FM Critical Care Fellowships?

[deleted19731]

So, I heard a rumor a few months ago that there was a possibility of critical care fellowships opening up for FM...

Has anybody heard anything about this? It would make sense IM, Peds, and EM can all be boarded that FM could also...

PS. I'm not really sure that I'd even be interested in this fellowship but I'm curious and my search didn't bring up much so I figured I'd ask the big dogs in here if they knew anything about it.

Oh, and I matched my #1 FM spot at one of the larger DO FM programs so YAY!!!

---

Members don't see this ad.

 

[JaggerPlate]

I've never understood why FM didn't pump up the number of fellowships available to grads. If there was a dermatology fellowship (don't tell derm I said this ... they've done an amazing job keeping their services in HIGH demand by keeping the number of newly minted derms each year quite small), for example, available to FM trained docs, I think you'd get a ton of people going into FM with the hopes of obtaining one of these. Granted, this essentially means more FMs would specialize further, but I have to think that they would still practice quite a bit of primary care (it's not like it would be the same as in internist completing a cards fellowship) and, as bad as it may sound, not everyone is going to get it and it'll create more FM trained docs in general. Seems like it would be a good way to pump student interest in FM.

 

[bronx43]

I've never understood why FM didn't pump up the number of fellowships available to grads. If there was a dermatology fellowship (don't tell derm I said this ... they've done an amazing job keeping their services in HIGH demand by keeping the number of newly minted derms each year quite small), for example, available to FM trained docs, I think you'd get a ton of people going into FM with the hopes of obtaining one of these. Granted, this essentially means more FMs would specialize further, but I have to think that they would still practice quite a bit of primary care (it's not like it would be the same as in internist completing a cards fellowship) and, as bad as it may sound, not everyone is going to get it and it'll create more FM trained docs in general. Seems like it would be a good way to pump student interest in FM.

There's no reason for FM to have a derm fellowship, because it simply adds no value. A family physician can already handle routine derm problems after residency. The reason why dermatologists make the amount of money they do is volume. They receive all the somewhat complicated cases and/or simply run-off patients from FPs that don't want to deal with derm problems. No FP is going to refer to another FP for any reason, let alone something most can handle themselves.
The way you make FM more attractive is by revamping the whole system of reimbursement - not by creating more subspecialization within the field.

 

[hawkeye pierce]

General interal medicine doctors refer to rheumatologists, cardiologists, oncologists, etc. Why wouldn't familiy medicine guys refer to other family medicine guys who are specialized?

 

[deleted87716]

In most cases, the only practical way to develop a referral-based practice is to affiliate with specialists and/or stop doing primary care (which is what our sports medicine fellows did). You have to identify and market yourself as a specialist.

 

[JaggerPlate]

There's no reason for FM to have a derm fellowship, because it simply adds no value. A family physician can already handle routine derm problems after residency. The reason why dermatologists make the amount of money they do is volume. They receive all the somewhat complicated cases and/or simply run-off patients from FPs that don't want to deal with derm problems. No FP is going to refer to another FP for any reason, let alone something most can handle themselves.
The way you make FM more attractive is by revamping the whole system of reimbursement - not by creating more subspecialization within the field.

Eh, I definitely agree with revamping the reimbursement system (definitely the obvious answer), but I fail to see how completing a fellowship in derm (for example) wouldn't help a. the advertising/referral base to get the volume and b. the ability to handle the complicated cases (as you've now had fellowship training in something that, according to you, one gets basic training in during residency).

 

[deleted87716]

If there are board-certified dermatologists in your area, I'd be concerned that referring a complicated derm patient to another FP instead of a specialist could fall short of the standard of care in the event of an untoward outcome.

 

[bronx43]

Eh, I definitely agree with revamping the reimbursement system (definitely the obvious answer), but I fail to see how completing a fellowship in derm (for example) wouldn't help a. the advertising/referral base to get the volume and b. the ability to handle the complicated cases (as you've now had fellowship training in something that, according to you, one gets basic training in during residency).

I mean, what would be the point of it when you have a board certified dermatologist to refer to? At the very most, FPs with derm fellowships (how long would that even be?) would split the market share for derm patients, which wouldn't exactly end in riches for either party. But this whole model of subspecialization within generalization begs the question of who is left to practice general medicine and refer? If all FPs did fellowships and aimed to receive referrals, where would those referrals come from?

 

[MossPoh]

I think family med for something like critical care goes against the whole idea of family medicine. Most family med people I know like the outpatient, wide variety, kind of deal. The ones that don't seem to wander to rural EDs somewhere.

With things that could be outpatient, I thought one of the perks of family medicine was the ability to cater your practice a little more towards what you like and still have a nice mix going on at the same time? In most of the country, dermatologists aren't exactly hurting for business with their huge wait times and people feeling frustrated with maybe seeing them for 5 minutes, freezing something off, giving a cream and walking out. (I know they do much more, but that is a repeating theme from my non-medical friends)

I'm sure if you are in a multi-partner practice then you can leverage yourself to be more of the "derm guy/gal" that the others direct patients with those concerns too. If you didn't know, then you get to punt it on.

