Bad impression of IM and FP

[MustafaMond]

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Mumpu is actually pretty intelligent and judging from other posts, he knows quite a bit of medical science. I'll bet he is MS3 or 4

 

[Mumpu]

Lowbudget, I agree with you on psych. They rag on every other specialty for "not addressing psych issues" and then refuse to see psychotic patients until they are "medically cleared." All your other points are playing on stereotypes. It's very easy to insult ANY medical specialty -- my experience has been that there are excellent people and sucky people in all of them.

PAC, I'm an MS3. Don't get into poo-throwing contests, you will lose. Instead of throwing out childish insults, why don't you try making intelligent arguments? What exactly did you dislike about that quote (is there some PA vs NP rivalry that I'm sensing?). I expressed my opinion on FP TRAINING (not FP as a profession) and I freely admitted to my bias (I'm interested in hospitalist IM). All you've done is troll and make personal attacks.

 

[Winged Scapula]

Ok guys and gals...

You've been "warned" once before about playing nicely and now my Inbox is being filled with complaints about the name-calling on this thread. Since I have yet to see any distinct violation of the TOS (although admittedly I haven't read all threads thoroughly), it will remain open. However, if you cannot keep this discussion civil, without name-calling, it will be closed and the violators placed on post probation.

Thank you for understanding.

 

[PACtoDOC]

Lowbudget, I agree with you on psych. They rag on every other specialty for "not addressing psych issues" and then refuse to see psychotic patients until they are "medically cleared." All your other points are playing on stereotypes. It's very easy to insult ANY medical specialty -- my experience has been that there are excellent people and sucky people in all of them.

PAC, I'm an MS3. Don't get into poo-throwing contests, you will lose. Instead of throwing out childish insults, why don't you try making intelligent arguments? What exactly did you dislike about that quote (is there some PA vs NP rivalry that I'm sensing?). I expressed my opinion on FP TRAINING (not FP as a profession) and I freely admitted to my bias (I'm interested in hospitalist IM). All you've done is troll and make personal attacks.

Mumpu,
You clearly have a difficult time paying attention. The thread I quoted you on was a thread where the original poster asked what was the difference between what an MD learned versus a DO. The reply was a direct quote of your reply. I apologize if you don't recall, but they were your words. I could care less about your opinions of PA's or NP's. That just happened to be in the quote. It really made no sense for the post anyway, but hec, they were your words, not mine.

I was merely trying to point out to the readers of this thread who might err in giving you too much credibility, when in fact, you actually thought that MD residency training was somehow longer than DO training. If you don't even know something so basic, then it is my belief that your comments here also lack credibility.

No Poo slinging...just throwing your words own around.

 

[hypersting]

To add another persepective, healthcare costs would go down if there were more FPs and other primary care docs to handle the "common" cases. Overuse of specialists is one of the reasons for such high costs. I agree with lowbudget, specialists should act like what they are.

 

[Mumpu]

Kimberli, I think the intelligent discussion on this thread may be DOA (thanks a bunch PAC!).

Hypersting, I agree with your comment but it opens a whole 'nuther can of worms. Namely, where do you draw the line between a PCP and a specialist? Should hypertension be treated by PCPs or cardiologists? Diabetes by PCPs or endocrinologists? Are 10-15 minute appointments enough to get a grasp of these medical issues? (specialists tend to have longer appointments). There is no good evidence for difference in outcomes (except maybe in cardiology) and no guidelines for when referrals should be made. I think the average PCP does an excellent job, but some people are referring machines and others sit on patients for too long.

 

[Willamette]

I think the average PCP does an excellent job, but some people are referring machines and others sit on patients for too long.

THIS, I agree with.

Willamette

 

[PACtoDOC]

Kimberli, I think the intelligent discussion on this thread may be DOA (thanks a bunch PAC!).

