FM Critical Care Fellowships?

[bunnymd]

Plenty of family doctors perform critical care. The resistance to further training and education puzzles me. I certainly don't know any who ONLY do critical care. It is predominantly in response to a need in a community. Honestly, there is no threat to "official" critical care doc's in a location where there are plenty of specialists available (no hospital in that locality would grant privileges to the fam docs). I trained with many family doctors who, despite rigorous inpatient training, pursued further training in rural medicine, OB, and hospitalist medicine simply because of the anticipated need in the community where they were planning to practice. And yes, they did this at a significant economic sacrifice.

As a family doc who is a "specialist" in geriatrics and palliative care, I find it interesting that there is minimal push-back to pursue this training. I guess that things would be different if these pursuits resulted in greater compensation or threatened the supply of "generalists."

Interestingly, internal medicine residents are accepted to allergy fellowships and expected to treat children without having laid hands on a pediatric patient since medical school.

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[VA Hopeful Dr]

Plenty of family doctors perform critical care. The resistance to further training and education puzzles me. I certainly don't know any who ONLY do critical care. It is predominantly in response to a need in a community. Honestly, there is no threat to "official" critical care doc's in a location where there are plenty of specialists available (no hospital in that locality would grant privileges to the fam docs). I trained with many family doctors who, despite rigorous inpatient training, pursued further training in rural medicine, OB, and hospitalist medicine simply because of the anticipated need in the community where they were planning to practice. And yes, they did this at a significant economic sacrifice.

As a family doc who is a "specialist" in geriatrics and palliative care, I find it interesting that there is minimal push-back to pursue this training. I guess that things would be different if these pursuits resulted in greater compensation or threatened the supply of "generalists."

Interestingly, internal medicine residents are accepted to allergy fellowships and expected to treat children without having laid hands on a pediatric patient since medical school.

It doesn't seem to be the CC people objecting - the 2 who've posted here seem to think its a good idea.

 

[KYTNOH]

I said anesthesia, pulmonology, and cardiology filled the role at my hospital. I don't care what study anyone trots out unless it directly comparing my hospital to those with "critical care specialist" it doesn't represent a valid comparison. Your repetitious posts do not make you right. The people who die at our hospital are almost always the ones that would die anywhere regardless. Let's take the surviving sepsis campaign as an example of the great "achievement" of critical care societies. It is what we do but it is more a ritualistic way for those with severe sepsis to die than it is a way to make them live.

Multiple studies have shown closed ICUs with cc trained dice lead to better outcomes when measuring lengths of stay and mortality. The data us strongly against your assertion. The one caveat to that could be how your hospital defines "critical care." If critical care is defined as managing the dka patient or rapid a fibbers on cardizem drips, then I agree you may have more difficulty finding anecdotal evidence of a significant difference. However, at many tertiary care centers none of those things go to the unit. Those things can be managed out of the ICUs (assuming no conern over cerebral edema). In ICUs an intubation/trach percentage in the range of 60-75% and which regularly have people on nitric, rotaprone, or ecmo you absolutely need cc trained people to optimize outcomes.

I would also argue that true cc management requires at least a half hour to an hour of dedicated time with each critically ill patient every day. You can't abide by surviving sepsis guidelines if you're out of the hospital during the day.

 

[KYTNOH]

Btw, I didn't mean that to come across in a manner that mitigates managing those patients. I was simply trying to point out that there are multiple levels of critical care within ccm.

 

[EdibleEgg]

Overall, I agree. I think there is definitely a place for critical care. However, I hate the idea of closed units. There's a lot that doesn't easily fit into a box. It's often very tough to get a bed and an accepting physician for transfer. It always amazes me of much more I'm capable of at three AM than I am at noon.

 

[AFSmiley]

As a lowly medical student going into Familly Med, I like the idea of opening up the Critical Care fellowship to Family Medicine Physicians. If Inpatient Medicine is within our scope of practice (and it obviously is going to remain that way with the ABIM/ABFM both developing "Recognition of Focused Practise in Hospital Medicine"), I believe Critical Care is a logical extension: you can be boarded in Critical Care after a residency in Internal Medicine, General Surgery, Anesthesia, Emergency Medicine, than why not add Family Medicine to that list. The Critical Care docs I worked with on my ICU rotation were Medicine trained but handled SICU type responsibilities (post op care for trauma surgeries, craniotomies, etc), got to do more procedures than the average hospitalist (Chest tubes, Central Lines/Arterial lines, etc) on a concistent basis, and basically did shift work much like a hospitalist. I could see that sort of position appealing to some of my peers in FM: some medicine patients, some surgery patients, procedures, lots of physiology, shift work....etc

I see this as an opportunity for Family Medicine to break a stigma that some other specialists and people in the public hold- that we don't care of really sick people. I've been told that I should get used to handling runny butts and runny noses all day long....

If I was truly interested in making this a reality, how does this sort of thing happen from a political standpoint? Meaning- get the Society of Critical Care Medicine to accept FamilyMed as a legitimate path to a fellowship and eventually board certification in critical care? Some high level ABFM-SCCM meetings or something?

~Smiley

NOTE: I am NOT saying Family Docs should be eligible for Pulmonology fellowship. Specializing in a single organ system for the most part has a clear path through Internal Medicine or Pediatrics which is a whole other animal.