 

[JaggerPlate]

I mean, what would be the point of it when you have a board certified dermatologist to refer to? At the very most, FPs with derm fellowships (how long would that even be?) would split the market share for derm patients, which wouldn't exactly end in riches for either party. But this whole model of subspecialization within generalization begs the question of who is left to practice general medicine and refer? If all FPs did fellowships and aimed to receive referrals, where would those referrals come from?

1. In many instances, there is not a BC derm to refer to - they are in extremely short supply due to the fact that number of residency programs are small and not expanding, so it would be helpful in this scenario (though it's far from my point).

2. I have no idea how long the derm fellowship would be ... this is a completely hypothetical, off-the-cuff scenario that I used as (what I assumed would be) a quick example; I have no plans of starting one of these programs, nor have I outlined the requirements.

3. Because of the small supply of derms and the large number of derm patients, saturation would be far from an issue. I'm 100% positive that you could put 5 dermatologists and 1 FP in the same general area and each one of these 5 derms would bill more at the end of the day. Most dermatology offices see huge numbers of patients per day and still have extensive appointment wait times.

4. The idea is to get more interest/applicants into FM because of the potential of fellowships. Maybe you get 100 more applicants into FM spots in a state where they need FPs because of the allure of fellowship options (it's a common IM argument); all 100 initially want to do a derm fellowship; 10 change their mind during intern year, 10 more during PGY 2/3, and only 30 get fellowships. Well, love it, hate it, etc you now have 50 more FM guys in that state who, for all intents and purposes, will practice FM where it's needed. Additionally, you still have the potential for derm fellowship trained FPs to practice FM as well as derm, whereas a straight up derm wouldn't consider throwing in FM on the side (frankly, I'd rather have a DO/MD dividing their time between FM and derm as an options for patients compared to a DNP or something like that).

Again, I really want to be clear that I was essentially just throwing out some random comments/thoughts in the beginning here ... I really had no idea I'd have to explain or expand upon this thought, so it's definitely not bullet proof, but hopefully that explained a little? I dunno??

 

[deleted87716]

Family medicine is a generalist field. It makes no sense to try to make it appealing to those who wish to specialize.

 

[JaggerPlate]

Family medicine is a generalist field. It makes no sense to try to make it appealing to those who wish to specialize.

Devil's advocate here:

Even if the result is more primary care providers (more lifeblood into the field, more competitive numbers from students, fill a gap in primary care WITHOUT the need for aggressive midlevels, etc)?

Also, how is this any different than IM (a generalist field - as you put it) where many individuals go through an IM residency only to practice Cards, GI, Endo, etc???

Additionally, please, please keep in mind that this was just an off the cuff comment I made. Hahaha, I have no intention of reforming FM or even supporting this idea, I've just always wondered why there weren't more fellowship options after FM.

 

[VA Hopeful Dr]

Devil's advocate here:

Even if the result is more primary care providers (more lifeblood into the field, more competitive numbers from students, fill a gap in primary care WITHOUT the need for aggressive midlevels, etc)?

Also, how is this any different than IM (a generalist field - as you put it) where many individuals go through an IM residency only to practice Cards, GI, Endo, etc???

Additionally, please, please keep in mind that this was just an off the cuff comment I made. Hahaha, I have no intention of reforming FM or even supporting this idea, I've just always wondered why there weren't more fellowship options after FM.

If you get more students into FM because they want to specialize, you're not actually increasing the number of PCPs out there.

 

[deleted87716]

Even if the result is more primary care providers (more lifeblood into the field, more competitive numbers from students, fill a gap in primary care WITHOUT the need for aggressive midlevels, etc)?

An FP who specialized instead of doing primary care wouldn't be filling the gap in primary care.

Also, how is this any different than IM (a generalist field - as you put it) where many individuals go through an IM residency only to practice Cards, GI, Endo, etc???

It wouldn't be any different. That's the problem. Very few people who go into internal medicine remain generalists.

 

[deleted19731]

I'm definitely opposed to FM specializing... I was asking from more of a "putting a few more tools in my tool box" perspective. Oh and the board was looking a little sluggish and I like to stir the pot occasionally.

I really don't get the fascination with derm from some of the powers that be in the FM world. I noticed that "primary care derm fellowship" in Texas the other day. Seems like a waste of two years of your life to me. Besides the cash aspect, I don't understand why derm is so cool. I'd rather eat glass than play differenial diagnosis of inflammatory skin lesions 90+ x's per day.

What I'd really like to see is a few more fellowships that are strictly procedural and minor surgery based for guy's like me who are gonna be headed out to the boonies. That would help FM get back to its "general practitioner/surgeon" roots and maybe stop hospital admin and insurance companies from avoiding us like we're a panhandler with leprosy when we mention doing something that involves a knife in the hospital.

 

[MossPoh]

If you get more students into FM because they want to specialize, you're not actually increasing the number of PCPs out there.

Just wanted to say that Dr. Who rocks.

Anyway, I think there is a much greater difference between even internal medicine and family medicine than many people think. Many of us tend to consider them the same out of the primary care is primary care is primary care type philosphy, but their origins are different. I'm sure you could put someone interested in one into the other and not have much conflict, but family medicine is the epitome of generalization. Ok, you choose not to do OB. That still leaves you with a lot of stuff left to cover.

Internal medicine residencies have a much more focused curriculum. There is much less exposure to surgical fields, peds, OB, etc. There tends to be more focus on those internal medicine subspecialities.