Hypersting, I agree with your comment but it opens a whole 'nuther can of worms. Namely, where do you draw the line between a PCP and a specialist? Should hypertension be treated by PCPs or cardiologists? Diabetes by PCPs or endocrinologists? Are 10-15 minute appointments enough to get a grasp of these medical issues? (specialists tend to have longer appointments). There is no good evidence for difference in outcomes (except maybe in cardiology) and no guidelines for when referrals should be made. I think the average PCP does an excellent job, but some people are referring machines and others sit on patients for too long.

Now except for the first sentence, I would agree with most everything you said. Many PCP's by virtue of ending up in the PCP profession by default (crappy scores and poor interview skills) end up being these same PCP's with little desire than to show up for work, see a few patients, and send everything out that any good PCP could handle. They give all PCP's a bad name. Keep it coming MUMPU, I think we can make a good PCP out of you yet!!

 

[tom_jones]

Look people:

Some of us fo not like IM and FP. We hate clinic and like to do procedures, so IM and FP people are going to have to deal with the fact that some people find their profession boring. At least its not overtly hated like ob/gyn

 

[Melanie]

Hi Everyone!

I've really enjoyed reading the posts on this board. I think that everyone has some good points. I too am considering FP and wanted to point out that specialists can practice "bad medicine" as well. I saw a specialist a few months ago and left with a prescription for the wrong medication and a refusal from the doc to draw my blood to check for an important hormone lever (which was the only reason I was there in the first place). It took me all day to settle the medication issue, and I eventually had to drive 35 minutes back to the office where I had been that morning and on top of that, the doctor never even apologized for her mistake. (Although that opens a new issue of how doctors sometimes think that they are just being noble by doing a good job, even though they are being paid for a service and should deliver that service well). I ended up going to my FP for the bloodwork, and will never see a specialist for this type of thing again. This isn't to say that FPs are always a good option, but it's been my experience that they are more receptive, easier to get appointments with, and generally quite competent. (Again, only my experience...I'm sure that FPs write the wrong scripts all the time.)

Access to healthcare is also important. If FPs are replaced by "more qualified" specialists in rural/underserved areas, then are we going to rethink this whole "gatekeeper" thing, because we would have to...or are folks in these areas going to just pick a specialist, which by the way, their insurance won't cover, because they don't have a referral. And, in my city of roughly 150,000, you have to wait 3 months to get an appointment with an internist or specialist. So, woudn't it be better to see an FP in the same day?

Regarding FPs being undertrained, I'd like to also point out, that there are problems in other specialities with training as well. For example, I am sure that a pediatric endocrinologist would tell you that general peds folks are "undertrained." Where does the specialization end?? There must be a level of specialization that can be practical. FPs make this extremely practical. Training is also a dynamic process. I think about EM and its evolution over the last 30 years when I make this point. I worked in an ED for about a year, and one of our best docs was a man who had done his residency in FP, because EM residencies didn't even exist until the late 1970s/early 1980s. I wonder how many practicing physicians (>10yrs.)would tell you that they reach back to their residency every day? I have a good feeling that many of them look more to their years of experience than their residency programs.

 

[JattMed]

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.

I take my hat off to FP docs.........I could never do it!
Too damned hard...........gotta be so competent in so many areas......tough gig!
People shouldnt knock it.
FPs should be trained longer, perhaps 6 years and given at least 2X what they earn.

 

[HiddenTruth]

I wonder how many practicing physicians (>10yrs.)would tell you that they reach back to their residency every day? I have a good feeling that many of them look more to their years of experience than their residency programs.

you raise a very interesting point. I truly agree with you that many physicians practice based on experience and ofcourse training, with experience being more heavily weighted; however, it is imperative to have a solid foundation before you can build a house on it. How many physicians look back at their medical school career? Most people would say not many. Well, according to your theory, why even go to medical school? Why even pursue significant training because you ar relying on experience to be a succeful and competent physician? What about the CT or neuro surgeons who go through 7-8+ years of training? Dear, all these threads are emphasizing specific training required to be competent physicians. Without adequate training, you cannot have a competent physician, regardless of how many years of experience he/she has. How can something stand without the framework?

