FM c OB vs OB

[Ariee]

Hi,

I've been having a heck of a time deciding what kind of MD I want to be. It's been a really hard road for me and I'm really looking back and reflecting...

I am an avid advocate of women's and children's health issues. I was repelled by OB/Gyn during my clinical rotation, because these residents were some of the malignant and miserable I'd ever seen. I didn't see myself fitting in this sort of daily lifestyle and being po'd all the time. Also, I didn't enjoy the Gyn surgeries, although the Gyn was fascinating. I'm just not a surgical person, I don't like the OR.

This is what led me to Family with OB as a fellowship. Are there any family with ob docs out there? Could you please let me know what your day is like? Are you happy? Tell me about this field please, I didn't get exposure during medical school. My FM rotation was an IM continuity clinic, I did not get exposure to the Peds, Ob, etc...

Also do you find that OB's don't like you because they feel as if though you're threatening their posistions?

Lastly, $$$, I'm concerned. I'm way in over my head, my husband is going to be an MD as well and we owe a lot of money, also we have to take care of our parents who on both sides are ill. If it's not too crass, could you throw a ball-park of a # out there.

Thank you,
Ariee

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[aparecida]

Hi Ariee,

I'm just a year ahead of you, but I wanted to say that I have the same clinical interests, and chose family medicine for basically the same reasons as you. I thought I was going to be an ob/gyn, but I had no interest in surgery and I was really turned off by their approach to things. I think that if you're not an ob/gyn at heart, you shouldn't be an ob/gyn, you know?

I liked the way women's health worked during my FM rotation much better. I loved having both the parents and the children be patients of the same physician. I felt that the FM people were patient and understanding during well-woman exams and even enjoyed doing that service for their patients, whereas the OB residents treated clinic and Pap smears as nuisances.

During deliveries, I thought the FM approach was saner, more caring, and less pro-intervention; I felt the FPs had a better relationship with their OB patients, and I loved the fact that additional FP residents showed up in case newborn resucitation was needed. (I always felt it was really strange and artificial how OB would be in the delivery room and peds would be in a separate resucitation room, and OB didn't care about the baby as soon as it was delivered, and peds didn't care about the fetus until the moment it was delivered.)

If you go to a program with strong OB, you don't really need to do an OB fellowship. You certainly can, but you may not feel it's necessary, unless you want to do more high-risk stuff. I am considering doing a family planning or women's health fellowship, but only because I matched at a Catholic-affiliated hospital (oops).

Every medical specialty believes they do things the "right" way, so they don't approve of other people doing those things differently. I think OBs and pediatricians both feel this way about FPs: "they don't do it like we do, so they must be doing it wrong."

As for the income issue, people will probably tell you to refer to the large number of existing threads, which have titles like "How much do FPs really make?" and "200K as an FP, is it possible?" They'll also say, "It depends." It depends on the following factors, among other things:
-academics generally has a lower earning potential than private practice (though it has great benefits);
-you will earn substantially more in the Southeast than elsewhere in the country, and often you will earn less in large cities;
-in private practice, being business-savvy and knowing how to code properly will earn you more than if you don't do these things well;
-caring for the underserved / accepting Medicaid will likely lower your income;
-you can potentially boost your income by doing lots of procedures, doing cosmetics, being a hospitalist, having a concierge practice, or supervising midlevels -- the question is how much of that you're willing to do;
-income tends to rise (though not always) with length of time you're in practice.

So, right out of residency, for an academic position in a large city in the Northeast, you might be looking at 100K or even less. For a business-savvy partner in private practice in the Southeast who's willing to put time into tweaking their patient mix, procedures and practices, you could certainly top 200K.

 

[aparecida]

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[aparecida]

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[aparecida]

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[aparecida]

(sorry, my computer sucks and made a bunch of double posts.)

 

[drsarah82]

although i do not know much about this, it is also what I am interested in. I had a hard time when searching for FM ob fellowships. any tips?

 

[aparecida]

http://www.aafp.org/fellowships/obstet.html

Also there are a few women's health, maternal/child health, and reproductive health fellowships among these at http://www.aafp.org/fellowships/other.html .

 

[Ariee]

Aparecida

Excellent! Thank you! It's comforting to know others understand and don't want to jump all over ya. For the first time in my life, I'm really feeling comfortable with myself and my decision...

This forum rocks!

Thanks again!

 

[Leukocyte]

My FM rotation was an IM continuity clinic, I did not get exposure to the Peds, Ob, etc..