If you are looking at adults only for bread and butter then yea, not much difference. I get the feeling that many people going into internal medicine have a greater fondness for inpatient stuff as well. Whether that is true, I have no clue. Personally, I rather have a good family doc that my spouse, kids and I can go to and know that the vast majority of our needs will be taken care. I'd rather leave the critical care to the person who thrives on shift work in the hospital.

 

[michaelrack]

If all FPs did fellowships and aimed to receive referrals, where would those referrals come from?

nurse practitioners

 

[bronx43]

nurse practitioners

I'm pretty sure Jaggerplate would fight that to the death, haha.

 

[CandidateofDerm]

I've never understood why FM didn't pump up the number of fellowships available to grads. If there was a dermatology fellowship (don't tell derm I said this ... they've done an amazing job keeping their services in HIGH demand by keeping the number of newly minted derms each year quite small), for example, available to FM trained docs, I think you'd get a ton of people going into FM with the hopes of obtaining one of these. Granted, this essentially means more FMs would specialize further, but I have to think that they would still practice quite a bit of primary care (it's not like it would be the same as in internist completing a cards fellowship) and, as bad as it may sound, not everyone is going to get it and it'll create more FM trained docs in general. Seems like it would be a good way to pump student interest in FM.

This idea smacks of desperation for someone who must not be able to get intzo dermatology and it eats them up! Why not have gi fellowships, cards fellowships, etc. coming out of fm? I guess yiu can step on everyones toes and jusy steal whatever specialty is the flavor of the five years. Neurology fellowship anyone? Why not! But you have to realize with this plan that you are basically going to be setting yourself up as a midlevel provider. I just have to ask, Are you going to make your own board certification like the the dnps are doing? Would you try to claim equivalence with dermatologists who study medicine, dermpath, mohs, hospital consults, etc for four years as their sole domain? My grandfather was an fp who could do everything. This thread would make him want to throw up! Don't let derm flunkies who went into fp rule your specialty and turn it into a back up plan for dermatology. This would rot your specialty from the inside out if actually did manage to capture people who were only going into fp for derm fellowships, but could not get them bc of competiteness.

And just to correct the misconception, dermatology spots are up something like 37 percent over the last 7 years and are continuing to go up.

 

[bronx43]

This idea smacks of desperation for someone who must not be able to get intzo dermatology and it eats them up! Why not have gi fellowships, cards fellowships, etc. coming out of fm? I guess yiu can step on everyones toes and jusy steal whatever specialty is the flavor of the five years. Neurology fellowship anyone? Why not! But you have to realize with this plan that you are basically going to be setting yourself up as a midlevel provider. I just have to ask, Are you going to make your own board certification like the the dnps are doing? Would you try to claim equivalence with dermatologists who study medicine, dermpath, mohs, hospital consults, etc for four years as their sole domain? My grandfather was an fp who could do everything. This thread would make him want to throw up! Don't let derm flunkies who went into fp rule your specialty and turn it into a back up plan for dermatology. This would rot your specialty from the inside out if actually did manage to capture people who were only going into fp for derm fellowships, but could not get them bc of competiteness.

And just to correct the misconception, dermatology spots are up something like 37 percent over the last 7 years and are continuing to go up.

Jesus, don't get your panties in a bunch. I assure you Jaggerplate has no intentions of calling for a mass encroachment on dermatology as a means of desperation. You and all the pimples you can see are safe, in all likelihood. He was simply asking a question of why primary care doesn't provide fellowships in much the same way internal medicine provides fellowships. And honestly, after much thought, that isn't a bad question to ask. There's no reason internal medicine should have the claim of being the sole portal to subspecialization, while FM remain a "general practice" field. The biggest distinction between IM and FM is one being outpatient in nature and the other inpatient. What happens after the "generalized" training in residency is up to the two fields, themselves. You can easily have a system where FM trains "outpatient" gastroenterologists, who can do scopes in an ambulatory setting. And for cases where hospitalization is required, the IM-trained "inpatient" GI physician can take over.
It all comes down to the fact that physicians in general are either adherent to some kind of ideal and are unwilling to sacrifice that ideal in order to play the game the system set up, are limited by artificially derived legislation, or are simply not business savvy enough to take advantage of the strength of their field to achieve maximal gain. It's a pity, really. FM really has potential as a field, given their status as being first in line in patient influence. If all FM docs played their cards right, the field wouldn't be in the situation it currently is.

 

[deleted87716]

Jesus, don't get your panties in a bunch. I assure you Jaggerplate has no intentions of calling for a mass encroachment on dermatology as a means of desperation. You and all the pimples you can see are safe, in all likelihood. He was simply asking a question of why primary care doesn't provide fellowships in much the same way internal medicine provides fellowships. And honestly, after much thought, that isn't a bad question to ask. There's no reason internal medicine should have the claim of being the sole portal to subspecialization, while FM remain a "general practice" field. The biggest distinction between IM and FM is one being outpatient in nature and the other inpatient. What happens after the "generalized" training in residency is up to the two fields, themselves. You can easily have a system where FM trains "outpatient" gastroenterologists, who can do scopes in an ambulatory setting. And for cases where hospitalization is required, the IM-trained "inpatient" GI physician can take over.
It all comes down to the fact that physicians in general are either adherent to some kind of ideal and are unwilling to sacrifice that ideal in order to play the game the system set up, are limited by artificially derived legislation, or are simply not business savvy enough to take advantage of the strength of their field to achieve maximal gain. It's a pity, really. FM really has potential as a field, given their status as being first in line in patient influence. If all FM docs played their cards right, the field wouldn't be in the situation it currently is.

