doctor Debate and refocus their energies toward winning the Who's the Better Surgeon Debate. Because not even the surgeons respect each other. And THEN they need to shut the f&ck up, get in the OR, and start cutting down their census on the M&M list.

It's a sandbox, people. Play nice, ok?

 

[PACtoDOC]

Great post Lowbudget!!

Hey guys, here is an example of a post this last week by Mumpu regarding the difference between what an MD learns versus what a DO learns.

"MDs go through longer residency training so in theory they have more experience before being left on their own. Having said that, I know NP's who are better in every respect than some fellows."

Does anybody else get the feeling that they are arguing with some kid who gets on Mommy and Daddy's computer when they are out?

Mumpu, step away from the keyboard, and focus more on understanding big healthcare issues before you start to be the founding father of FP revamping.

You better worry more about you upcoming SAT than about what is wrong with family medicine

Either you are the most misinformed medical student ever, or you are some innocent teen we should go easy on. I am hoping for the former so that I can laugh a little harder while the bottom falls out of your credibility!!