 

[jimfp]

as a first year FM intern, i would really like to see more training in critical care medicine. at an unopposed program we're trained to be the only docs in town in rural cities from 0-~25,000 ppl. we are talking towns too that can be closed off by the ground and air in winter months and it is essential to have critical care skills to care for and stabilize patients. my intent would not be to provide ECMO skills or post-cabg ...really a combined Trauma-Crit Care focus would be ideal.

 

[jimfp]

As a lowly medical student going into Familly Med, I like the idea of opening up the Critical Care fellowship to Family Medicine Physicians. If Inpatient Medicine is within our scope of practice (and it obviously is going to remain that way with the ABIM/ABFM both developing "Recognition of Focused Practise in Hospital Medicine"), I believe Critical Care is a logical extension: you can be boarded in Critical Care after a residency in Internal Medicine, General Surgery, Anesthesia, Emergency Medicine, than why not add Family Medicine to that list. The Critical Care docs I worked with on my ICU rotation were Medicine trained but handled SICU type responsibilities (post op care for trauma surgeries, craniotomies, etc), got to do more procedures than the average hospitalist (Chest tubes, Central Lines/Arterial lines, etc) on a concistent basis, and basically did shift work much like a hospitalist. I could see that sort of position appealing to some of my peers in FM: some medicine patients, some surgery patients, procedures, lots of physiology, shift work....etc

I see this as an opportunity for Family Medicine to break a stigma that some other specialists and people in the public hold- that we don't care of really sick people. I've been told that I should get used to handling runny butts and runny noses all day long....

If I was truly interested in making this a reality, how does this sort of thing happen from a political standpoint? Meaning- get the Society of Critical Care Medicine to accept FamilyMed as a legitimate path to a fellowship and eventually board certification in critical care? Some high level ABFM-SCCM meetings or something?

~Smiley

NOTE: I am NOT saying Family Docs should be eligible for Pulmonology fellowship. Specializing in a single organ system for the most part has a clear path through Internal Medicine or Pediatrics which is a whole other animal.

part of family medicine training should be understanding and recognizing that catching a UTI early in the process prevents septic shock later on, that is why family medicine is essential, volume helps us do that. its not just about what you treat, its also about what you didnt need to treat because you recognized early disease process.

 

[Hernandez]

part of family medicine training should be understanding and recognizing that catching a UTI early in the process prevents septic shock later on, that is why family medicine is essential, volume helps us do that. its not just about what you treat, its also about what you didnt need to treat because you recognized early disease process.

sorry just amused at the idealism after admitting several pts that went from walkie-talkie to damn near dead in hours in the last several days of call.

 

[jimfp]

sorry just amused at the idealism after admitting several pts that went from walkie-talkie to damn near dead in hours in the last several days of call.

cant save em all

 

[AFSmiley]

I enjoyed my ICU rotations so much 4th year that it's making me debate FM vs Internal Medicine w/ a Critical Care fellowship.

I could really see myself getting in with a group on their rotation as the Intensivist on call, and then having my own General IM clinic on the outside inbetween instead of doing Pulm/Sleep clinic.

We'll see how my Intern year treats me and go from there.

 

[CambieMD]

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

Those who wish to become specialists should go into IM where they can do fellowships. An FP doc with a fellowship in derm will stil has less training than a board certified dermatologist. FP docs should concentrate on doing what they do well.

How long will the FP critical care fellowship be. IM CCM docs train for three years following residency. Will the fP docs train for an additional three years following rheir residency training.

Cambie

 

[TreeOfSouls]

I would advocate for an FP dermatology fellowship for the following simple reason- as a patient, my FP doc responded that she could "take care of" a very small dark spot beneath my eye that I pointed out at my annual exam. My instinct told me to request a referral to a dermatologist instead; the dermatologist immediately recognized the basal cell carcinoma and, within two weeks, I had MOHs. Perhaps if the FP doc had completed a fellowship, she would have realized what she was actually looking at OR, conversely, if such fellowships existed and she hadn't done one, she might not have offered to "take care of it" instead of simply referring me to a dermatologist.

 

[deleted87716]

I would advocate for an FP dermatology fellowship for the following simple reason- as a patient, my FP doc responded that she could "take care of" a very small dark spot beneath my eye that I pointed out at my annual exam. My instinct told me to request a referral to a dermatologist instead; the dermatologist immediately recognized the basal cell carcinoma and, within two weeks, I had MOHs. Perhaps if the FP doc had completed a fellowship, she would have realized what she was actually looking at OR, conversely, if such fellowships existed and she hadn't done one, she might not have offered to "take care of it" instead of simply referring me to a dermatologist.

How did you know what your FP meant by "take care of it?" Did you ask...?

Maybe they meant doing a biopsy, just as your dermatologist did.

 

[TreeOfSouls]

Blue Dog, the offer was to remove it, not do a biopsy. This occurred in an extremely reputable clinic/practice; yet, the FP doc was clearly planning to remove it as if it were a "skin tag" or mole when, in fact, it was basal cell carcinoma requiring MOHs surgery.

P.S. When I saw the dermatologist, he knew right away what it was from a visual exam- at least that it was biopsy worthy, had a photo taken for case study, had the resident take a look (who also would have missed the diagnosis, BTW, until he explained to her what to look for/notice), and did the biopsy- all completed within 15 minutes.. and MOHs surgery, consequently, was completed within a few weeks without the scarring that can occur when similar cancers are not promptly treated.

