May 7, 2017
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Hey everyone,

So I'm liking the family medicine life for personal reasons (decided that I didn't want to be consumed by my job) and was looking to POSSIBLY apply next year to some programs! On to the questions...

1) what are some of the challenges in FM currently?
2) how are the hours in residency and during practice?
3) can you have much autonomy?
4) overall salary if you want to remain in a metropolitan city
5) demands in residency?
6) Step score for lower/higher tier programs? (please include both US and US-IMG)
7) are loan-repayment programs (non-govt sponsored) and signing bonuses a thing when signing contracts to work as a FM doc? (since the demand is super high)
8) my attending would kill me for repeating this but he said to stay away from family med, and I quote him here "you'll be poor, you'll never be able to raise a family and pay off loans working as a FM doc." Seemed a bit extreme but I rationalized N = 1. Is there validity in his fear mongering?

Thanks everyone, I know you all are probably busy, but this insight would help make my decision so much easier.
 

FamilymedMD

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Nov 25, 2009
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1. Challenges include being replaced by midlevels thanks to payers (and some patients) who consider providers a commodity. The amount of work in addition to face to face appointments is high and the pay lower compared to nonprimary care specialties.
2. I'm old and was a resident before the work hour limitations. During practice, it's up to you. You can find part time jobs or you can work your butt off growing a practice or paying off loans.
3. It depends. Not much if you're employed. Total autonomy if you start your own practice. That's unheard of for years now with insurance practice but common in direct primary care.
8. That's a bit of an exaggeration but not that far off compared to the procedural specialties. Hopefully, we're changing that so you can make a reasonable income and still have a life in primary care.
 
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FamilymedMD

10+ Year Member
Nov 25, 2009
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Rockport, ME
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If it was the early 90s again, no way. Family medicine was busy setting itself up for decades of low pay and little respect from the rest of the medical industry.

Now, I'm not sure. The insurance/Medicare party is over and the specialties that benefited in the last twenty years are also the most dependent on insurers, the government or some central payer to maintain some of their previous income. Primary care specialties, on the other hand, can work independently of the system at an affordable price and still make a reasonable income with a better lifestyle.
There always was a lot of good things about primary care but it has been trapped in the lower tiers of a failing system. I'd probably pick it as a contrarian bet.
 
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Jul 10, 2013
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Long post because I'm sort of wordy. From the perspective of a new residency grad, so I'm lacking in work experience but am fresh in regards to having some dealings with the market for a FM physician:

2. My residency followed duty hours fairly reliably, throughout my 3 years I would say I worked a 5-day work week about 2/3 of the time and a 7-day week about 1/3 of the time (weekend demands were heavier in 1st year). When working a 5 day week it was about a 40 hour week half the time (think averaging like 8a-4p M-F) and a 60 hour week half the time (think something like 7a-7p M-F) depending on whether on a lighter rotation month or a more demanding rotation month. When working a 7-day week it was about 60 hours half the time (think 8a-4p M-F plus a call weekend of 7a-7p Sa+Su on Labor & Delivery if an intern or a single 24 hour admission/rounding call shift as a senior resident) and an 80 hour week half the time (think 7a-7p M-F plus a call weekend of 7a-7p Sa+Su or a single 24 hour admission/rounding call shift) depending on whether on a lighter rotation month or more demanding rotation month. Obviously rotations such as ER and such require more sporadic shift hours. Although I certainly had 90 hour work weeks here or there a few times during residency they were far between, for every one of those there were a couple 40 hour weeks somewhere else to balance it out in the long run. But overall I documented my hours accurately and I averaged 55 hour weeks throughout my 3 years. That doesn't account for probably an average of 2-5 hours/week of home clinic charting throughout the 3 years. We also carried a panel of personal continuity OB patients and on average about once a month would get called in for a labor management and delivery of one of our OB patients, however those hours are included in my above total hour estimates. Half the time that would occur when we were working anyway, so would just take us out of our other clinic or rotation duties, and half the time would be at night or on the weekend so we would have to come in extra. Certainly some programs will be tougher for hours, I don't picture many programs being any lighter. However our city also had IM, Peds, Gen Surg, and Psych resident programs, and per word of mouth through the med students we apparently had the reputation of being the hardest worked residents, which surprised me as I found the demands quite reasonable for my preceding expectations. My wife naturally regularly disagreed with my assessment of my work demands being reasonable however.