Sure, many of them look back to their years of experience than their residency training; however, their years of experience are based heavily on the type of training they have received (referring strictly to medical knowledge). According to your theory, there should be no undergraduate college. People should get into medical school--only the last two years--and do a one year residency just to learn the way things work and rely on experience to be an adequate and competent doctor. Well my friend, experience comes from training. Without adequate training, there is no profound experience. Good luck!

HT

 

[Melanie]

I was in no way establishing a "theory" by making my post. I don't think that two sentences with question marks are a very good basis for a "theory", do you? It's uncomfortable for us to think about our medical training being completely irrelevant, isn't it? And, it's scary to think for MD students that PAs for example could become excellent practitioners despite their lack of 4-year MD program training. Medicine is an amount of knoledge that can be obtained in many ways. Perhaps in 100 years our system of medical education/residency training, etc. will be completely obsolete? (This is NOT a theory)

 

[JattMed]

.......and Mel' takes off the gloves............'ding ding'

 

[HiddenTruth]

Medicine is an amount of knoledge that can be obtained in many ways. Perhaps in 100 years our system of medical education/residency training, etc. will be completely obsolete? (This is NOT a theory)

True, but the underlying foundations and principles taught in medical school and training are very limited to those specific areas. Now, whether or not how useful these underlying principles and foundations are to your practice of medicine is another story, which can be argued.

"Perhaps in 100 years our system of medical education/residency training, etc. will be completely obsolete? "

this is exactly what i said in my post above as to what you think.

 

[Melanie]

Okay Hidden Truth,

I'm sorry, I misunderstood what you were referring to as a "theory." And, yes, that is most definitely a theory. I think that our medical system and system of medical education in 100 years will be very different than it is now. Look at our medical system 50 years ago in America, or 30 years ago for that matter. There have been BIG changes in training as well as the practice of medicine. Systems of education have to change with an increase of material. In this case, new technology has rapidly added a lot of material to the medical school curriculum. At some point, our education system will have to change to accomodate these changes.

My main problem with some of the posts on this topic was suggesting that somehow all bad medical decisions in America are made by FPs who don't have enough training. The reason I brought up residency training and its significance is because the suggestion of 6-10 years of FP residency training was brought up. I think the idea of equating residency training with competency (without considering any other factors) is oversimplified and not a workable solution to this alleged problem.

 

[JattMed]

Are you guys gonna get married now?
I'll call the Priest.

 

[hypersting]

Kimberli, I think the intelligent discussion on this thread may be DOA (thanks a bunch PAC!).

Hypersting, I agree with your comment but it opens a whole 'nuther can of worms. Namely, where do you draw the line between a PCP and a specialist? Should hypertension be treated by PCPs or cardiologists? Diabetes by PCPs or endocrinologists? Are 10-15 minute appointments enough to get a grasp of these medical issues? (specialists tend to have longer appointments). There is no good evidence for difference in outcomes (except maybe in cardiology) and no guidelines for when referrals should be made. I think the average PCP does an excellent job, but some people are referring machines and others sit on patients for too long.

Circular logic I suppose, but shouldn't a good PCP know the difference as to when they should refer or not. I guess that's what you are driving at. I don't think its up to a regulatory body to completely restrict the autonomy of a PCP in making guidelines as to what cases they should handle or refer.

There is no good evidence for difference in outcomes (except maybe in cardiology) and no guidelines for when referrals should be made.

I smell a paper here. What do you think? You get first author, I get second In all seriousness, I would be interested to know what a PubMed search on this would show up. And if there isn't anything good, lets get to it.

 

[Mumpu]

You can do a lot of procedures in IM and FP, depending on where you work. I wouldn't say that Ob/Gyn's are universally hated -- there are some jaded asshats in every profession but there are also some great doctors. Heck, I've even had amazing experiences with pathologists.

A lot of competency is a matter of education. It's basically impossible for a generalist (FP, IM, peds, etc.) to keep up with developments in every specialty. Then again, studies have shown that when major trials come out, there are significant changes in management so it looks like people read at least JAMA or MEJM.