 

[lowbudget]

Hmmm... to remove it and not get a biopsy would suggest, to me anyways, that you were gonna get a wide excision vs. a leading edge punch or shave. In discussing a similar case with a more veteran colleague on the use of wide excision vs. punch/shave as the trick out of the bag, the standard of care in my neighbhorhood is punch/shave first and let the path guide your next step. Personally, when I'm in doubt, I go the distance and take it full-thickness with a punch or excisional biopsy and use the stitches to mark the spot since I don't trust my patients to return to clinic on a timely manner before the skin heals and if I can't find where I cut and if I don't have clean borders, we'll never find the lesion. It's like a squirrel losing his nut (and his nut).

That said, I'll cut if it's on the trunk or extremities. I leave the face for someone else to cut on, even if I personally think uglifying their face probably wouldn't make a difference. Then again, I live in a place where there are plastic surgeons, dermatologists, and Mohs surgeon on every corner. I'll forgo $100 to avoid getting bad mouthed, thank you.

I got burned once shaving a superficial lesion that ended up being a BCC on someone's cheek. Nice shave, no cosmetic issues, got lucky with clear margins; but I referred her on to ("just a general") derm for toilet paper coverage. Next visit, patient told me I got lucky and that she needs a referral to see dermatologist for skin checks because her dermatologist told her that she needed "a real professional" to take care of her.

I told her that I'd be more than happy to provide that referral (uh, actually, I already "referred" her) and that seeing how she's gonna need a real professional to take care of her skin, I advised her that she probably shouldn't be so damn cheap and instead switch from her HMO to either a PPO or POS or discounted-FFS plan where a referral paperwork would be not necessary. Don't waste your time or my time just to save a buck, especially if you don't value the services I provide. I don't think I ever saw her again.

My point is I followed standard of care, got lucky with clear margins, but even if I didn't get lucky the next step would have been Mohs' (and not some general derm) and yet I got trashed-talked.

So, my question to you, Tree, is why did you bother asking your family doc for her opinion if you didn't trust her with it? Why not just go straight to a Moh's surgeon for diagnosis and management? And, don't tell me it's because your insurance dictate that you get a referral from your PCP. If you don't value your PCP's services, don't buy into a plan that requires a PCP.

(And, to be clear, I'm not being defensive, and this only happens to me occasionally, and I'm super gracious/generous with referrals. And trust me, I'm no saint: I will trash-talk other doctors with the best of them especially if patients get all jacked up. It's called capitalism. But I don't understand the disconnect patients make when it comes to making rational consumer decisions regarding their health care. You don't buy car insurance this way; so why would you buy health insurance this way? The only reason I can think of is it's because our patients are totally clueless about themselves and unrealistic about their expectations and utilization. Personally, I think HMO's and insurance plans requiring referrals are meant for either super-healthy people requiring little to no specialist care; or are meant for patients with no medical sophistication who need a PCP to help them with diagnosis and management. But, if you're going to be hoidy-toidy about stuff, cut the crap and pay up for an insurance plan that's appropriate for your needs.)

 

[TreeOfSouls]

So, my question to you, Tree, is why did you bother asking your family doc for her opinion if you didn't trust her with it? Why not just go straight to a Moh's surgeon for diagnosis and management? And, don't tell me it's because your insurance dictate that you get a referral from your PCP. If you don't value your PCP's services, don't buy into a plan that requires a PCP.

I'm not going to name specific doctors and clinics/practices on this forum. But, suffice to say that it is an extremely reputable clinic/practice and I'm very happy (in general) to have insurance covering my care there as it is considered one of the "pinnacles" of medical care. I would imagine that most people with the option to be treated here- would be.

But, yes- the insurance does require patients to receive a referral from the PCP to see a dermatologist. It is not required for other specialists as far as I know. My guess is that dermatologists would be very (overly) popular with patients here and they want some kind of "gate keeping" function in place to make sure that dermatological medical problems can be scheduled quickly (as mine was) rather than having a schedule full of elective/cosmetic procedures. But, again, I'm not the administrator, so that's just my own personal guess as to why the policy exists.

I did change my PCP as a result of the experience because this was a prominent area of my face and could have had a very unhappy ending with the wrong treatment. However, I believe that she genuinely felt qualified to make the call when, unfortunately, she wasn't- which goes back to why I posted in this thread advocating for a derm fellowship for FP docs who are interested in treating dermatological problems or who want to be better diagnosticians and provide higher quality care in that area. Ultimately, I would have still needed MOHs surgery but it's scary to think about the alternative result if I'd gone along with her offer instead.

 

[MedicineDoc]

I don't have anything against MOHs surgery but I don't think you would have ended up with a different result had your fp biopsied it and then sent you to derm if needed. I remember inquiring about MOHs with one of my fp attendings who is known for encyclopedic knowledge of medicine and his response was "cha ching". MOHs is Extremely lucrative for derm. I have seen huge tissue defects even with MOHs what needs to come off is going to have to come off especially noticeable on the nose. If your fp had taken it off and it had been negative it would have been convienently "taken care of". If positive as you say it was, I don't think you would have lost anything but just Have been referred with same ultimate result. Tissue removal is often performed in stages anyway to allow for natural shrinking down of tissue defects.

 

[TreeOfSouls]

I don't have anything against MOHs surgery but I don't think you would have ended up with a different result had your fp biopsied it anf then sent you to derm if needed.

As stated a few times in my posts, FP doc was not planning to biopsy, just remove. I won't continue reiterating the same details of my experience but I do remain interested in the topic (expanded FP fellowships) beyond what my FP doc "could" have done.