In practice I'm signed to work 32 hours of clinic patient care per week (8 hours of appointments plus a lunch break 4 days/week, for me it's set up as 11a-8p one day, and 8a-5p the other 3 days). Some places I interviewed offered options of working similar length shifts anywhere from 3, 3.5, 4.5, or 5 days/week as well depending on the physicians preference. I work in a rural town rather than a metropolitan city so have also agreed to work up to an additional 60 hours/month of ER/hospital admission coverage. I will also carry a panel of OB patients which will require coming in for about 15 labor management/deliveries year. I get 5 weeks (20 days) of vacation per year and that increases the more years that I've worked there, though at that point my income will be based on production so the more vacation you take the less income you'll take home.

3. All depends on the specific system you work for and how physician vs administrative focused they are in their management, in general I think you'd find the smaller systems tend to be more physician friendly. Obviously you'd have more autonomy with private practice

4. I signed for a guaranteed salary of $220,000/year 1st two years, then based on production, also if I exceed that salary based on production during the 1st two years I can switch over at any time. All 4 places I interviewed paid based on production, with the initial guaranteed salary the 1st couple years until you reached that point varying slightly between $200-220,000/year. Plus I get approx. $100-110 per hour wage for ER call. My partners average $365,000/year pre-tax income, but when you take out their ER call time that figure generally comes down to about $280,000/year. You will make less though in a metropolitan city though with less broad-scope practice and no OB, so for 4 days/week of clinic hours I'd guess you'll probably need to take about $70-90,000 off of that $280,000, maybe less further if you want to live in a heavily populated coastal area where everyone wants to live and you therefore aren't in such demand.

5. I think I touched on this a bit in question #2 above. We did 39 four-week rotation blocks throughout the 3 years. Six blocks on the inpatient (day) medical service (6a-5p, one late day per week until 9p). Three blocks of night float (7p-7a). Three blocks of Labor & Delivery (7a-7p). One of ICU (7a-7p). Two of inpatient Peds, another of outpatient Peds. Two of ER. One of rural rotation as an upper-level resident (including doing clinic as well as covering ER on your own with a backup attending available if needed). And a smattering of other various rotations, generally exposing you to the specialists and what you need to know about the various specialties in order to practice primary care. Five blocks of electives. We worked about 20 weekends/year 1st year and 15 weekends/year 2nd/3rd year of weekend call on top of our M-F rotations. We carried our own personal panel of patients in continuity clinic, and generally spent 2 half-days/week there 1st year, 3 half-days/week as a 2nd year, and 4 half-days/week 3rd year. Continuity with your patients is stressed in family medicine, you're expected to take ownership in regards to the care and coordination of your patients care, therefore we were responsible for things like following up on their lab/imaging results from clinic and calling them as needed or flagging their nurse to call them. If one of our personal continuity clinic patients was admitted to the service, we were expected to start our day 30 min to an hour earlier and round on them instead of expecting the inpatient service residents do it, though that didn't happen especially often since as residents we don't carry as large of a panel as the attendings do. We carried a panel of OB patients (usually about 5-8 patients at any given time) and for continuity we would be expected to come in for labor management and delivery if we weren't out of town and signed out when they delivered. We each carried a panel of 1-4 nursing home patients at any given time for which we would have to find time to round on every 60 days, and for continuity we would handle all their faxes as needed for lab results or changes in status. Some residency programs that are more urban or in an academic hospital may not have such emphasis on continuity as my small Midwest city did and might not have as high of continuity expectations.