And there is a good reason why your FM rotation was basicly an "IM continuity clinic"....because that is what most of your work will be (in residency and as a general FP), so make sure you enjoy adult/geriatric medicine.

As a FM resident who hates FM (oops, sorry ), including Inpatient med and the OP clinic, I like the OB/GYN visits....mainly because they are generaly "easier" visits and the Pts are generaly "healthy". OB in general is "straight forward"...unlike medicine where you often have to deal with "train-wreck" pts with multiple medical problems (including psycho-social disasters ) and manage pts that are on 20+ medication. Compared to that, OB is "a piece of cake", in general.

Now what I hate about OB is that it ties you up. Once our patients turn 37 weeks, we cannot be more than 30 minutes away from the hospital. Case in point....I am currently on vaccation, but I did not travel to visit my brother because I have 2 OBs at 37 weeks...Sure I could have asked a friend to "cover" my deliveries, BUT I would not get credit for them as "continuity deliveries".

 

[lowbudget]

And there is a good reason why your FM rotation was basicly an "IM continuity clinic"....because that is what most of your work will be (in residency and as a general FP), so make sure you enjoy adult/geriatric medicine.

I don't know about all that. My FP mentors (in the real world) told me that for some reason, in FP in particular, your patient panel over time will start to reflect you. You'll start seeing friends of patients, people from your kid's soccer club, families from your church, and patients who share similar interests as you. Young FP's see young families because that's their social circle and older FP's will have patients that "grow old" with them. If you're a young professional mother/father with kids, you will attract young professional families with kids because these people relate to you; unless there's something particularly special about your practice that doesn't mirror the community you work in. Duh, everyone's gonna see adult/geri patients, but it's not as tragic as you make it out to be...

And even if it is, so what? Those tragic people are the people who need you the most...

Now what I hate about OB is that it ties you up. Once our patients turn 37 weeks, we cannot be more than 30 minutes away from the hospital. Case in point....I am currently on vaccation, but I did not travel to visit my brother because I have 2 OBs at 37 weeks...Sure I could have asked a friend to "cover" my deliveries, BUT I would not get credit for them as "continuity deliveries".

Yea, well, that's just FP residency. It's an educational thing to do continuity deliveries. 10's the minimum in 3 years. I don't think that's unreasonable. Sooner you get them done, the sooner you go out and play.

I did my requirement and thought it was a pretty cool experience, even though I most likely won't do OB. These continuity deliveries is how I got to be primary surgeons on their C/S's & BTL's. At my program, we did a good amount, and I did my share of normal/complicated SVD's and assisted plenty of elective/urgent/stat C/S's with different obstetricians.

And without asking, I progressed from retracting-and-watching to here-do-your-half-of-the-surgery.

Saw a whole bunch of pathology for what was supposed to be a "low risk" setting, but actually was as "high risk" as it could be to in the scope of FP residency... taking care of pregnant women who have multiple co-morbidities.

So when my personal patient came up, my attending handed me the knife to be the primary while he assisted. I fumbled through my 1st one, taking 45 minutes to do an entire repeat C/S. The next one I blazed through a repeat C/S in 20 minutes including a BTL. Not bad for a novice.

I'll admit the experience was pretty exhilarating. And I hate the OR. It felt just as good as when you drop in your first intubation and patient recovers. And felt just as good when I ran my first code and patient lived to be discharged. And that during-chest-compressions central line when everyone was watching & waiting so they can deliver the 1st epi.

And just as good as when I delivered a mec-covered baby, controlled mom's hemorrhage, and suctioned, intubated, and resuscitated the baby before Neo & OB attendings got there (with only 1 nurse in the room with me).

When my attending handed me the knife again & again, it was a big deal to me... because it meant "I trust you" and "I believe in you" and so does this patient (and her unborn child). I don't think I would've gained that much confidence in myself if someone else didn't first give it to me.

It's great training.

 

[lowbudget]

Here's my thing, for what it's worth. I don't think FP's need to (or should have to) go through fellowship to do low risk deliveries. To do surgical OB? Definitely. I think that:

Decent, accredited FM residency OB experience - will get you your numbers & you'll graduate. Basically, meet requirement.

Good FM residency OB experience - do the above, expose you to pathology/situations, get you plenty of low risk SVD's and perhaps vacuums, and practice all the skills taught in ALSO. And a few C/S's to get you started (which definitely improves your 1st assist skills).

Excellent FM residency OB experience - do above and get a lot of C/S's.