 

[MedicineDoc]

As stated a few times in my posts, FP doc was not planning to biopsy, just remove. I won't continue reiterating the same details of my experience but I do remain interested in the topic (expanded FP fellowships) beyond what my FP doc "could" have done.

I don't buy that unless your doctor went to clown school. I'm pretty sure there aren't any combined residencies in FP and circus clown. I think it's more likely you misunderstood.

 

[MedicineDoc]

On a side note it always amuses me when someone says with an air of pride in their voice something like "I went to the best heart surgeon in "this here whole united states" (who operated on cousin Ethel last year) for my ingrown toenail. He graduated from harvard and went to high school with cousin mikey". Another funny one is "guess how much my back surgery cost...no go ahead guess". ...."150,000" dollars. Does it feel any better? "Well not yet but it was worth every penny". "He's the best back surgeon in 2 states!!!".

 

[deleted87716]

As stated a few times in my posts, FP doc was not planning to biopsy, just remove. I won't continue reiterating the same details of my experience but I do remain interested in the topic (expanded FP fellowships) beyond what my FP doc "could" have done.

I'm not suggesting it's impossible to miss something (even your derm apparently thought the lesion looked atypical, so a derm fellowship wouldn't necessarily have mattered in this case), but it still sounds to me like you're making some assumptions about what your FP meant by the colloquialism "take care of it."

Unless you specifically asked her what she intended to do with the specimen after she removed it and she told you she was going to throw it in the trash, I think it's at least equally likely that she would've sent it to pathology, in which case your outcome would've been no different.

In that case, the words "remove" and "biopsy" are essentially the same thing, as is often the case for small lesions.

And, FYI, there are a number of other treatment options for superficial BCC aside from Mohs surgery.

 

[TreeOfSouls]

Hey, if it makes you feel better.... by all means continue inventing wild theories about me, the medical center where I received treatment, my insurance, my financial status, my FP's inner thoughts and motivations, etc. But, I'm not sure what it gets you or how it contributes to the actual point of the discussion, which was whether or not there should be additional fellowships for FP docs, particularly dermatology and/or critical care.

It IS fascinating, however, the various assumptions made that- because my FP doc made a bad call regarding my BCC:

* I must not have understood what she was saying (Yep, I'm probably just a big idiot... as are all patients, right? Or at least the ones who notice physician errors. After all, if a patient doesn't understand you, it wouldn't be because you lack appropriate communication skills to convey relevant information to your patients, they must just be very stupid regardless of level of education, field of practice, or professional experience. And, if you are wrong about something, they probably just didn't "understand" that you were actually right.)

* If she WAS wrong (which she would never be since she's a FP doc, I just didn't read her mind properly as the lowly patient or couldn't comprehend her complex pearls of communication), then she probably went to "clown school", which is also probably how she ended up employed here X 2

* Wait, they don't have clown school residency, so I must just be stupid (again, the "stupid patient" theory)

* I must have crappy insurance (because they would definitely take crappy insurance here; in fact, the crappier the better because I'd love to pay more out of pocket for MOHs surgery, as would any patient)

* If so, I must have chosen the crappy insurance because I'm just too cheap to purchase better insurance (and, surely, I must also then spend my wads of discretionary cash on pointless minutiae like cigarettes, Nikes, and Doritos- perhaps even limousines- in lieu of choosing better insurance, which I clearly didn't put as much thought into as I would choosing my car tires)

* If I have expensive insurance, it must be because I'm too uninformed to choose a less expensive but just as good plan (e.g. I'm actually wealthy but a complete idiot)

* I must not have really needed MOHs surgery (so many other options; removing BCC along the eyelash line is really simple and any idiot could do it- probably even the NPs at Minute Clinic could do it blindfolded with no scarring because it's JUST THAT simple)

* I must not be going to a good medical center (but delusionally believing that I am because again: patient = idiot)

* If I am going to a good medical center, I'm probably overpaying so that I can brag about how much I paid (even though I really get crappy care, which all the "best" places provide because best really means "crappy"... also because, again, I'm probably a wealthy buffoon who just wants to brag about medical issues- not an informed consumer wanting high quality, well-established medical care)

* If the place where I received treatment is widely considered to be one of the best, I must surely be wrong about that (and so is everyone else receiving care here and all the docs who practice here and all the history of this institution and all of the studies generated from it and all of its associated rankings/evaluations X 3)

Wow... all that was divined from a single, brief anecdotal story that's fairly commonplace. You don't know me, you don't know my financial situation, you don't know my cultural background or decision making process, you don't know my doc, you don't know my medical history, health status, or specific details of the BCC, you have no idea what clinic/practice/office/hospital I received care from, and you don't know what insurance plan I have- yet, you could divine all of that!

Seriously, have fun theorizing about these various fantasies and fictional scenarios if it brings you some personal satisfaction/comfort/benefit... it's been interesting to hear them. But, I'm not going to discuss my BCC experience further since there doesn't seem to be much point and it's apparently only devolving and sidetracking the discussion.

SO... back to the actual topic, which was/is: whether or not there should be additional fellowships open to FP docs, particularly in dermatology and/or critical care...

 

[VA Hopeful Dr]

Hey, if it makes you feel better.... by all means continue inventing wild theories about me, the medical center where I received treatment, my insurance, my financial status, my FP's inner thoughts and motivations, etc. But, I'm not sure what it gets you or how it contributes to the actual point of the discussion, which was whether or not there should be additional fellowships for FP docs, particularly dermatology and/or critical care.