FYI, hospital care is an integral part of family medicine training and scope.

Not to belabor the point, but ours is a specialty of breadth. If you don't like that, you picked the wrong specialty.

IM remains an option for those who want an entry point for specialization.

 

[bronx43]

FYI, hospital care is an integral part of family medicine training and scope.

Not to belabor the point, but ours is a specialty of breadth. If you don't like that, you picked the wrong specialty.

IM remains an option for those who want an entry point for specialization.

I understand. My question is why does IM have to be the sole entry point for specialization? IM is also a specialty of breadth, albeit of a slightly different kind than FM. Nothing about offering fellowships after FM training negates the "breadth" of the specialty, just as IM remains a generalized field, regardless of its post-residency subspecialization.

 

[MJB]

This idea smacks of desperation for someone who must not be able to get intzo dermatology and it eats them up! Why not have gi fellowships, cards fellowships, etc. coming out of fm? I guess yiu can step on everyones toes and jusy steal whatever specialty is the flavor of the five years. Neurology fellowship anyone? Why not! But you have to realize with this plan that you are basically going to be setting yourself up as a midlevel provider. I just have to ask, Are you going to make your own board certification like the the dnps are doing? Would you try to claim equivalence with dermatologists who study medicine, dermpath, mohs, hospital consults, etc for four years as their sole domain? My grandfather was an fp who could do everything. This thread would make him want to throw up! Don't let derm flunkies who went into fp rule your specialty and turn it into a back up plan for dermatology. This would rot your specialty from the inside out if actually did manage to capture people who were only going into fp for derm fellowships, but could not get them bc of competiteness.

And just to correct the misconception, dermatology spots are up something like 37 percent over the last 7 years and are continuing to go up.

oh, good lord.

 

[deleted87716]

I understand. My question is why does IM have to be the sole entry point for specialization?

Present a compelling argument why we need to provide more pathways for specialization.

 

[deleted87716]

Why does FM make an exception for these?

• Adolescent Medicine
• Geriatric Medicine
• Hospice and Palliative Medicine
• Sleep Medicine
• Sports Medicine

Every single one of those you can get through a different residency.

So, are you suggesting that there shouldn't be any FM fellowships at all?

There are those who would agree with that.

 

[CandidateofDerm]

oh, good lord.

There is a poster that is suggesting that FM should train the outpatient GIs and IM should train the inpatient GIs, and you have to say good lord about what I'm saying! Why don't you go float this idea or some of other gems in this thread to real world physicians and see how far you get outside the anonymous SDN family medicine board.

What I think is funny is that people on this FM board can't decide whether they want to do dermatology or constantly insult it. Dermatology is a complex field and when people insult it with comments about pimples or just put a steroid on it, it just is a signal to me that you are ignorant and most likely giving patient's substandard care. You don't know what you don't know. That is I why I read about all those crazy diagnosis that aren't in the top 20 things you see everyday. Because you do see them eventually.

 

[bronx43]

Present a compelling argument why we need to provide more pathways for specialization.

You don't need to provide more pathways for specialization. But you can. And if you do, it can maximize financial gain for FM within the current setup of the system.

 

[deleted87716]

You don't need to provide more pathways for specialization. But you can. And if you do, it can maximize financial gain for FM within the current setup of the system.

I hope I don't need to point out the difficulty one would have in advocating for something without a good reason.

As for "maximizing financial gain," that would only apply in the current reimbursement environment, as you noted. However, the current reimbursement environment is broken and unsustainable.

You're suggesting we become part of the problem. I'd rather see us become part of the solution.

 

[MedicineDoc]

Present a compelling argument why we need to provide more pathways for specialization.

I don't think there is any reason to restrict the ability of fm docs to become more educated in areas of interest. There is no reason why fm can't serve as a foundation just like IM does. It would just make the specialty stronger and further entrench the specialty as a whole.

 

[deleted87716]

There is no reason why fm can't serve as a foundation just like IM does. It would just make the specialty stronger and further entrench the specialty as a whole.

How?

You guys keep saying that, but be specific. Even with the best possible spin you could put on it, what you're advocating is FM as a "back door" path to specialization.

We don't need more FPs acting as specialists. We need more FPs doing family medicine.

 

[IdontTakeCall]

To answer the actual posters question, I don't see this happening. He average FP resident does less than 8 months, alot of Places less than 5 months of inpatient medicine during there residency, let alone critical care time. Having rotated through lots of hospitals with IM and FP residents I found a significant difference in the knowledge base in terms of critical care medicine, and this is mainly because of lack of exposure for FP residents. They are creating hospitalist fellowships for FP grads because of the lack of internal medicine training they get due to all of their outpatient requirements, let alone 2 and 3 year critical training after that. And on top of that, why on earth would you enter a FP residency, to train preventative medicine in clinics and be a primary care.... To then try and work in an ICU with verycomplicated dying patients 90 hours A week in the hospital. Seems to me to the exact opposite of what FAMiLY medicine is supposed to be. If you wanted to be an intensivist than why not go IM where you will get 4x the inpatient exposure. He'll I have met third year FP residents who never did an ICU rotation where they are running the unit. Scary to imagine that same person as my co-fellow in a CC fellowship. Sorry if that offended any FPs wasn't my intention, just my thoughts as a future intensivist.