6. For most U.S. MD grads getting into the Family Medicine program of their choice is easy. A US MD grad could fail step boards multiple times and then pass with below average scores and still get in to a family medicine program as long as you're willing to apply to dozens and not picky about location, though not a top one. I can't speak to the experiences of IMG applicants, but I imagine if you go to one of the IMG medical schools with a relatively better reputation and are an otherwise well-rounded applicant without red flags you just need to pass your boards first attempt and would usually end up ok. You'll get more per application by applying to the programs with other current residents that are former IMGs, which will probably limits you to about 1/3 of programs, though if you are a very above average IMG applicant you probably have opportunity in the majority of FM programs. Per my experience of the culture in 1 program, I think board scores mean very little in FM and the impressions taken throughout the interview process mean worlds more. At least for our program the ranking process, which heavily included both residents and faculty alike, once you got an interview was based almost entirely on the conversations that were had and the impressions of those you interacted with. Mostly we looked for those that stood out positively for being interested in the program, engaged, reliable, personable, and generally would just make for a good personality fit in that we would enjoy being around them.

7. I personally received a contract signing bonus of $125,000, plus $1,000 stipend/month for every month up until my start date. I have to stay 5 years or else you pay this back prorated (e.g. leave after 1 year and payback $100,00, after 2 years $75,000, etc).

8. Totally depends on how much you need to make. I had an ENT in medical school give me the same line and show me a chart on how much the various specialties make on a national average, and how many other specialties were double the income of FM or some highly specialized physicians triple. However it's all about perspective. I grew up in poverty and my wife with parents in the working class, so $200-300 some thousand per year seems like more than enough to meet our dreams. If you would have asked my guess on my 1st day of medical school how much a family physician makes I would have said about $100,000/year, or even after a year or two of medical school after reading about national averages a little I would have still said about $125,000/year. So for me compensation in the $300 thousand range seems like a steal for the opportunity to do the type of work that I love and have a fairly decent work-life balance of about 50-hour weeks. I suppose though for some with student loans of $400,000 or who want a house in high cost-of-living region worth $800,000 or something, it would be unreasonable to expect to make it on an income of $200,000/year, but I wouldn't think those circumstances apply to most.
 
OP
Nucleus Accumbens
May 7, 2017
230
181
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Long post because I'm sort of wordy. From the perspective of a new residency grad, so I'm lacking in work experience but am fresh in regards to having some dealings with the market for a FM physician:

2. My residency followed duty hours fairly reliably, throughout my 3 years I would say I worked a 5-day work week about 2/3 of the time and a 7-day week about 1/3 of the time (weekend demands were heavier in 1st year). When working a 5 day week it was about a 40 hour week half the time (think averaging like 8a-4p M-F) and a 60 hour week half the time (think something like 7a-7p M-F) depending on whether on a lighter rotation month or a more demanding rotation month. When working a 7-day week it was about 60 hours half the time (think 8a-4p M-F plus a call weekend of 7a-7p Sa+Su on Labor & Delivery if an intern or a single 24 hour admission/rounding call shift as a senior resident) and an 80 hour week half the time (think 7a-7p M-F plus a call weekend of 7a-7p Sa+Su or a single 24 hour admission/rounding call shift) depending on whether on a lighter rotation month or more demanding rotation month. Obviously rotations such as ER and such require more sporadic shift hours. Although I certainly had 90 hour work weeks here or there a few times during residency they were far between, for every one of those there were a couple 40 hour weeks somewhere else to balance it out in the long run. But overall I documented my hours accurately and I averaged 55 hour weeks throughout my 3 years. That doesn't account for probably an average of 2-5 hours/week of home clinic charting throughout the 3 years. We also carried a panel of personal continuity OB patients and on average about once a month would get called in for a labor management and delivery of one of our OB patients, however those hours are included in my above total hour estimates. Half the time that would occur when we were working anyway, so would just take us out of our other clinic or rotation duties, and half the time would be at night or on the weekend so we would have to come in extra. Certainly some programs will be tougher for hours, I don't picture many programs being any lighter. However our city also had IM, Peds, Gen Surg, and Psych resident programs, and per word of mouth through the med students we apparently had the reputation of being the hardest worked residents, which surprised me as I found the demands quite reasonable for my preceding expectations. My wife naturally regularly disagreed with my assessment of my work demands being reasonable however.