It IS fascinating, however, the various assumptions made that- because my FP doc made a bad call regarding my BCC:

* I must not have understood what she was saying (Yep, I'm probably just a big idiot... as are all patients, right? Or at least the ones who notice physician errors. After all, if a patient doesn't understand you, it wouldn't be because you lack appropriate communication skills to convey relevant information to your patients, they must just be very stupid regardless of level of education, field of practice, or professional experience. And, if you are wrong about something, they probably just didn't "understand" that you were actually right.)

* If she WAS wrong (which she would never be since she's a FP doc, I just didn't read her mind properly as the lowly patient or couldn't comprehend her complex pearls of communication), then she probably went to "clown school", which is also probably how she ended up employed here X 2

* Wait, they don't have clown school residency, so I must just be stupid (again, the "stupid patient" theory)

* I must have crappy insurance (because they would definitely take crappy insurance here; in fact, the crappier the better because I'd love to pay more out of pocket for MOHs surgery, as would any patient)

* If so, I must have chosen the crappy insurance because I'm just too cheap to purchase better insurance (and, surely, I must also then spend my wads of discretionary cash on pointless minutiae like cigarettes, Nikes, and Doritos- perhaps even limousines- in lieu of choosing better insurance, which I clearly didn't put as much thought into as I would choosing my car tires)

* If I have expensive insurance, it must be because I'm too uninformed to choose a less expensive but just as good plan (e.g. I'm actually wealthy but a complete idiot)

* I must not have really needed MOHs surgery (so many other options; removing BCC along the eyelash line is really simple and any idiot could do it- probably even the NPs at Minute Clinic could do it blindfolded with no scarring because it's JUST THAT simple)

* I must not be going to a good medical center (but delusionally believing that I am because again: patient = idiot)

* If I am going to a good medical center, I'm probably overpaying so that I can brag about how much I paid (even though I really get crappy care, which all the "best" places provide because best really means "crappy"... also because, again, I'm probably a wealthy buffoon who just wants to brag about medical issues- not an informed consumer wanting high quality, well-established medical care)

* If the place where I received treatment is widely considered to be one of the best, I must surely be wrong about that (and so is everyone else receiving care here and all the docs who practice here and all the history of this institution and all of the studies generated from it and all of its associated rankings/evaluations X 3)

Wow... all that was divined from a single, brief anecdotal story that's fairly commonplace. You don't know me, you don't know my financial situation, you don't know my cultural background or decision making process, you don't know my doc, you don't know my medical history, health status, or specific details of the BCC, you have no idea what clinic/practice/office/hospital I received care from, and you don't know what insurance plan I have- yet, you could divine all of that!

Seriously, have fun theorizing about these various fantasies and fictional scenarios if it brings you some personal satisfaction/comfort/benefit... it's been interesting to hear them. But, I'm not going to discuss my BCC experience further since there doesn't seem to be much point and it's apparently only devolving and sidetracking the discussion.

SO... back to the actual topic, which was/is: whether or not there should be additional fellowships open to FP docs, particularly in dermatology and/or critical care...

OK, you seem to be missing a few points here.

1. Everyone makes mistakes. It happens. It could be that your FP screwed up, that's obviously possible. It could also be that you misunderstood what your FP was going to do with the lesion he/she removed. You need to accept the possibility of the latter scenario.

2. Its fairly common practice to send pretty much anything removed from a person to pathology just to make sure its nothing worrisome. Hence some of the reaction around here to your suggestion that your FP wasn't going to send it for microscopic evaluation.

3. MOHS surgery isn't always the only answer. That's all anyone is saying. We don't know enough to say for sure, but your attitude upon entering this thread seemed to indicate that it was and that your FP screwed up for thinking otherwise.

4. Bragging about how great this clinic was and then pointing out a perceived ****-up is an indirect way of saying "If the best FP around can screw this up, I'm sure the rest of you would too". How can you not expect that to get a negative reaction?

You came in here with a very vague story that we here, as FPs, found slightly suspicious and you were told why we thought that way. We even explained why we would do things differently. You then chose to get defensive.

 

[deleted87716]

have fun theorizing about these various fantasies and fictional scenarios if it brings you some personal satisfaction/comfort/benefit... it's been interesting to hear them. But, I'm not going to discuss my BCC experience further since there doesn't seem to be much point and it's apparently only devolving and sidetracking the discussion.

Well, you brought it up.

The only person here claiming to be able to read minds appears to be you, since you've failed to answer the basic question of whether or not your FP intended to send the specimen to path. That's the crux of your entire anecdote.

The bottom line is that you just don't know. Therefore, you shouldn't assume anything.

 

[MedicineDoc]

We work with patients. We know that a high percentage of them are A. Clueless B. Take away the wrong meaning despite how clearly it was spelled out C. Have set beliefs that defy any kind of logic. We also know that generally speaking anyone making it through med school and residency training is much less likely to be confused or possess characteristics such as the above. You being a lay person makes us naturally skeptical of the understanding you took away from your interactions/communications with your doctor. We after all deal with people who are largely clueless no matter what is said to them very frequently but hardly ever deal with completely clueless physicians, such as you describe, although we frequently interact with physicians as well.

 

[lowbudget]

Tree,
To me, I see your case differently than you do so I want to be very clear about what I say to avoid misinterpretation. Questions surrounding critical care fellowships and dermatology fellowships are questions about scope of practice (and secondarily, malpractice). To me, your case falls outside of that debate. Your case is one about patient satisfaction.

