Duke Family Medicine is Revived

[deleted87716]

Excerpts:

Less than a year after its announced demise, the Duke University Family Medicine Residency Program, like a phoenix, has risen from the ashes. The program, which stopped accepting new applicants in May 2006, will recruit residents for July 2008, according to an announcement by Brian Halstater, M.D., residency program director and assistant professor in the Department of Community and Family Medicine at Duke University School of Medicine, Durham, N.C....

AAFP President Rick Kellerman, M.D., of Wichita, Kan., lauded the move to revive the program. The Duke family medicine residency program, he said, "is important to the country because of Duke's stature. Duke has a long tradition of producing family physicians for the state of North Carolina as well as producing national leaders for family medicine..."

A key to the Duke effort was the Preparing the Personal Physician for Practice, or P4, initiative, said Victoria Kaprielian, M.D., professor and vice chair for education in Duke's community and family medicine department.

"What we were doing was not working for us, and we didn't think we had an option to do anything different," said Kaprielian of the 2006 decision to close the program. "This was a decision we made for ourselves. Then P4 happened."

Complete article here: http://www.aafp.org/online/en/home/...dent-student-focus/20070509dukeresidency.html

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[sophiejane]

So how does that work, in the first years of a residency program? There will be only interns...how do you share the workload? I guess attendings have to step in to cover the wards?

It will be interesting to see what kind interest there is in this program next year after so much bad press. I'm not sure I would want to be in the guinea pig class.

 

[Miami_med]

I guess it all depends on whether or not Duke decides to teach its Family Medicine Residents the medicine part or not.

 

[Jack Daniel]

I guess it all depends on whether or not Duke decides to teach its Family Medicine Residents the medicine part or not.

Three mod posts in a row. I better break this trend quickly.

Anybody break the news to Panda, yet?

 

[deleted87716]

Anybody break the news to Panda, yet?

Panda.

OK, that's two...somebody say it a third time, and he'll appear. 😉

 

[sophiejane]

Panda.

OK, that's two...somebody say it a third time, and he'll appear. 😉

Oh what the hell, it's like a morgue around here. I'm actually starting to miss him...

PANDA!!PAAAAANNNNNNDDDAAAAA!!!! (was that loud enough?)

 

[Apollyon]

One of the most telling things in that article is that Victor Dzau (the Chancellor) allocated money. Duke is like the rich guy that is rich because he's cheap - cheap like KIA and McDonalds and never tips. FM got in a big uproar when the funding for our increase to 8 residents (which Duke had agreed to with ACGME, and, when they reneged, ACGME scheduled a site visit) came at the expense of them going from 6 residents to 4.

 

[8744]

Oh what the hell, it's like a morgue around here. I'm actually starting to miss him...

PANDA!!PAAAAANNNNNNDDDAAAAA!!!! (was that loud enough?)

"P4."

Says it all and I don't care.

 

[sophiejane]

"P4."

Says it all and I don't care.

That's like saying having another child can save a marriage. P4 is not going to breathe new life into a dead program on its own. All the other programs on the P4 list are well established and have great reputations.

 

[deleted87716]

"P4."

Says it all and I don't care.

There's nothing wrong with P4 in and of itself. Variety is the spice of life. A community medicine emphasis, for example, may not be everyone's cup of tea (it certainly wouldn't be mine), but there are people out there who might find it attractive. If P4 helps attract more people to family medicine, I'm all for it.

Whether or not it's enough to enable the Duke program to rise from the grave remains to be seen.

 

[Miami_med]

That's like saying having another child can save a marriage. P4 is not going to breathe new life into a dead program on its own. All the other programs on the P4 list are well established and have great reputations.

I think the idea is that this may be the number one way to get "unwell" established. I am concerned that by putting such an emphasis on the same politically correct ideaology that most of us do our best to run away from in medical school, Family Medicine will receive more smile and nods as even more students run away. I actually have a huge amount of respect for FM, though I don't think that I'm particularly suited to it. You want to put your best foot forward, and having the academic medical centers promote P4 FM may not have the impact on medical students that it is hoped to. Remember that the goal isn't to convince people already going into FM, it's those of us on the outside that have to be won over.

Sorry to hijack

 

[sophiejane]

I think the idea is that this may be the number one way to get "unwell" established. I am concerned that by putting such an emphasis on the same politically correct ideaology that most of us do our best to run away from in medical school, Family Medicine will receive more smile and nods as even more students run away. I actually have a huge amount of respect for FM, though I don't think that I'm particularly suited to it. You want to put your best foot forward, and having the academic medical centers promote P4 FM may not have the impact on medical students that it is hoped to. Remember that the goal isn't to convince people already going into FM, it's those of us on the outside that have to be won over.