 

[JaggerPlate]

I think his point is that some would come to FM and end up not specializing, which would then help fill the primary care gap.

Yup. I outlined it pretty clearly (even used fake numbers) above ... but 'shrug.'

BTW, good job, Jagger, brewing up a storm here.

LOL yup. I must say, it's pretty impressive when an off-the-cuff comment made during a study break devolves into a thread where NPs are brought up, I'm called a derm reject (as a MS-1), and even busy attendings jump in on the subject.

Ahh ... SDN.

 

[lowbudget]

Family medicine is a generalist field. It makes no sense to try to make it appealing to those who wish to specialize.

100% with Blue Dog on this one.

Family medicine is for people who want to generalize. There are plenty of specialities to go into if you want to specialize. That said, family medicine rolls in a lot of different specialties and a lot of things that specialists are known to do are, in fact, part of general medicine.

 

[lowbudget]

Also, how is this any different than IM (a generalist field - as you put it) where many individuals go through an IM residency only to practice Cards, GI, Endo, etc???

There is a significant difference between how IM trains and how FM trains, even though we are both "generalists". IM residents spends more time on each of its own specialties (cards, GI, endo, rheum, hem/onc), while FM spends time doing non-IM subspecialties (OB, Gyn, Uro, Ophtho, EM, Pedi, Ortho/SM).

An IM resident who spend way more time inpatient on in the ICU, Cards, and Pulm is better suited to go into Cardiology as a subspecialty than an FM resident who spends less time than that.

 

[lowbudget]

FYI, hospital care is an integral part of family medicine training and scope.

Not to belabor the point, but ours is a specialty of breadth. If you don't like that, you picked the wrong specialty.

IM remains an option for those who want an entry point for specialization.

Hospital care is a very important part of family medicine. It's only recently with corporate medicine that family doctors have been giving up on inpatient privileges because the reimbursement and travel time hospital is not worth skipping out on patients in the clinic.

That said, in 2005, the RRC made a conscious decision to change the critical care requirement from 1 month to 40 continous patients followed. Even if you did hospital medicine all 3 years in family medicine residency, does that qualify you as a critical care "specialist"? No of course not. Can you perform critical care medicine? Absolutely, if you got the training for it. I still admit patients to the ICU and manage them, but I don't do it by myself. My hospital has a "closed ICU" with a "mandatory Pulm/CC" consult with an intensivist, but those guys don't follow my patients to the floor when it's time to step down. So, even though I'm not the #1 in the ICU doesn't mean that I don't need to know critical care medicine. Well, in some hospitals, you DON'T HAVE intensivists 24-7, so FP's need to be up to date with critical care. One hospital I was at only had 1 Pulm/CC and all he wanted to do was manage the vent. Everything else was me, like it or not.

So if FM were to have a CC fellowship, I would totally be for it. It doesn't make you a "specialist" per se like Pulm/CC, but it gives you the advanced training to fill the gap. Who cares if that's considered "specialist" training or not. Take care of the f*cking patient, sh%t.

 

[lowbudget]

Why does FM make an exception for these?

• Adolescent Medicine
• Geriatric Medicine
• Hospice and Palliative Medicine
• Sleep Medicine
• Sports Medicine

Every single one of those you can get through a different residency.

Because these sub-specialties incorporates a large element of general medicine or primary care medicine into the specialty.

ABMS will not approve a sub-specialty CAQ if that sub-specialty is duplicated elsewhere. It needs to stand alone as its own sub-specialty. If you look into those specialties per above, these are targeted towards a special patient population, but the training you get is still very much general medicine... for that special population. It's not like nephrology where you focus on the kidney exclusively, or surgical interventions of the eye for example.

 

[MedicineDoc]

To answer the actual posters question, I don't see this happening. He average FP resident does less than 8 months, alot of Places less than 5 months of inpatient medicine during there residency, let alone critical care time. Having rotated through lots of hospitals with IM and FP residents I found a significant difference in the knowledge base in terms of critical care medicine, and this is mainly because of lack of exposure for FP residents. They are creating hospitalist fellowships for FP grads because of the lack of internal medicine training they get due to all of their outpatient requirements, let alone 2 and 3 year critical training after that. And on top of that, why on earth would you enter a FP residency, to train preventative medicine in clinics and be a primary care.... To then try and work in an ICU with verycomplicated dying patients 90 hours A week in the hospital. Seems to me to the exact opposite of what FAMiLY medicine is supposed to be. If you wanted to be an intensivist than why not go IM where you will get 4x the inpatient exposure. He'll I have met third year FP residents who never did an ICU rotation where they are running the unit. Scary to imagine that same person as my co-fellow in a CC fellowship. Sorry if that offended any FPs wasn't my intention, just my thoughts as a future intensivist.

Maybe where you are but where I am there is no IM and we are inpatient heavy and take hospital call regardless of rotation and do icu work as well as moonlight in the Er on top of Er shifts in addition to urgent care and clinic. We have alot of residents go hospitalist. No fellowship needed.

 

[MedicineDoc]

We also do Er.