In practice I'm signed to work 32 hours of clinic patient care per week (8 hours of appointments plus a lunch break 4 days/week, for me it's set up as 11a-8p one day, and 8a-5p the other 3 days). Some places I interviewed offered options of working similar length shifts anywhere from 3, 3.5, 4.5, or 5 days/week as well depending on the physicians preference. I work in a rural town rather than a metropolitan city so have also agreed to work up to an additional 60 hours/month of ER/hospital admission coverage. I will also carry a panel of OB patients which will require coming in for about 15 labor management/deliveries year. I get 5 weeks (20 days) of vacation per year and that increases the more years that I've worked there, though at that point my income will be based on production so the more vacation you take the less income you'll take home.

3. All depends on the specific system you work for and how physician vs administrative focused they are in their management, in general I think you'd find the smaller systems tend to be more physician friendly. Obviously you'd have more autonomy with private practice

4. I signed for a guaranteed salary of $220,000/year 1st two years, then based on production, also if I exceed that salary based on production during the 1st two years I can switch over at any time. All 4 places I interviewed paid based on production, with the initial guaranteed salary the 1st couple years until you reached that point varying slightly between $200-220,000/year. Plus I get approx. $100-110 per hour wage for ER call. My partners average $365,000/year pre-tax income, but when you take out their ER call time that figure generally comes down to about $280,000/year. You will make less though in a metropolitan city though with less broad-scope practice and no OB, so for 4 days/week of clinic hours I'd guess you'll probably need to take about $70-90,000 off of that $280,000, maybe less further if you want to live in a heavily populated coastal area where everyone wants to live and you therefore aren't in such demand.

5. I think I touched on this a bit in question #2 above. We did 39 four-week rotation blocks throughout the 3 years. Six blocks on the inpatient (day) medical service (6a-5p, one late day per week until 9p). Three blocks of night float (7p-7a). Three blocks of Labor & Delivery (7a-7p). One of ICU (7a-7p). Two of inpatient Peds, another of outpatient Peds. Two of ER. One of rural rotation as an upper-level resident (including doing clinic as well as covering ER on your own with a backup attending available if needed). And a smattering of other various rotations, generally exposing you to the specialists and what you need to know about the various specialties in order to practice primary care. Five blocks of electives. We worked about 20 weekends/year 1st year and 15 weekends/year 2nd/3rd year of weekend call on top of our M-F rotations. We carried our own personal panel of patients in continuity clinic, and generally spent 2 half-days/week there 1st year, 3 half-days/week as a 2nd year, and 4 half-days/week 3rd year. Continuity with your patients is stressed in family medicine, you're expected to take ownership in regards to the care and coordination of your patients care, therefore we were responsible for things like following up on their lab/imaging results from clinic and calling them as needed or flagging their nurse to call them. If one of our personal continuity clinic patients was admitted to the service, we were expected to start our day 30 min to an hour earlier and round on them instead of expecting the inpatient service residents do it, though that didn't happen especially often since as residents we don't carry as large of a panel as the attendings do. We carried a panel of OB patients (usually about 5-8 patients at any given time) and for continuity we would be expected to come in for labor management and delivery if we weren't out of town and signed out when they delivered. We each carried a panel of 1-4 nursing home patients at any given time for which we would have to find time to round on every 60 days, and for continuity we would handle all their faxes as needed for lab results or changes in status. Some residency programs that are more urban or in an academic hospital may not have such emphasis on continuity as my small Midwest city did and might not have as high of continuity expectations.

6. For most U.S. MD grads getting into the Family Medicine program of their choice is easy. A US MD grad could fail step boards multiple times and then pass with below average scores and still get in to a family medicine program as long as you're willing to apply to dozens and not picky about location, though not a top one. I can't speak to the experiences of IMG applicants, but I imagine if you go to one of the IMG medical schools with a relatively better reputation and are an otherwise well-rounded applicant without red flags you just need to pass your boards first attempt and would usually end up ok. You'll get more per application by applying to the programs with other current residents that are former IMGs, which will probably limits you to about 1/3 of programs, though if you are a very above average IMG applicant you probably have opportunity in the majority of FM programs. Per my experience of the culture in 1 program, I think board scores mean very little in FM and the impressions taken throughout the interview process mean worlds more. At least for our program the ranking process, which heavily included both residents and faculty alike, once you got an interview was based almost entirely on the conversations that were had and the impressions of those you interacted with. Mostly we looked for those that stood out positively for being interested in the program, engaged, reliable, personable, and generally would just make for a good personality fit in that we would enjoy being around them.