Sorry to hijack

I'm having a hard time understanding what you are trying to say. What is the politically correct ideology you are referring to? I wasn't aware of people running away from FM due to ideology--my impression was that it mostly had to do with salary, not wanting to deal with chronic illness, not being able to handle the breadth of scope, and for some, the "prestige" factor.

I think the best way to get medical students interested in FM is to give them outstanding experiences in it as students. We need more and better mentor-teachers at that level. We need to give students ample time to see how different FM practices can be.

 

[deleted87716]

I think the idea is that this may be the number one way to get "unwell" established. I am concerned that by putting such an emphasis on the same politically correct ideaology that most of us do our best to run away from in medical school, Family Medicine will receive more smile and nods as even more students run away.

I'm not sure that you understand P4. It's not about ideology or political correctness. It's about "updating" traditional primary care practice to address the evolving needs of our patients and the country as a whole. Physician satisfaction and patient satisfaction are mutual goals. The current residency initiatives are quite varied, and allow residents fine-tune their training to mesh with the type of practice they want to have when they graduate.

"Family medicine residencies participating in P4 will endeavor to teach future doctors how to build a personal medical home where patients experience seamless, coordinated care. By implementing more progressive curricula that focus on futuristic ways of caring for patients, budding family physicians will learn how to elevate levels of patient care and satisfaction prior to completing residency."

Details here: http://www.transformed.com//P4-participants.cfm

 

[ajce9]

P4 big worthless in my opinion.

Anther year spent in a specialty that already pays the lowest. that sounds real exciting. not.

Usually when you add a year to a program or when you do a fellowship the point is to increase your bottom line and your skills. P4 in family medicine does neither of those.

To me its like lets just hang around another year because I've got nothing better to do with my life.

👎

 

[ajce9]

I'm not sure that you understand P4. It's not about ideology or political correctness. It's about "updating" traditional primary care practice to address the evolving needs of our patients and the country as a whole. Physician satisfaction and patient satisfaction are mutual goals. The current residency initiatives are quite varied, and allow residents fine-tune their training to mesh with the type of practice they want to have when they graduate.

"Family medicine residencies participating in P4 will endeavor to teach future doctors how to build a personal medical home where patients experience seamless, coordinated care. By implementing more progressive curricula that focus on futuristic ways of caring for patients, budding family physicians will learn how to elevate levels of patient care and satisfaction prior to completing residency."

Details here: http://www.transformed.com//P4-participants.cfm

It wasnt long ago when family medicine and most medical school embrased the idea of primary care as the gatekeeper. We were all sold on that idea. We all jumped on the band wagon and it turned out to be a disaster. It failed and now we are stuck in the role of ambiguity.

P4 is just another gimick. Anything to try to jump start FM.

The reason we are doing all of this is because we are trying to increase payment for our services. We are trying to add value to it because others don't see the value in our services.

What we should be doing is increasing the pressure on the people who control the money. Because it is a well known fact that the reason med students are not going into family medicine is because they know it is the lowest paid specialty. It can have the best lifestyle in the world but if lifestyle was the only thing people went into medicine for they could become a PA and have an even better lifestyle. Why torture yourself with medical school and residency.

 

[deleted87716]

To me its like lets just hang around another year because I've got nothing better to do with my life.

An additional training year is an option in only a handful of P4 programs.

It wasnt long ago when family medicine and most medical school embrased the idea of primary care as the gatekeeper.

No, it was HMOs who pushed the gatekeeper thing. Most primary care docs were pretty put off by it, and still are.

The reason we are doing all of this is because we are trying to increase payment for our services.

Reimbursement isn't really part of the P4 initiative; not directly, anyway.

it is a well known fact that the reason med students are not going into family medicine is because they know it is the lowest paid specialty.

Actually, pediatrics is the lowest-paid specialty, and general internal medicine is pretty much neck-and-neck with FM. The problems with student interest are due more to perception than reality, IMO. They need to be addressed, of course, but increasing reimbursement isn't a panacea. I agree with Sophiejane that mentoring and med school exposure to real primary care (not just academic FM departments) needs to be improved.

Why torture yourself with medical school and residency.

Because that's how you become a doctor.