 

[doccomet]

I was referred to this site by my students, and I'm an FM clerkship director and asst residency director, obviously biased to FM. The differences as I see them for IM/Peds vs FM are twofold, and of course you are entitled to your opinion.
1. Even in IM/Peds practices 90% of their time on average is spent in the oputpatient setting, and 10% inpatient, yet their training is largely the inverse, and the subtle differences in management of inpatient problems(DM for example) are markedly different than the issues seen in the outpatient setting. I want a physician trained where they provide care.
2. The care of the family in its entirety, ie knowing the interactions of the family and other illnesses/roles/problems inherent in a family is truly valued by FM physicians and we are trained to provide care in this context to a much larger degree than othger specialties. I know that argument doesn't flywith many docs, but it does for me and for my patients. Its often seen as the "fluff" part of medicine, but I view it as an integral part of patient care.
I want someone who can manage the common things uncommonly well, and can recognize and coordinate my care for the rare things in the context of my family and my life outside of my disease, and for me that's where the strength of FM training lies

 

[MustafaMond]

I was referred to this site by my students, and I'm an FM clerkship director and asst residency director, obviously biased to FM. The differences as I see them for IM/Peds vs FM are twofold, and of course you are entitled to your opinion.
1. Even in IM/Peds practices 90% of their time on average is spent in the oputpatient setting, and 10% inpatient, yet their training is largely the inverse, and the subtle differences in management of inpatient problems(DM for example) are markedly different than the issues seen in the outpatient setting. I want a physician trained where they provide care.
2. The care of the family in its entirety, ie knowing the interactions of the family and other illnesses/roles/problems inherent in a family is truly valued by FM physicians and we are trained to provide care in this context to a much larger degree than othger specialties. I know that argument doesn't flywith many docs, but it does for me and for my patients. Its often seen as the "fluff" part of medicine, but I view it as an integral part of patient care.
I want someone who can manage the common things uncommonly well, and can recognize and coordinate my care for the rare things in the context of my family and my life outside of my disease, and for me that's where the strength of FM training lies

My 2 cents:

1) IM docs are better at handling more medically complex older patients.

2) We are also better at handling the more serious inpatient issues, and ICU care.

3) In general, our knowledge on the above far outweighs FP.

That said, there are great FM docs and ****ty IM docs.

 

[doccomet]

I don't ever see the reason to comparer one vs. the other.
On what basis do you make your comparisons? We don't take the same tests, or report to the same governing bodies, and in many of the recent studies on predictors of chronic illness outcomes IM and FM score equally. We can both be good specialties and good physicians, but look at things differently. I just don't understand the reasoning behind arguing who is better.

 

[jdaasbo]

FP has a bad rap and I really feel that as an FP to be succesful you need to know how to limit your scope of practice safely, or you need to be very very smart . I have met FP's that are wonderful in outpatient settings who are just not comfortable managing inpatients settings. Many of my friends from med school who now are in FP programs don't feel that they are learning inpatient medicine to the same degree as their IM counterparts and don't feel comfortable taking care of sick people in the hospital. Several of them have stated that they dont want to do ANY inpatient medicine when they are done with their training. At my institution, there is no FP residency and the few FP attendings on staff cannot admit to certain parts of the hospital (like the CCU) without having an IM doctor accept the patient as the primary physician.

I have met a handful of amazing FP's who were 100% up to speed with the latest literature and felt confident managing sick patients in the hospital. They all were amazingly intelligent.

I do feel that the culture of FP and IM is totally different. medical students interested in non pediatrics primary care always discuss whether FP or IM is "right for them." As I look at the students in this situation at my present institution, it is pretty clear from the get go which will choose FP and IM. I agree with the previous posting, that FP involves the non-medical l family milleu aspects of patient care more than other specialties. I see this being more meaningful in rural "marcus welby" settings. I think that this model of family medicine is hard to do in larger cities or busy populated suburban areas.

I am also fearful that FP, as more docs choose to limit their practice to outpatient care, may fall victim to NPs and PAs (who work for less, are liked by patients, and in many areas have high levels of autonomy). I am not sure what he role of FP will be in 15 years.