 

[VA Hopeful Dr]

There is a poster that is suggesting that FM should train the outpatient GIs and IM should train the inpatient GIs, and you have to say good lord about what I'm saying! Why don't you go float this idea or some of other gems in this thread to real world physicians and see how far you get outside the anonymous SDN family medicine board.

What I think is funny is that people on this FM board can't decide whether they want to do dermatology or constantly insult it. Dermatology is a complex field and when people insult it with comments about pimples or just put a steroid on it, it just is a signal to me that you are ignorant and most likely giving patient's substandard care. You don't know what you don't know. That is I why I read about all those crazy diagnosis that aren't in the top 20 things you see everyday. Because you do see them eventually.

You're correct of course, none of us know anything about dermatology. I bow to your encyclopedia knowledge.

So here's how the real world works. A large part of what your average dermatologist sees in a day (I'm not talking Mohs trained, obviously) could be handled by a decent family doctor. It is the rare/difficult conditions that you guys exist for.

You seem to be taking this all a little too personally, which to me is a sign of insecurity. If I say that OB's are nothing but glorified catchers, is a good obstetrician going to get all worked up over it? Of course not. He/she knows their own value and nothing anyone else says is going to matter. He might even get a chuckle about it after the emergency c-section on the 500 pound eclamptic patient when both mom and baby are doing great a day later.

Every specialty gets in jokes at every other, just ignore it and do your job.

 

[IdontTakeCall]

Maybe where you are but where I am there is no IM and we are inpatient heavy and take hospital call regardless of rotation and do icu work as well as moonlight in the Er on top of Er shifts in addition to urgent care and clinic. We have alot of residents go hospitalist. No fellowship needed.

Where you are is the exception, not the rule. My third and fourth year of med school I rotated at 16 different hospitals, 11 of them had FP residencies. The most months of dedicated inpatient service any of them had over 3 years was 8, and even then, 3/4 of the team leaves at noon to go to afternoon clinic. The teams load has 12-14 patients for 3-4 residents. Where I did my IM months the teams were taking 9 per resident. I am not saying that there aren't FPs who have the experience to run a multidisciplinary ICU, but the greater majority do not, atleast not right out of residency. I have had this talk with many of my FP attendings and with the hospitalists at the various hospitals I have been at and none of them have ever disagreed with the fact that as an FP resident you will get substantially less inpatient medicine and critical care time than your IM counterpart. On top of that the procedure time is dismal for most FP residents. I have met many many third years who have never put in a central line nor intubated a patient on their own. That doesn't bode well for starting day one of your CC fellowship and being the inhouse oncall fellow. Like I said, I am sure there are many FPs who are capable of doing this but as they will be the exception, I cant see any governing body granting FP grads CCM fellowship spots and the ability to be the inhouse intensivist unless there is a large shift in the amount of inpatient and CC training during your 3 years of residency. Likewise, they aren't going to allow me to have an office seeing patients for their primary care nor handle continuity in obstetrics nor pediatric well child visits coming out of as an EM/CC attending, I will not have the experience nor the proper training, and I am ok with that. I wont be able to do Lap choleys either, but thats ok I didnt do a surgery residency. But after all of that, it still boils down in my mind to, if you wanted to do intensive care, why would you do a primary care residency? They are completely opposite styles of medicine. If I wanted to deliver babies all day and do C/s I'd have gone OB/GYN. If I wanted to sew in valves Id have gone surgery. You went primary care, stick with it. Lord knows we need more anyway or this whole damn health care system is gonna collapse.

 

[lowbudget]

There is a poster that is suggesting that FM should train the outpatient GIs and IM should train the inpatient GIs, and you have to say good lord about what I'm saying! Why don't you go float this idea or some of other gems in this thread to real world physicians and see how far you get outside the anonymous SDN family medicine board.

What I think is funny is that people on this FM board can't decide whether they want to do dermatology or constantly insult it. Dermatology is a complex field and when people insult it with comments about pimples or just put a steroid on it, it just is a signal to me that you are ignorant and most likely giving patient's substandard care. You don't know what you don't know. That is I why I read about all those crazy diagnosis that aren't in the top 20 things you see everyday. Because you do see them eventually.

Oh please. Give me a break. Quit acting like GI's are the only people who can do GI and Derm are the only people who do Derm. There's plenty of GI and Derm in general medicine; most of which, in a world with primary care, doesn't make it to GI and Derm because we get it and we got it.

Truth of the matter is there's so much dermatologic manifestations of many medical pathologies, most of which a dermatologist can't manage with just 1 year of internal medicine prelim (especially in children) that it makes more sense to train primary care in the art of dermatology than it is to train a dermatologist in the art of primary care.

I/we refer cases to a dermatologist that is worthy of someone who spent 4 years training solely in the skin, which usually is either a total zebra or an atypical presentation of a typical disease that we treat. Unfortunately, the "real world" fact is that it is nearly impossible to get a dermatologist to see a patient in a timely manner satisfactory to the management of the medical problem or the desire of the patient, so it makes total sense that primary care doctors would educate themselves on dermatology as it pertains to their practice to bridge the gap.