 

[8744]

"Family medicine residencies participating in P4 will endeavor to teach future doctors how to build a personal medical home where patients experience seamless, coordinated care. By implementing more progressive curricula that focus on futuristic ways of caring for patients, budding family physicians will learn how to elevate levels of patient care and satisfaction prior to completing residency"

MOTSGG.

 

[8744]

"More Of The Same Gobbldy-Gook."

 

[8744]

I bet Press Ganey is involved. Nothing more need be said.

And I won't.

Out.

 

[deleted87716]

I bet Press Ganey is involved.

No, I think they're more a threat to those of you working in the hospital. 😉

 

[Miami_med]

I'm having a hard time understanding what you are trying to say. What is the politically correct ideology you are referring to? I wasn't aware of people running away from FM due to ideology--my impression was that it mostly had to do with salary, not wanting to deal with chronic illness, not being able to handle the breadth of scope, and for some, the "prestige" factor.

I think the best way to get medical students interested in FM is to give them outstanding experiences in it as students. We need more and better mentor-teachers at that level. We need to give students ample time to see how different FM practices can be.

You'd be wrong. Salary is part of it. Ideaology is just as much a part of it. Some of us who considered doing family medicine at some point were interested less in the pure primary care and more in the breadth of practice that could be achieved in the specialty. As someone who was blessed with some entrepaneurial talent, there was an appeal to being able to basically tailor a "specialty" in practice that could encompass bits and pieces of other specialties. I never really wanted to be a "primary care doctor" in the traditional sense of having an office and seeing the same patient for 30 years. FM seemed to have the breadth to NOT be the primary care doctor.

As time has gone along, I've realized that FM is trying to move and become a "primary care specialty," as opposed to simply a specialty of breadth. Most of us in medical school are painfully aware that medicine has become a minefield of turf war. FM generally loses, which is why there is a progressive loss of everything from minor surgical priveledges to obstetrics at most hospitals. If FM really wanted to sell itself, it should fight for the right to keep its breadth. As of now, most people that I know who want a good breadth of work in all age ranges with some medical and surgical variety and some control over their lives are heading into EM. Why? Because you see everything up front, and I can't see how they could take all of the variety and the procedures away from you.

All money aside, those of us who tend to be "jack of all trades, master of none" types are generally disenchanted with the current environment. I am not the only one. I am painfully aware that all current priveleges are not set in stone, and I don't want to feel that I have to move to Nome, Alaska in order to be assured that I could do an appy or deliver a baby.

As FM keeps trying to sell itself as a pure primary care specialty, and that is exactly what P4 does, it will lose its appeal to those not already set on primary care. It will eventually lose its rights to do things outside of primary care. Most of us with half a brain know that many FM docs make more than the average, but this often occurs with the expansion of practice rights into territory that feels unsafe in the long term medical environment. It's the docs that try to practice social work instead of medicine that don't make money, and that is exactly the model that is being pushed by P4.

That's what I meant, and I apologize if I offended anyone.

 

[Miami_med]

P.S. Some of us see the "medical home" as the ultimate loss of physician autonomy. The idealogy is part of a "progressive" movement that ends in the logical conclusion of a centralized healthcare system. This is something that I am personally highly opposed to. It turns the original autonomous independent physician into someone who spends his whole life trying to impress his staff in order to get good "peer review" scores.

 

[deleted87716]

Some of us see the "medical home" as the ultimate loss of physician autonomy.

With respect, I think that says more about the person than the concept. Physician and patient autonomy need not be mutually exclusive. Some people view change as a threat, others as an opportunity. I'm in the latter group.

As for the concept of patient satisfaction and ratings, that's happening whether we like it or not. Healthcare is becoming increasingly consumer-oriented, for better or for worse. You can ride the wave, or be swept beneath it.

 

[Miami_med]

With respect, I think that says more about the person than the concept. Physician and patient autonomy need not be mutually exclusive. Some people view change as a threat, others as an opportunity. I'm in the latter group.

As for the concept of patient satisfaction and ratings, that's happening whether we like it or not. Healthcare is becoming increasingly consumer-oriented, for better or for worse. You can ride the wave, or be swept beneath it.

Sure,

Many people probably do like the concept. I'm just not sure that it turns on those that might be convertable. I don't have a problem with mutual autonomy. Nothing that I have read about P4 or heard about the "medical home" leads me to believe that the physician has any autonomy at all. I love consumer directed business, healthcare included. I'm a capitalist, and all true capitalism is consumer driven. However, there is no reason that people can't vote with their feet. In a private business this happens now. If they don't like you, they go somewhere else. Surveys are subjective and even dangerous. This just means that we will have to try and select a patient population that will give good survey data. Better not have any outliers. I have no problem with the medical team in and of itself, though I resent the impending force that will push it onto all of us. I also resent the idea that I have to impress my own staff with survey data. I know that a good staff and a good relationship with them is key to any business. I believe that the natural end result of this isn't a happy staff, but a physician who loses control of his practice. I believe that physician control and staff happiness are not mutually exclusive, and I believe that people can get along as people without making a bunch of survey companies rich. Some disagree.