When we (... I) talk about a possible critical care fellowship for FP's, we talk about it in the context of medical access, health care inequities, and continuity of care. We talk about taking care of the patient better with advanced training in a place where critical care access is in shortage. It's the same thing when it comes to dermatology fellowship. The San Antonio fellowship is all about taking care of the underserved, something dermatologists are NOT interested in doing. Period. Nationwide. What these people are doing is already within the scope of a FP's practice, maybe on the edges, maybe pushing the envelope a little, but with proper training and recognition would still be within our scope.

Your case is different. As I read your case, the only way I can see if your FP would have been "wrong" is if your FP said that the mole was benign, don't worry about it (b/c ultimately it was BCC). But no. Your FP followed standard of care which was to move forward to make the diagnosis (be it via punch or excisional, both of which are within the scope of FM's practice). Now, whether or not your FP would be competent/qualified to perform it on the face is debatable. For me, I would not have. Not for an elective mole removal. Not in a community (like mine) where derm, plastics, and Moh's are easily accessible. But that's how I practice primary care in my community. To me, I think your FP was following protocol. I don't see a scope of practice issue (and hence potential malpractice for offering a procedure) and so I don't think anything wrong happened.

Which, leads me to conclude that this was a patient satisfaction issue. In your community, you have (in theory) easy access to derm/plastics/Moh's. Which, is why it was your expectation was for your FM doc to look at the lesion and give you a Moh's referral. But, instead, your doc wanted to take 1 extra step to "take care of it" prior to that referral, if necessary. Your FP's action did not meet your expectation. That's why you are dissatisfied with the care (despite the fact that she was following standard of care). You see?

If your family doctor had done a dermatology fellowship, it would not have made a difference. You still would have been dissatisfied! If anything, a fellowship-derm trained FP would be *more* likely to cut your face.

Now, don't get me wrong. I wasn't there, but in reading your presentation, I would have done things differently. I'm not saying if anyone was right or wrong. I'm just saying that this is how I would have approached the case. I would have said: Hmm, that's a messed up looking mole and I don't know if it's benign or malignant. I would have asked if the mole was concerning to you and what you would like to have done. I would have said that in general I don't cut face electively especially in people who care about cosmetic outcomes. I would have offered a consult/2nd opinion from a dermatologist; and given you the choice between having the mole "taken care of" now or wait for the referral to get processed and for you to get the appointment. To me, this is not an emergency so I don't particularly care. My hope is that my patient take their face away from here because I don't have a plan B if I jack it up. I don't do flaps. I don't do facial reconstruction. I don't do scar revisions. So to me, if I don't have clean margins, if your wound gets infected, or if you have a bad outcome that came directly from this procedure, I'm going to law school. And for what? $200? Sure, a mole removal pays better than a urinary tract infection but to me personally it's not worth it on your face. Some people don't care. When I offer plastics/derm to my country-folk patients, they laugh at me and say, "Doc, do I look like I care? Just take care it, I trust you and wanna get back to work".

So I think your family doc could have done the patient satisfaction piece better (and, possibly mitigate her procedural malpractice risk) by offering for derm/plastics/Moh's to do your procedure. But as far as I'm concerned with the medical management, I don't see anything wrong.

To me, your insurance and your local health care system set you up for disappointment. You had your expectations, and yet they forced you to see a doctor you already believed was not qualified to handle your case to handle your case. All your doctor was doing was following protocol...

So, why did you switch PCP's and not switch insurance?! Clearly, your insurance did you wrong. Clearly, your insurance restricted your access to a qualified onco-derm who would have been better qualified to handle your facial BCC. And yet you questioned the judgement of your PCP? And, unfortunately, for you, they only restrict derm! How messed up is that? Now that you are a BCC case, you *don't* want an FP doing your skin checks. To be your gatekeeper to derm? You don't want that! As I illustrated in my case, from here on out, you are dermatologists's annual skin check because your risk of BCC is so much higher than the average population. And, sounds like you live in the same type of community I work in with easy access to derm, which means, that the standard of care to manage your moles just got kicked up a couple of notches. Holler. As a BCC patient, you now need unrestricted access to a dermatologist. So why would you continue to go through a PCP?

So, if I were you, I would be smart, cut out the middle man, and drop your insurance because your new PCP will be working under the same constraints and disappointed again in the future. Your insurance is what is messed up, not family medicine. And not the need for family medicine to do more dermatology fellowships. Your insurance doesn't meet your expectations, so that is what needs to go. Do you see my point?

I know that in this day and age that people are more loyal to their insurance companies than they are to their family doctors. That's well known. When some insurance bureaucrat tells you to switch doctors, you switch doctors regardless of whether that doctor is doing the right thing for you or not. We are more likely to be anti-government yet pro-insurance company than we are pro-common sense. We don't need more rating systems or education on how to pick doctors. We need to educate people on how to buy insurance!

So I'm here to say no. I'm here to clear the debate. It's not about scope of practice. It's not about competency or length of training. This is about money. This is about patient satisfaction. This is about you not getting what you paid for and expected. You can't blame your FP if she did nothing wrong.

 

[Instatewaiter]

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.