7. I personally received a contract signing bonus of $125,000, plus $1,000 stipend/month for every month up until my start date. I have to stay 5 years or else you pay this back prorated (e.g. leave after 1 year and payback $100,00, after 2 years $75,000, etc).

8. Totally depends on how much you need to make. I had an ENT in medical school give me the same line and show me a chart on how much the various specialties make on a national average, and how many other specialties were double the income of FM or some highly specialized physicians triple. However it's all about perspective. I grew up in poverty and my wife with parents in the working class, so $200-300 some thousand per year seems like more than enough to meet our dreams. If you would have asked my guess on my 1st day of medical school how much a family physician makes I would have said about $100,000/year, or even after a year or two of medical school after reading about national averages a little I would have still said about $125,000/year. So for me compensation in the $300 thousand range seems like a steal for the opportunity to do the type of work that I love and have a fairly decent work-life balance of about 50-hour weeks. I suppose though for some with student loans of $400,000 or who want a house in high cost-of-living region worth $800,000 or something, it would be unreasonable to expect to make it on an income of $200,000/year, but I wouldn't think those circumstances apply to most.

Wow, that was so insightful! Thank you so much! :)

My wife really wants to do FM (I'm on the border between that and anesthesia). Like I said, my work-life balance is so much more important to me now since I'm in my late-20's and have gained a better perspective on life and what is the most important to me, which is comfort. That's why I was weary when my attending said, "I'd be poor." My wife goes to a Big3 caribbean school (very well known school) and attained a 210 on Step 1. She's nervous bc she had to repeat a semester in her basic sciences and she had a 1 year gap to study for her step. However, her attending's love her personality and one even said she was the most empathetic and caring intern she has ever had. She works very hard, but standardized exams are not her thing. She doesn't have an SDN account, but she's applying in the 2020 match (when the AOA/ACGME merger is happening), so she doesn't know if she should just cut her losses at this point... Esp, bc we eventually want to get pregnant and she's thinking its going to be a tough one for us to manage that even in FM residencies. Whats your take?
 

VA Hopeful Dr

Senior Member
15+ Year Member
Jul 28, 2004
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26,775
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Hey everyone,

So I'm liking the family medicine life for personal reasons (decided that I didn't want to be consumed by my job) and was looking to POSSIBLY apply next year to some programs! On to the questions...

1) what are some of the challenges in FM currently?
2) how are the hours in residency and during practice?
3) can you have much autonomy?
4) overall salary if you want to remain in a metropolitan city
5) demands in residency?
6) Step score for lower/higher tier programs? (please include both US and US-IMG)
7) are loan-repayment programs (non-govt sponsored) and signing bonuses a thing when signing contracts to work as a FM doc? (since the demand is super high)
8) my attending would kill me for repeating this but he said to stay away from family med, and I quote him here "you'll be poor, you'll never be able to raise a family and pay off loans working as a FM doc." Seemed a bit extreme but I rationalized N = 1. Is there validity in his fear mongering?

Thanks everyone, I know you all are probably busy, but this insight would help make my decision so much easier.
1. Increasing bureaucratic burden
2. Resident varies: inpatient blocks usually 80 hour weeks, outpatient around 40-50 depending
3. Yes, easily. There are employers that leave you alone so long as you produce decently and your patients don't complain much. You can also go into PP.
4. Depends on what you mean by metropolitan. NYC/SF likely 150k. Charlotte, Seattle, Denver type places are closer to the median 200s.
5. Huh?
6. No clue, ask the programs you're interested in.
7. Yes and yes
8. That's nonsense. Its not very hard to break 200k as a family med doc, and 300k is quite doable. Heck, Kaiser pays well and is offering like 100k signing bonus/loan repayment. Granted its amortized over 10 years, but paying off 33% of your loans (if you have 300k in loans) the day you start work is a pretty sweet deal.
 
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