 

[sophiejane]

You'd be wrong. Salary is part of it. Ideaology is just as much a part of it.

All money aside, those of us who tend to be "jack of all trades, master of none" types are generally disenchanted with the current environment. I am not the only one. I am painfully aware that all current priveleges are not set in stone, and I don't want to feel that I have to move to Nome, Alaska in order to be assured that I could do an appy or deliver a baby.

I have no doubt that this is what you and some of your classmates or others you've met in medical school feel, but please don't speak for all of us. In my class of 126, 22 are doing family medicine. I know most of my class pretty well, and I've never heard anyone grumbling about ideology in FM. Maybe we are blissfully unaware, but even those students among us who have actually read the whole Future of Family Medicine article (myself included), not all are disenchanted.

There are several among those 22 that were planning on doing OB/Gyn, surgery, pathology, EM, etc who switched to FM in 4th year. And I can guarantee you it had nothing to do with statistics. These people were at the top of the class and have great board scores.

I plan on doing obstetrics, and I don't live anywhere close to Nome, Alaska. I know for a fact that there are many jobs in my state for FP with OB, because I've attended the recruiting fairs, and I know recent grads who are doing it successfully. Procedures abound. You just have to get trained to do them and live in an area that needs someone to do them (you aren't going to do a lot of colonoscopies as an FP in Manhattan, for example. You never could. even before the Future of Family Medicine and P4).

I don't know many people training in FM who have any desire to do appendectomies, but if it's really your thing and you feel really cheated by not being able to do them, by all means, get trained at a program that teaches you to do them. I doubt you will find anywhere to work that will allow you to do enough of these to keep your skills current, however. It's been a very, very long time since "appys" were part of the FPs scope of practice.

You may have your pulse on the current feelings about FM in your area, among your classmates, but to assume you speak for medical students in general is a mistake.

 

[Tn Family MD]

I have to say I kind of feel the pain of those folks out there like Miami Med. I am as die hard committed to FM as they come, but it is sickening to me how some people view the specialty of FM and where they feel it is headed. Even some attendings in our residency make me just want to pull my hair out by the roots at how they practice and how they expect the residents to practice. However, we also have some excellent attendings that can teach some pretty cool procedures. One of our community attendings in particular has set up his own Ambulatory Surgery Center in one of the neighboring counties to where our residency is located. He is doing some off-the-hook cool stuff like ultrasound guided facet injections for patients with back pain, EGD's and c-scopes too numerous to count, vasectomy, and the list goes on and on. Another of our community attendings is doing 40-60 c-sections per year. We are allowed to rotate with both of those guys if we so desire. Some of our attendings here at our university hospital are also doing some cool procedures as well, including treadmill stress tests, vasectomies, colposcopy with LEEP, IUD insertion, and c-scopes. There are good FM role models out there. You probably will have to seek them out, though. I feel this is a result of scrambling in too many people into the specialty who never wanted to do FM in the first place. Their heart is just not into it and therefore they end up taking the path of least resistance which is definitely not a procedure rich path for this specialty.

Some of you guys may be interested in checking out the Medicos para la Familia fellowships. They are run by a guy named Dr. William MacMillian Rodney. He is somewhat of a lightning rod in our specialty. He is controversial because he defends fiercely our turf when it comes to expanding our scope of practice and doing procedures. He is an EXCELLENT role model and I plan on doing one of the fellowships, either the one in Nashville, TN or the one in Memphis, TN. He has some interesting articles and letters on his website about the role of the "limited generalist" in FM and how it is damaging to everyone in the specialty who wishes to practice full spectrum FM. You can check out his website at www.psot.com

If you are interested in doing procedure heavy full spectrum FM, you should definitely get to be familiar with this guy and these fellowships. He is getting his fellows training in everything from c-sections (fellows average 80-120 over their two years) to EGD to c-scope to D&C (even office D&C in some cases). Some view him as a maverick but I definitely see myself practicing the type of FM he advocates. I can't imagine practicing FM in any other way.