It seems strange to me why an FM doc would want to go into critical care since the focus of FM and IM are so different. Most FM programs have minimal ICU time (1+ MICU months during the 3 years and per the ACGME website only need to take care of 15 ICU patients) in their training specifically because there is so much else to fit in. In IM, outpatient clinic time tends to be an after thought so the outpatient training is nowhere near as robust as FM. Similarly, because not only does OB, peds and IM have to be fit in but also a significant amount more clinic time, FM doesn't have much room for extra ICU time. Most IM programs have a about 3-6 months of ICU time and those going into CCM tend to do significantly more to get letters and experience. There just isn't that much room for that in FM training

 

[MedicineDoc]

In my residency we follow our patients wherever they go and take whatever comes up on the list whether it walks in the door or is carried in the door to the ER. We don't need multiple icu months to get icu experience. There is no IM at our hospital. Medicine is medicine no matter whether you try to break it into artificial separateness. Kids are not little aliens and pregnant women aren't mutants. Icu patients are not magically transformed into a different species that requires a different type of doctor no matter what kind of turf battles people try to wage.

 

[Bostonredsox]

In my residency we follow our patients wherever they go and take whatever comes up on the list whether it walks in the door or is carried in the door to the ER. We don't need multiple icu months to get icu experience. There is no IM at our hospital. Medicine is medicine no matter whether you try to break it into artificial separateness. Kids are not little aliens and pregnant women aren't mutants. Icu patients are not magically transformed into a different species that requires a different type of doctor no matter what kind of turf battles people try to wage.

Your program seems to have a robust amount of ICU time as compared with the norm. The FP residents at my hospital rotate with is on our ICU months but they do one month total in their 3 years (I am required to do 4, but as im going pulm/cc im doing another 2 plus 3 pulm consult months) and no night float, we cover their patients at night. Having had conversations with several of my old buddies from school who are FPs, the average FP CC exposure is more than they get at my place, but far less than they get at yours. So I think for the sake of argument, you can't use your house as the main example, as you guys are not the norm.

 

[lowbudget]

MedicineDoc's right in that there are a lot of curricular elements that you won't see if you simply glaze over the block curriculum chart. Most unopposed programs are structured in the way MedicineDoc described. Just because you have multiple blocks of ICU doesn't make you critical care competent either, especially if you have multiple layers of hierarchy and the diagnostic/decision making process is not in your hands.

 

[Reductio]

I'm really surprised by the heated arguments on this thread. I think a LOT of it stems from totally different ideas of the purpose of advanced training.

First of all, for an internist, pediatrician, or surgeon, a fellowship means a departure from general practice and the focus on NOTHING BUT the specialty of cardiology, ID, plastics, vascular, etc.

In my experience I've seen that a fellowship means something entirely different to most FPs, psychiatrists. From what I've seen, many FPs and psychiatrists plan/do fellowships to be able to provide better care for their patients. It doesn't seem to be about changing their practice setting, its about changing the practitioner to fit the setting.

I've talked to many FP residents and attendings who plan/did fellowships in adolescent, Addiction, OB, rural, because they wanted to be better clinicians in their general practice. for their (regional) patient population. I know psych residents who are planning on doing fellowships to advance their skill at talk-therapy, since they focus more on Rx in residency nowadays - they aren't trying to become counsellors.

Nobody is saying that an FP with 1 year of CC fellowship is an "Intensivist", just like nobody is saying a FP with a year of Addiction fellowship is an "Addiction Psychiatrist", or a year of OB Fellowship is an "OB/Gyn". Full-spectrum FPs do deliveries, and we know that lately, many FP residencies are doing the bare minimum in OB training. So, some FPs do a fellowship to strengthen their weak points. I happen to think this is a very admirable quality, that's not commonly seen.

I'm surprised that the FPs here didn't pick up on this.

I'm an IM resident. On the IM interview trail, and from what Ive learned from my friends, many midwestern hospitals, have generalists (IM and FP) following their patients into the ICU. There are huge regional medical centers that dont have any Intensivists. General IM and FP docs have to manage their own patients, and I'd guess that younger FP docs may be less comfortable with this since they have fewer total ICU/Cardio/Nephro/Pulm/ID/Inpatient months.

Generalists follow ICU patients in many other non-academic community hospitals all over the country.

What's wrong with letting an FP who wants to be comfortable with following their ICU patients have some extra training in doing so?... especially given the fact that it's something that they have to do in their practice already?

 

[Hernandez]

I'm really

To me i don't see people saying FM can't do CC with a fellowship, but several of us were offended at the suggestion that a straight CC docs have nothing to offer. and one Fm poster made it sound that CC is worthless as he can run a ice w/o fellowship well already

 

[MedicineDoc]

I don't need a fellowship to take care of patients in the icu. Just because you have been taught in an environment where intensivist have suceeded in their power grab of locking other docs out of the icu doesn't mean it's a model handed down from God as the one true way of delivering quality healthcare. This is not an isolated opinion. There are many doctors who practice in ICUs all over the country who have seen both methods and agree with me that patient care is not measured by how many catheters you have stuck in the patient. My opinion is shared not just by fm docs. There are many different mds who practice in the icu without cc fellowships and are very comfortable there. In fact most of the doctors of all specialties at our hospital are comfortable in the icu. I resent the fact that you imply we practice substandard care.

 

[Reductio]

I don't need a fellowship to take care of patients in the icu. Just because you have been taught in an environment where intensivist have suceeded in their power grab of locking other docs out of the icu doesn't mean it's a model handed down from God as the one true way of delivering quality healthcare. This is not an isolated opinion. There are many doctors who practice in ICUs all over the country who have seen both methods and agree with me that patient care is not measured by how many catheters you have stuck in the patient. My opinion is shared not just by fm docs. There are many different mds who practice in the icu without cc fellowships and are very comfortable there. In fact most of the doctors of all specialties at our hospital are comfortable in the icu. I resent the fact that you imply we practice substandard care.