I don't know too much about OB fellowships, but to my understanding, it'll get you more deliveries & more surgical experience. But if you want to do OB (because of your practice setting) but don't want to do surgical OB, you may be able to still do it if you go to a good FM program.

 

[Ariee]

Hi Lowbudget,

I wanted to thank you for your excellent post. You know what folks, there, medical students now-a-days need to hear things like this. Every field I ask about, the physician always tells me that they're unhappy & wish they'd done something else.

I actually talked myself into Anesthesia a few months ago, went NUMB from boredom during my rotation and decided I'd put to good use all of my medical knowlege. I really can't wait to get started and your post low-budget excites me.

My FM rotation was an IM continuity clinic, that's not an analogy, that's what it was. My preceptor was an IM doctor. My medical school did not set up the rotation, the hospital I was at set it up and sent my schedule to my school and I went along with it, because it was my 2nd rotation and I thought that's what it really was. I was basically managing patients recently d/c'd from the hospital, which I understand will be part of my pt population. However, my point was that I did not get to see Peds and OB while I was doing my FM rotation, which should have been the case in an academic setting (I humbly think).

Malpractice insurance in FM with OB seems to be a little bit of a put-off, but I'm thinking if I really enjoy it, it'll be worth it, especially if I make sure I'm trained well as you suggested, low-budget.

Keep posting!
Ariee

 

[Leukocyte]

medical students now-a-days need to hear things like this. Every field I ask about, the physician always tells me that they're unhappy & wish they'd done something else.

In the name of all that is holy, please DO a Sub-I or two in a "real" FM program before you decide/commit to a specialty. "Hearing" good things about a specialty should not be a major factor in choosing that specialty. Make sure you get as much personal experience as humanly possible in your prospective specialty....so you do not end up like the "physicians who always tell you that they're unhappy & wish they'd done something else" Good Luck

 

[EastWestN2grt]

Ok just to keep this interesting discussion going I would be interested to find out which type of fp residencies leukocyte and lowbudget are doing(did)? More specifically, are the different experiences due to being in an opposed vs unopposed residency? And I guess the follow up question should be rural vs urban? I can imagine an opposed, urban, academic fp residency is probably very limited in the variety of patients one gets to see, compared to an unopposed residency anywhere else. Comments?

 

[Leukocyte]

Ok just to keep this interesting discussion going I would be interested to find out which type of fp residencies leukocyte and lowbudget are doing(did)? More specifically, are the different experiences due to being in an opposed vs unopposed residency? Comments?

Nope, it has nothing to do with the type of residency Lowbudget and me are doing. It is rather more simple really:

- Lowbudget: A smart cockie who did his "homework", researched, and experienced the career feild of Family Medicine BEFORE he appiled/decided to go into FM. He (apparently) made an well informed decision...and that is why he is sooooo happy right now.

- Me: A stubborn "horse" who went into FM by default because he had no idea what field to go into at the end of his 4th med school year. He hated, HATED, Internal Medicine by the way, but still...ignored the warning signs, and marched along into the bowls of FM. As lucky as he is...his FM program is VERY heavy in IM...inpatient IM. Now, it took him 2 years of FM residency to finally acknowledge his mistake of choosing FM. However, since he only has 1 more year left in residency,he will complete it...and move on.

That is all to it, simple.

My Program:

-Unopposed, In a small city.

-VERY heavy on IN-PATIENT adult medicine...starting second and third year. We do it continuously all year round, even when we are on other rotations (we do MAR at least 2 half days when on other rotations).

-Heavy in OB (we do more than the required 10 conts), but weaker in Peds.

-Most of our graduates work as full time hospitalists. Others have a mixed in-patient/out-patient practice.

Good Luck, and do your homework well.

 

[cali-ob]

Ok just to keep this interesting discussion going I would be interested to find out which type of fp residencies leukocyte and lowbudget are doing(did)? More specifically, are the different experiences due to being in an opposed vs unopposed residency? And I guess the follow up question should be rural vs urban? I can imagine an opposed, urban, academic fp residency is probably very limited in the variety of patients one gets to see, compared to an unopposed residency anywhere else. Comments?

I'm in an opposed, urban (county hospital) academic setting. Most of my clinic patients are young women and their children 30 and under. I love it. I do have about 1 older chronic med person per week on average (some weeks it's a schedule full of kids and pap smears!). But on our service we have few kids, and mostly middle aged and older very sick complicated patients. So I think between the two I get a great broad exposure. And our OB patients are all usually complicated

 

[montessori2md]

Could anyone speak to the medmal costs of FPw/OB vs OB vs. FP w/o OB?