 

[Miami_med]

I have no doubt that this is what you and some of your classmates or others you've met in medical school feel, but please don't speak for all of us. In my class of 126, 22 are doing family medicine. I know most of my class pretty well, and I've never heard anyone grumbling about ideology in FM. Maybe we are blissfully unaware, but even those students among us who have actually read the whole Future of Family Medicine article (myself included), not all are disenchanted.

I'm not trying to speak for all medical students, and I didn't mean to spark such controversy in this forum. I am speaking from my limited experience and those that I have talked to. This doesn't even apply to all members of my class. FM does a great recruiting job down here, including flying interested parties to national conferences for free. However, I still feel that P4 is a mistake that will backfire in the future. It is a personal opinion, and you are free to disagree.

 

[oldbearprofessor]

P.S. Some of us see the "medical home" as the ultimate loss of physician autonomy. The idealogy is part of a "progressive" movement that ends in the logical conclusion of a centralized healthcare system. This is something that I am personally highly opposed to. It turns the original autonomous independent physician into someone who spends his whole life trying to impress his staff in order to get good "peer review" scores.

http://www.medicalhomeinfo.org/training/index.html

I don't wish to create or be part of a debate here, so I will create a thread in pedi about the "medical home" training. I hope you'll expound more on your concerns about it here or there as I genuinely don't see the reason for this concern. However, as I've never had this training, I may be missing something and would like to understand it.

Thanks

OBP

 

[deleted87716]

I'm reading Miami Med's concerns about healthcare teams and physician autonomy as negative because the doctor isn't the one doing everything.

The fact that some components of patient care are delegated to others in no way limits physician autonomy, IMO. Personally, I'd rather let other people do the things they do well so I can focus on doing the things that I do well.

 

[sophiejane]

All money aside, those of us who tend to be "jack of all trades, master of none" types are generally disenchanted with the current environment.

This was the comment that suggested to me that you were speaking for more than just yourself. In a way, you could consider everyone interested in FM as a "jack (or jane) of all trades"...we all are interested in broad scope primary care--that is at the root of what we want to do. Otherwise we would do peds, IM, etc.

 

[sophiejane]

Personally, I'd rather let other people do the things they do well so I can focus on doing the things that I do well.

Exactly. This is why FPs don't need to be doing abdominal surgery.

 

[ajce9]

With respect, I think that says more about the person than the concept. Physician and patient autonomy need not be mutually exclusive. Some people view change as a threat, others as an opportunity. I'm in the latter group.

As for the concept of patient satisfaction and ratings, that's happening whether we like it or not. Healthcare is becoming increasingly consumer-oriented, for better or for worse. You can ride the wave, or be swept beneath it.

No offense kent but you have mentioned in most of your previous post that you don't like to do many procedures that most Family docs strive to want to do (colonoscopies, egds, cosmetics etc.). Yet in this post you state that you like change and you see opportunity in this type of change for FP.

How can you have opportunity if what you see in your practice as a "primary care medical home" general cases. No matter how complicated those general cases are they are still general.

Family medicine was not meant to be that way.

No offense again, but I think you are an idealist. You see things in the perfect world while the rest see it in the business world. The world where it's cut throat and everyone has to compete.

To give you an answer to the your replies to my last post you are just wrong.

When the HMOs came out with the PCP model the FPs jumped on like it was the best thing since the ball point pen. They sold their practices and found out year later that they had made a huge mistake. This is common knowledge I'm surprized you don't know it.

Medicine is torture to learn but there is suppose to be a payoff at the end.

I stand corrected pediatrics is the lowest paid.

There is not a medical student I have spoken with that has chosen not to go into family medicine that does not site salary as the number one reason for not doing it. The number two reason is that they don't want to put up with the turf was BS.

Internal medicine does make about as much as FP but most who go into Internal medicine want to sub-specialize and those who don't have the same complaints as the FP guys about the current structure of medical payment.

The AAFP themselves have put out a series of articles complaining about the low payments and how it is ruining family medicine.

They just don't dare to go after the other specialties and fight for FPs right to be able to do the procedures they want to do.

 

[ajce9]

Exactly. This is why FPs don't need to be doing abdominal surgery.

It is not what you want to do.

Most FPs I know all want to do procedures. Many would love to have the chance to train and do certain surgical procedures. some don't.

the point is that they should have the opportunity and not be held back because some fps choose to do general medicine.

 

[ajce9]

Personally, I'd rather let other people do the things they do well so I can focus on doing the things that I do well.[/quote]


Exactly, so if an fp can do a procedure well then they should be allowed to do it.

just because you can't do a procedure well does not mean that other FPs can't either, so maybe you should not look at it from just your scope of practice and your skill level.