The San Antonio dermatology fellowship is actually run out of the family medicine department with focus on the underserved which means that the cases that you see during that fellowship are cases that a typical family physician would be seeing anyways. It's not some zebra case that gets consulted at some tertiary care academic medical center. I don't know for sure, but I seriously doubt the underserved are banging down the doors to get Botox injections, fillers, and lasers for pimples and paying cash for them; which, if anyone wanted to "backdoor" into, it would be that.

If you became a dermatologist, you should absolutely support your primary care doctors who strive to learn more about dermatology so that they don't refer BS cases to you. One. Two is that no primary care doctor is going to refer a dermatologist cases if the dermatologist doesn't support the primary care doctor's practice. We simply refer cases to your competitor who will.

 

[lowbudget]

Where you are is the exception, not the rule. My third and fourth year of med school I rotated at 16 different hospitals, 11 of them had FP residencies. The most months of dedicated inpatient service any of them had over 3 years was 8, and even then, 3/4 of the team leaves at noon to go to afternoon clinic. The teams load has 12-14 patients for 3-4 residents. Where I did my IM months the teams were taking 9 per resident. I am not saying that there aren't FPs who have the experience to run a multidisciplinary ICU, but the greater majority do not, atleast not right out of residency. I have had this talk with many of my FP attendings and with the hospitalists at the various hospitals I have been at and none of them have ever disagreed with the fact that as an FP resident you will get substantially less inpatient medicine and critical care time than your IM counterpart. On top of that the procedure time is dismal for most FP residents. I have met many many third years who have never put in a central line nor intubated a patient on their own. That doesn't bode well for starting day one of your CC fellowship and being the inhouse oncall fellow. Like I said, I am sure there are many FPs who are capable of doing this but as they will be the exception, I cant see any governing body granting FP grads CCM fellowship spots and the ability to be the inhouse intensivist unless there is a large shift in the amount of inpatient and CC training during your 3 years of residency. Likewise, they aren't going to allow me to have an office seeing patients for their primary care nor handle continuity in obstetrics nor pediatric well child visits coming out of as an EM/CC attending, I will not have the experience nor the proper training, and I am ok with that. I wont be able to do Lap choleys either, but thats ok I didnt do a surgery residency. But after all of that, it still boils down in my mind to, if you wanted to do intensive care, why would you do a primary care residency? They are completely opposite styles of medicine. If I wanted to deliver babies all day and do C/s I'd have gone OB/GYN. If I wanted to sew in valves Id have gone surgery. You went primary care, stick with it. Lord knows we need more anyway or this whole damn health care system is gonna collapse.

1. Get your facts straight. Anyone can start a fellowship in anything. You simply can't board certify if you didn't attend an unaccredited fellowship, but that doesn't prevent graduates from enrolling in an unaccredited fellowship. So, basically there is no "governing body" that can prevent an FP from enrolling in a fellowship if that program is willing to take the FP. All the governing body can do is prevent the FP from getting a board certification in critical care.

2. Ok, fine. Hospitals can close off their ICU's to Pulm/CC's only, but they can't close it off to FM without also closing it off to GIM's also. This poses a political issue in most hospitals because most Pulm/CC usually falls under IM for privileging and no IM section is going to cut themselves out of the ICU (think: money).

3. Outside of the academic medical center, primary care doctors who have traditional practices serve as the primary attending when their patients go to the ICU and simply have Pulm/CC on board as a consult. "Intensive Care" is within the scope of family medicine, although only in part; just like it is for emergency medicine & neurology. Believe it or not, patients do live.

4. Family doctors who are trained in critical care procedures at unopposed programs are actually not that rare. When I graduated, I had the same number of both central lines and intubations as an EM classmate-friend of mine, and both of us had more intubations than an IM classmate-friend of mine, who got her FIRST intubation as a Pulm/CC... FELLOW! Bottom line is that there're big variations in training in all specialties, not just FM.

5. No one said family doctors can do everything. We all know that. But you'll be surprised that we can do more than nothing.

 

[MedicineDoc]

Seriously what are you talking about "run a multidisciplinary icu". Does that mean consult when needed? We take care of our patients where ever they are in the clinic or the icu. We run the hospital service and see our patients in clinic. There is nothing magically complex about taking care of icu patients with available consultants. I don't believe you are the authority on fm ability to do hospitalist medicine based on your experiences as a medical student (otherwise known as a clueless barnacle).

 

[hawkeye pierce]

Low budget,
I'm no expert but i'm fairly certain sleep and sports medicine are fellowships offered by other specialties as well.

 

[EdibleEgg]

Take care of the f*cking patient, sh%t.

Best SDN quote ever. Period.


I did a fellowship after my residency. I'm very happy that I did. I doesn't make me an intensivist, or a gastroenterologist, but it did make me a better FP. When I was a forth year medical student, I did some real soul searching and decided on FM at a University affiliated residency. Two of the biggest factors in that decision were the ICU was open with FM residents followed all of their own patients through the ICU, and there was a FM attending performing upwards of 500 colonoscopies a year. Midway through my intership, the ICU became "closed" and the FM attending was barred from teaching residents.... we could watch, but not touch the scope. I was very aggressive, and still got some exposure through residency. However, I did a year of locums after my residency, and realized there were several gaps in my training. I did a year long fellowship in rural medicine, basically splitting my time between EM/CC/GI.