 

[secretwave101]

I don't think FP's need to (or should have to) go through fellowship to do low risk deliveries.

So with you on that one.

I've come to be very suspicious of FM fellowships. Not to be too critical, but I tend to think they are no more than a means of getting an extra year of work out of people. FM fellowships aren't even really fellowships. There is no true fellows board, no standard or scope of care, no increased income, no specific billing codes. The whole idea of a fellowship is to make a generalist into a specialist.

The only exception I can think of to this is surgical OB, which still doesn't require a fellowship year unless your specific training program didn't give you experience with it. Otherwise, if you want to do a fellowship...go into IM and become a specialist. This is the point of fellowships.

I know I just offended every FM fellow in the country. But I really do think FM fellowships are nothing more than FM docs trying to look legitimate by copying their IM brethren. Plus the extra year costs a ton of money in lost wages.

 

[montessori2md]

I partially agree about the fellowships, but I also know that for M1 and M2s part of the equation of specialty interest includes the variability in that specialty. W/ IM, for a lot of students it is appealing that you can sub-specialize, even if you go and do straight IM for 5 years, if you get bored, you can at least try for a fellowship.

FM may just be playing at that, to some extent, but it does sell to lowly students who don't realize that the fellowship is not necessarily going to increase revenue.

The fact that FM has sports med favoritism absolutely matters to a certain percentage of folks who want to be team MD for a US olympic team, or what have you, even if it is an unrealistic goal for many of them. Sports med may not help you gain revenue, but it can give your practice a niche you enjoy.

 

[deleted87716]

The purpose of doing a fellowship after a family medicine residency is simply increased competency. It's not a path to specialization. Increased competency does not imply incompetency if one does not complete a fellowship (as pretty much everything offered in the way of FM fellowships is already within our scope of practice), nor does it necessarily lead to increased income (but it can).

Only a few fellowships (sports medicine, geriatrics, adolescent medicine) lead to a Certificate of Added Qualification (CAQ) by the American Board of Family Medicine (ABFM). The rest simply jazz up your C.V.

 

[secretwave101]

To try to clarify my opinion here: I don't disagree that FM docs can specialize. Most do, in one way or another.

I just disagree with the fellowship concept. That's the beauty of FM...you don't need to get special training to follow your interests. Unlike the purpose of a true fellowship - which is to qualify you to practice as a sub-specialist - FM fellowships are expensive resume-padding.

I don't even see the use of the CAQ. Who cares? "Dude, I'm kinda gooder at this stuff than shmo down the road who only says he's better, but doesn't have a cool-font certificate on his wall like me."

You can bias your 3 year residency toward any area that interests you - surgical OB, sports, geriatrics, rural, international, peds, inpatient/hospitalist, outpatient/clinic - whatever you want.

Unless, as Blue Dog points out, you really do need a BOATload of extra experience in a specific area, FP fellowships inflate egos, resumes and training costs (and do NOT inflate income). Nothing more.

 

[mwest]

I am not too impressed my the "Women's Health" fellowship after FP. I enjoy working with women's issues and have wished that there was a women's health fellowship focused on 'primary' /non-OB/non-operative GYN issues that includes family planning, well-women preventative care, osteoporosis, HRT, weight loss, eating disorders, female athletic triad, etc. I have worked in a project that really convinced me that women are not 'little men' and there are so many different situations where a woman reacts differently than a male. eg. Aspirin dose, certain anesthesia. "Women's Health" is so much more than OB. I wish there was a fellowship program after FP were more focused into getting more clinical, networking, and research experience in these issues other than just getting more numbers in high-risk OB.

 

[mwest]

I just disagree with the fellowship concept. That's the beauty of FM...you don't need to get special training to follow your interests. Unlike the purpose of a true fellowship - which is to qualify you to practice as a sub-specialist - FM fellowships are expensive resume-padding.

I don't even see the use of the CAQ. Who cares? "Dude, I'm kinda gooder at this stuff than shmo down the road who only says he's better, but doesn't have a cool-font certificate on his wall like me.".

In my opinion I think it does help in getting jobs in group practices where they may be biased against hiring FPs with diverse fellowship backgrounds ( women's health, PCSM in particular). Also, medicine being such a 'credentials' oriented field, a lot depends on having a certficate hanging on the wall than we would like to think.