If you do well at general fp that is great. Keep doing that. If some other FP does well at a more broad practice, then great they should be allowed to keep doing that.

 

[sophiejane]

It is not what you want to do.

Most FPs I know all want to do procedures. Many would love to have the chance to train and do certain surgical procedures. some don't.

the point is that they should have the opportunity and not be held back because some fps choose to do general medicine.

I am speaking very specifically about appendectomies. I never said all procedures should be referred out. I love procedures, and want to be good at doing the ones that I will use fairly regularly and that will be of most benefit to my patients. I think learning appendectomies is a fairly obvious waste of time, since the jobs that will allow you to do these regularly are extremely rare (as in Nome, Alaska rare). One a year is not going to allow you to keep your skills current. If given the choice between a general surgeon that does 2-3 appendectomies a week or an FP who does 2 a year, tell me, which would you choose for your child?

If you want to discuss my personal wishes, well, I'd like to do surgical obstetrics, colonoscopy, and colposcopy. There is an identified need for this service in the geographical areas in which I want to practice. All of these are extremely do-able for the rural FP, and I personally know folks doing all or some of them successfully (one of whom has all but asked me to join his practice in a few years--even more incentive to learn the procedures now).

 

[ajce9]

If you want to discuss my personal wishes, well, I'd like to do surgical obstetrics, colonoscopy, and colposcopy. There is an identified need for this service in the geographical areas in which I want to practice. All of these are extremely do-able for the rural FP, and I personally know folks doing all or some of them successfully (one of whom has all but asked me to join his practice in a few years--even more incentive to learn the procedures now).[/quote]



The procedures you listed can be done in a rural setting but can't be done in an urban or suburban setting.

This is the problem. The last time I checked the patients anatomy did not change 300 miles up the road.

So, if a rural doctor can do those procedures the city doc should be able to them as well.

But there are people out the and some of them are FPs who are trying to reduce or eliminate your choice of doing these procedures.

So, FPs have refused to fight against specialists for what is their right.

We all know that patient outcomes over the last 20 years have been better with FPs than with specialist. Yet, we seem to give in everytime a specialist start to cry about how they should be the only one doing some procedure.

 

[Miami_med]

Exactly. This is why FPs don't need to be doing abdominal surgery.

I have no problem with division of labor, but in going into practice, I would like to determine how that labor is divided up. I won't hide it, I would want to be in charge of ALL ASPECTS of my own practice. I would also like to determine the scope of the practice. P4 seems to push a specific scope of general primary care with specific responsibilites that in my most humble opinion will kill the utter flexibility that used to define FM. I really don't see why an FP couldn't learn to do Appys. The fact that they can't (outside of Nome, Alaska) is evidence of the impact already occuring in the turf wars. I may not want to do rural medicine. Most doctors actually don't. That's why the cities are overfilled with FM grads who are working for peanuts and the rural counties are crying for help. Even if I were willing to go to the country, I'm curious as to why I shouldn't be able to bring the same skill set to the city or country.

I'm not advocating a return to the old days of one guy doing everything, but I don't really understand why I shouldn't be able to tailor my training in a way that produced competency in specific skills. You have to admit that even now, I would be hard pressed to start a practice that included surgical obstetrics and appys within 50 miles of most cities of any real size. This would be true even if I did a million of both in residency. The only reason a person couldn't then stay competent is because they can't get priveledges to do those things. That's my point.

FM is trying to change its image with P4. I've read the articles. I believe that it is a mistake. It only promotes the idea that FM docs are only primary care docs. If they really wanted to sell the specialty, it would go something like this:

Become an FP, tailor your practice to what exactly suits your needs and desires as a physician, and we the leaders of the specialty will tirelessly fight for your right to do it.

That sort of thing might convince a guy like me to give it another serious look, but I'm not holding my breath. I also think that the other med students posting on this very thread about the same things might atleast suggest that there are a few of us out there that are concerned about the shrinking scope of practice of FM and are considering that fact highly in our choice of specialty.

 

[ajce9]

I have no problem with division of labor, but in going into practice, I would like to determine how that labor is divided up. I won't hide it, I would want to be in charge of ALL ASPECTS of my own practice. I would also like to determine the scope of the practice. P4 seems to push a specific scope of general primary care with specific responsibilites that in my most humble opinion will kill the utter flexibility that used to define FM. I really don't see why an FP couldn't learn to do Appys. The fact that they can't (outside of Nome, Alaska) is evidence of the impact already occuring in the turf wars. I may not want to do rural medicine. Most doctors actually don't. That's why the cities are overfilled with FM grads who are working for peanuts and the rural counties are crying for help. Even if I were willing to go to the country, I'm curious as to why I shouldn't be able to bring the same skill set to the city or country.