It did not make me a gastroenterologist or an intensivist. It did significantly broaden my skill set. I practice primary care, my scope is just a little larger than most (so are my hours, but so is my pay). One of the great things about family medicine is the breadth of scope. I don't see any problem with fellowships that broaden that scope. In my current hospital, there is an CC boarded MD available Monday through friday, during the day, for consult only. There is a derm PA that comes here 2 days a week. I'm happy that I stepped out of the box.

Most of the fellowship paths are political dogma anyway. I can see how an internal medicine residency would prepare you better for a cardiology or pulmonology fellowship, but I think family medicine would probably prepare you more for an allergy fellowship. Whatever, I don't really care. Just stay out of my way when I'm taking care of the f*cking patient.

 

[CandidateofDerm]

Best SDN quote ever. Period.


I did a fellowship after my residency. I'm very happy that I did. I doesn't make me an intensivist, or a gastroenterologist, but it did make me a better FP. When I was a forth year medical student, I did some real soul searching and decided on FM at a University affiliated residency. Two of the biggest factors in that decision were the ICU was open with FM residents followed all of their own patients through the ICU, and there was a FM attending performing upwards of 500 colonoscopies a year. Midway through my intership, the ICU became "closed" and the FM attending was barred from teaching residents.... we could watch, but not touch the scope. I was very aggressive, and still got some exposure through residency. However, I did a year of locums after my residency, and realized there were several gaps in my training. I did a year long fellowship in rural medicine, basically splitting my time between EM/CC/GI.

It did not make me a gastroenterologist or an intensivist. It did significantly broaden my skill set. I practice primary care, my scope is just a little larger than most (so are my hours, but so is my pay). One of the great things about family medicine is the breadth of scope. I don't see any problem with fellowships that broaden that scope. In my current hospital, there is an CC boarded MD available Monday through friday, during the day, for consult only. There is a derm PA that comes here 2 days a week. I'm happy that I stepped out of the box.

Most of the fellowship paths are political dogma anyway. I can see how an internal medicine residency would prepare you better for a cardiology or pulmonology fellowship, but I think family medicine would probably prepare you more for an allergy fellowship. Whatever, I don't really care. Just stay out of my way when I'm taking care of the f*cking patient.

We are debating totally different things here. I have no problems with pcp's doing dermatology and being competent in dermatology or any other specialty. In fact, if certain derm issues make it into the clinic I consider it a failure on the part of the pcp. But what your brethren are advocating for is fellowship pathways that would train family medicine dermatologists who only do dermatology, not an fm doc with areas of dermatology, ccm, gi, etc. What you are doing is what fm docs are supposed to do and only recently have they stopped practicing this way in the last 15-20 years.

 

[lowbudget]

We are debating totally different things here. I have no problems with pcp's doing dermatology and being competent in dermatology or any other specialty. In fact, if certain derm issues make it into the clinic I consider it a failure on the part of the pcp. But what your brethren are advocating for is fellowship pathways that would train family medicine dermatologists who only do dermatology, not an fm doc with areas of dermatology, ccm, gi, etc. What you are doing is what fm docs are supposed to do and only recently have they stopped practicing this way in the last 15-20 years.

Fine. Let's get on the same page and speak the same language then. What's your definition of "doing dermatology" or "doing critical care"? What does that mean to you?

 

[CandidateofDerm]

Fine. Let's get on the same page and speak the same language then. What's your definition of "doing dermatology" or "doing critical care"? What does that mean to you?

Well for starters, I think that there is a somewhat arbitrary eyeball test that you know it when you see it. If you are advertising yourself as a "skin specialist" or trying to pass yourself off as "fellowship trained in dermatology" then you are probably are going too far. This is what this thread is clearly about. People who want there to be a critical care fellowship so they can abandon fm and be a ccm doctor instead. Or likewise do a fellowship in any number of specialities from cardiology to gi so they can advertise as such and transition into a narrower specialty field.

 

[IdontTakeCall]

Fine. Let's get on the same page and speak the same language then. What's your definition of "doing dermatology" or "doing critical care"? What does that mean to you?

Doing critical care in my opinion is being the intensivist and running the unit. If you do a CC fellowship and follow your patients into the unit but still have to consult the intensivist to get on board forthe patients care than your fellowship was meaningless except that it allowed you to better understand ccm, even though to still need the intensivist to make the decisions. If you can do the fellowship after your FP residency and then be given privileges to run the unit the same as an IM or EM or GAS who did a cc fellowship than that sounds appropriate. But if after the fellowship training you can't run the unit and still have to consult the intensivist I Don't think the fellowship was worth it, unless youve got 2 years time to burn on fellows salary, not worth it to me. I guess what I'm trying to say is if I could do a cards fellowship after my EM residency, but afterwards couldn't bill as a cardiologist, nor do angioplastys, then why did I do the fellowship?

 

[IdontTakeCall]

In another light I think of it like this, if after 3 years of residency trying to support my wife and kids on 45k a year or so while working 80 hours a week, I then say to my wife, honey, I know I'm now an attending and can go work and end this 11 year long run as a student and resident and start working on our 350k in student loans, but instead I'm gonna do a fellowship for 2 years at 55k or so a year again at the end of which I will not make any more money nor be able to realistically do anything different than before... But I'll have a much better knowledge base of my icu patients, which are a minisculy small percentage of the patients in my practice, but not be able run the icu and command the intensivists salary....she'll say good for you, I'll get the divorce papers drawn up.