 

[carrigallen]

Interesting discussion.

I was especially surprised at the comparison of FP to med-peds; I do not consider them similiar. It seems to me that med-peds is more of a trendy hospitalist discipline, and is often followed by a fellowship. Could anyone help clarify the difference between medicine, med-peds and peds?

It seems to me that med-peds is better compensation than peds. All three may have a fellowship afterwards. What use is med-peds without a fellowship?

 

[HiddenTruth]

It seems to me that med-peds is better compensation than peds. All three may have a fellowship afterwards. What use is med-peds without a fellowship?

just to add to the question, does med-peds have their "own" fellowships, or would u apply into the regular cardiovascular fellowship as IM's do? It's a bit odd if a med-peds doc is doing the same fellowship as an IM or peds doc cuz obviously you are missing out in one discipline of patient care (adults or pedes respectively). Please advise--thanks.

HT

 

[Mumpu]

The only specilalist I know is a pediatric cardiologist who specializes in adult congenital heart disease. My impression has been that most med-peds go into primary care. But I've been wrong before.

 

[doccomet]

FP has a bad rap and I really feel that as an FP to be succesful you need to know how to limit your scope of practice safely, or you need to be very very smart . I have met FP's that are wonderful in outpatient settings who are just not comfortable managing inpatients settings. Many of my friends from med school who now are in FP programs don't feel that they are learning inpatient medicine to the same degree as their IM counterparts and don't feel comfortable taking care of sick people in the hospital. Several of them have stated that they dont want to do ANY inpatient medicine when they are done with their training. At my institution, there is no FP residency and the few FP attendings on staff cannot admit to certain parts of the hospital (like the CCU) without having an IM doctor accept the patient as the primary physician.

I have met a handful of amazing FP's who were 100% up to speed with the latest literature and felt confident managing sick patients in the hospital. They all were amazingly intelligent.

I do feel that the culture of FP and IM is totally different. medical students interested in non pediatrics primary care always discuss whether FP or IM is "right for them." As I look at the students in this situation at my present institution, it is pretty clear from the get go which will choose FP and IM. I agree with the previous posting, that FP involves the non-medical l family milleu aspects of patient care more than other specialties. I see this being more meaningful in rural "marcus welby" settings. I think that this model of family medicine is hard to do in larger cities or busy populated suburban areas.

I am also fearful that FP, as more docs choose to limit their practice to outpatient care, may fall victim to NPs and PAs (who work for less, are liked by patients, and in many areas have high levels of autonomy). I am not sure what he role of FP will be in 15 years.

As a wise man once said... If you think a NP or PA can take your place then they probably should. The training for these two areas is lacking in many critical features, most importantly the basics of medical science we are all taught in medical school. They know "if a then b", but not why which is critical to recognizing outliers and deviations from patterns. As far as managing inpatients, my experience (and thus not science) in my institution is that our family docs are consistently better in terms of mortality and LOS for similar patients diagnoses, and similar complexities based on scores. Be careful of generalizations.
Marcus Welby wasn't a physician. Look back to the teachings of Osler and his discussions of generalists or family doctors, and you will see their true value.

 

[lowbudget]

http://www.medpeds.org/PDF/FellowshipGuide2004.pdf

 

[Doc Ivy]

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.

So this is why my FP hasn't hasn't bothered to test me for sickle cell trait after I had a costal osteomyelitis from Salmonella surgically debrided (which he totally missed by the way--- he thought I had reflux)... and I'm of African descent!?! Please, that's just negligence, I can see that and I'm just a M2!

 

[doccomet]

So this is why my FP hasn't hasn't bothered to test me for sickle cell trait after I had a costal osteomyelitis from Salmonella surgically debrided (which he totally missed by the way--- he thought I had reflux)... and I'm of African descent!?! Please, that's just negligence, I can see that and I'm just a M2!

Find a new doc, but don't generalize to a specialty! Good luck.

 

[raptor5]

It's funny how everyone wants to bad mouth an FP but no one wants to be an FP. Fix the problem from the inside. So what I say is "Don't talk with it, come with it!"