I'm not advocating a return to the old days of one guy doing everything, but I don't really understand why I shouldn't be able to tailor my training in a way that produced competency in specific skills. You have to admit that even now, I would be hard pressed to start a practice that included surgical obstetrics and appys within 50 miles of most cities of any real size. This would be true even if I did a million of both in residency. The only reason a person couldn't then stay competent is because they can't get priveledges to do those things. That's my point.

FM is trying to change its image with P4. I've read the articles. I believe that it is a mistake. It only promotes the idea that FM docs are only primary care docs. If they really wanted to sell the specialty, it would go something like this:

Become an FP, tailor your practice to what exactly suits your needs and desires as a physician, and we the leaders of the specialty will tirelessly fight for your right to do it.

That sort of thing might convince a guy like me to give it another serious look, but I'm not holding my breath. I also think that the other med students posting on this very thread about the same things might atleast suggest that there are a few of us out there that are concerned about the shrinking scope of practice of FM and are considering that fact highly in our choice of specialty.

I couldn't agree more. As an FP I want to be able to tailor my practice the way I want. I should be able to get the training I want to be able to do that.

The only thing standing in my way is the specialist propaganda and the FPs who don't like to do certain procedures and feel their way of doing Family Medicine is the only way.

I find that to be very Narcisistic.

 

[ajce9]

To get to the original topic of P4 and medical home.

Why do we need another year of residency of teach the "concept" of a medical home?

Are we saying that 3 years is not enough to teach a simple "concept"?

I mean I read the report "future of family medicine" real fast the first time and got the basic idea. After reading a one more time I understood.

To put it in practice do highly educated doctors really need one more year?

 

[deleted87716]

No offense kent but you have mentioned in most of your previous post that you don't like to do many procedures that most Family docs strive to want to do (colonoscopies, egds, cosmetics etc.). Yet in this post you state that you like change and you see opportunity in this type of change for FP.

I'm afraid I'm having some difficulty following you. My earlier comments had nothing to do with procedures, and there's nothing about P4 that should lead you to think that anyone is trying to de-emphasize procedural training in family medicine residency.

How can you have opportunity if what you see in your practice as a "primary care medical home" general cases. No matter how complicated those general cases are they are still general.

Again, I'm not really sure what you're trying to say. Rather than trying to explain to you what is meant by a "medical home," it might be more useful for you to read what's on the P4 web site (linked in an earlier post.)

I think you are an idealist. You see things in the perfect world while the rest see it in the business world. The world where it's cut throat and everyone has to compete.

*Snort.* If you actually knew me, you'd realize how absolutely ridiculous that comment is.

When the HMOs came out with the PCP model the FPs jumped on like it was the best thing since the ball point pen. They sold their practices and found out year later that they had made a huge mistake. This is common knowledge I'm surprized you don't know it.

You're talking about two separate issues, I'm afraid. Any primary care physician who participates with an HMO ends up acting as a "gatekeeper." You don't have to sell your practice. Actually, most of the people I know who sold their practices to large health systems a decade or so ago have retired. It seems like good timing on their part, if you ask me.

 

[ajce9]

I'm afraid I'm having some difficulty following you. My earlier comments had nothing to do with procedures, and there's nothing about P4 that should lead you to think that anyone is trying to de-emphasize procedural training in family medicine residency.



Again, I'm not really sure what you're trying to say. Rather than trying to explain to you what is meant by a "medical home," it might be more useful for you to read what's on the P4 web site (linked in an earlier post.)



*Snort.* If you actually knew me, you'd realize how absolutely ridiculous that comment is.



You're talking about two separate issues, I'm afraid. Any primary care physician who participates with an HMO ends up acting as a "gatekeeper." You don't have to sell your practice. Actually, most of the people I know who sold their practices to large health systems a decade or so ago have retired. It seems like good timing on their part, if you ask me.

It seems you have missed the whole point.

 

[deleted87716]

It seems you have missed the whole point.

Was there one? 😕

You still seem to think that P4 is about extending the length of residency and eliminating procedures. If you're going to argue against something, you really should try to understand it first.

 

[8744]

"Family medicine residencies participating in P4 will endeavor to teach future doctors how to build a personal medical home where patients experience seamless, coordinated care. By implementing more progressive curricula that focus on futuristic ways of caring for patients, budding family physicians will learn how to elevate levels of patient care and satisfaction prior to completing residency"

"Progressive," "Futuristic," "Caring"....words that should make you reach for your revolvers. (Especially "futuristic" which means exactly nothing.)

Geez, folks, how about making family medicine about diagnosing, treating, and managing medical complaints. It's not rocket science. P4 is just another attempt to sex it up.

Other than the trauma and the critical care, you know the difference between me and you? I don't agonize over my purpose in life and I have exactly zero angst over what I'm supposed to do every day. Patient comes in. Patient has complaint. Complaint is explored, worked up, and then patient is treated or admitted for further workup or treatment. I would say that as long as the wait times are not too bad (which is highly variable in our Emergency Department) patient satisfaction is pretty high as long as we stick to this simple formula.

 

[sophiejane]

I would say that as long as the wait times are not too bad (which is highly variable in our Emergency Department) patient satisfaction is pretty high as long as we stick to this simple formula.

Therein lies the real difference. There is no "simple formula" in Family Medicine. It is broad, varied, and unpredictable. Outpatient care doesn't fit a formula.

I don't know, Kent, do you or any other FPs have issues relating to your purpose in life or angst about your career? I've never met an FP who does, come to think of it. Maybe there were a lot of them at Duke?

AAFP is just an organization trying to make the profession it represents better for patients. That's all. I don't think every FP agrees with every word the AAFP says--that's the beauty of this profession, in my opinion. It gets invented and reinvented at the physician level every day, depending on what patients present with and what they need, and what each individual physician brings to the table. And I think that's a good thing.

 

[deleted87716]

Still miss him, Sophiejane? 😉

 

[iatrosB]

Still miss him, Sophiejane? 😉

Yes...it's nice to have life in the forum again.

 

[sophiejane]

Still miss him, Sophiejane? 😉

Uh, no. It's kind of like when you have a garage sale, while it's happening you are hating it so much and vowing never ever to do it again because the $67 you make is nowhere near worth the hours of sweat you put into it....but a few years go by and you forget how wretched it was and then you think, "We should have a garage sale!" And the whole sick cycle plays itself out again...

 

[8744]

Therein lies the real difference. There is no "simple formula" in Family Medicine. It is broad, varied, and unpredictable. Outpatient care doesn't fit a formula.

I don't know, Kent, do you or any other FPs have issues relating to your purpose in life or angst about your career? I've never met an FP who does, come to think of it. Maybe there were a lot of them at Duke?

AAFP is just an organization trying to make the profession it represents better for patients. That's all. I don't think every FP agrees with every word the AAFP says--that's the beauty of this profession, in my opinion. It gets invented and reinvented at the physician level every day, depending on what patients present with and what they need, and what each individual physician brings to the table. And I think that's a good thing.

Whoa there Sophiejane, Family Practice is a specialty in crisis. The AAFP says as much at every opportunity. Maybe it is just the academic side but there appears to be a lot of floundering about looking for a niche, a purpose, something upon which to hang their hats and say, "This is what we do and who we are."

Specialties like surgery, for example, don't have this problem because they know what they do and don't have to reinvent themselves for every patient.

As for family practice being varied, I know this is true and one of the few remaining legitimate selling points for the specialty. But the flexibility should be within the confines of traditional-style doctoring of the kind I describe. Everything else is unworkable and is going to bog you down in trying to be everything to everybody which you cannot do. The simple formula is "One patient at a time."

Family practice, especially the community medicine model and probably P4, suffers from "mission creep."

 

[sophiejane]

I think that's the problem. It's the broadest specialty, and therefore not surprising that it's difficult to come to a consensus on exactly what it is.

I love that, actually. I don't think it's a crisis. It's growth, and that always feels unsteady. Patients are still getting good care, docs are still enjoying what they do. I honestly don't care what anyone calls it or how they define it.

 

[ajce9]

Was there one? 😕

You still seem to think that P4 is about extending the length of residency and eliminating procedures. If you're going to argue against something, you really should try to understand it first.

Actually, I've seen and read the link and understand it well. Yes I know, a medical home where all your needs are met and your care is well coordinated.

that sounds great, I don't have anything against it.

The point you missed is that we don't need an extra 365 days to teach someone this concept that could be taught in the existing 3 years.

The second point is that if you are going to create a 4th year of residency it should be value added. In other words it should be a fellowship that will increase your bottom line when you start practicing as an attending.

I hope that cleared up some of the confusion for you.😀