To me i don't see people saying FM can't do CC with a fellowship, but several of us were offended at the suggestion that a straight CC docs have nothing to offer. and one Fm poster made it sound that CC is worthless as he can run a ice w/o fellowship well already

Oh, I had previously ignored the sideshow.

 

[Hernandez]

I don't need a fellowship to take care of patients in the icu. Just because you have been taught in an environment where intensivist have suceeded in their power grab of locking other docs out of the icu doesn't mean it's a model handed down from God as the one true way of delivering quality healthcare. This is not an isolated opinion. There are many doctors who practice in ICUs all over the country who have seen both methods and agree with me that patient care is not measured by how many catheters you have stuck in the patient. My opinion is shared not just by fm docs. There are many different mds who practice in the icu without cc fellowships and are very comfortable there. In fact most of the doctors of all specialties at our hospital are comfortable in the icu. I resent the fact that you imply we practice substandard care.

Clearly you have either self esteem issues or reading comprehension issues. No where did I state any of the above. My only observation of you is that you're an angry defensive doc who apparently has issues with critical care folk.

My personal bias is that a closed icu is better and there is decent data to back that up on certain measures ( length o stay, mortality, addressing end of life issues, and cost). I've worked in both models and even seen s closed icu run by IM docs and both models work, my biggest concerns with your model that I've seen are IM/FM docs who do the out pt/in-pt concurrently and are damn near impossible to reach and are never within easy ccess for them to get to the ICU when things go wrong. Thy would essential consult enough people that they hoped they had enough coverage. Or even worse, their NP walks in and out why the house officer is doing the lines, running the code, etc and then they walk out without touching the pt to write a nice pretty note that includes 45 cc time.

What I like about the closed intensivist run model is that were avaiable at a seconds notce to address issues, we can stay up to date on all the literature, and frankly, sometimes a pt needs a doc who doesn't have other obligations to stay at theirs bedside to make multiple adjustments each day, of more importantly to have detailed end of life discussions with family.

The part time available fm/Im docs who ran the models I've seen can do none of that with consistency

 

[MedicineDoc]

Clearly anyone who doesn't agree with you is a *******. That must make the world a very simple place for you and free up that huge brain that is like a loaded shotgun for doing things that no one but you is capable of.

 

[VA Hopeful Dr]

Clearly anyone who doesn't agree with you is a *******. That must make the world a very simple place for you and free up that huge brain that is like a loaded shotgun for doing things that no one but you is capable of.

I fail to see the need for this hostility. Both of the CC fellows that have been in this thread have said they see no problem with us taking care of ICU patients. That's what you want, right?

They then say that CC trained intensivists are better at dealing with ICU patients than most FM docs. The studies reflect that, and common sense suggests that. Why the outrage?

 

[lowbudget]

What I like about the closed intensivist run model is that were avaiable at a seconds notce to address issues, we can stay up to date on all the literature, and frankly, sometimes a pt needs a doc who doesn't have other obligations to stay at theirs bedside to make multiple adjustments each day, of more importantly to have detailed end of life discussions with family.

The part time available fm/Im docs who ran the models I've seen can do none of that with consistency

Agree with some of the abvoe advantages of a closed system with intensivist coverage.

One huge disadvantage that threatens patient care is the hand-off. The 1-on-1-off or 2-on-2-off leads to change in strategy and many times the wheel is reinvented. On the other hand, sometimes it's nice transitioning out a less competent intensivist in lieu of one that's better or one with a fresher look.

The other hand-off risk is in the step down. When intensivists transfers patient out of the ICU, there's a big no-man's land with no clear strategy if the primary was not involved during the patient's ICU stay. The step down risk can sometimes be pretty big, especially when the step down was forced as a matter of bed management (i.e. someone more critical who needs that ICU bed).

As primaries, we do the best we can to fill the gaps where there are glaring system flaws that can fail the patient. Articles and data don't live my day-to-day. I too believe that a closed system is not the be-all-end-all of ICU systems; hence a big proponent for increasing opportunities for training and increasing the spread of critical care knowledge.

 

[MedicineDoc]

I'm not anywhere near outraged. That is you're interepretation. You are just annoying as they are with you're similar liberties with assumptions that you base arguments on. Opinions stated as fact automatically annoy me as do study findings applied with sweeping brush strokes. I am entitled to my opinion (which is pretty commonly held by the way) without having my reading comprehension called into a question by a guy who afterall didn't graduate from the I'm smarter than you medical school.

 

[smq123]

I'm not anywhere near outraged. That is you're interepretation. You are just annoying as they are with you're similar liberties with assumptions that you base arguments on. Opinions stated as fact automatically annoy me as do study findings applied with sweeping brush strokes. I am entitled to my opinion (which is pretty commonly held by the way) without having my reading comprehension called into a question by a guy who afterall didn't graduate from the I'm smarter than you medical school.

Perhaps you are not outraged, but your tone suggests a lot of hostility, whether or not you realize it. Hernandez has not said anything rude, insulting, or wrong, so there is no need to accuse him of thinking that all who disagree with him are "*******es."

 

[MedicineDoc]

Perhaps you are not outraged, but your tone suggests a lot of hostility, whether or not you realize it. Hernandez has not said anything rude, insulting, or wrong, so there is no need to accuse him of thinking that all who disagree with him are "*******es."

I invite you to go back and read the thread. I'm sure not going to do it. I already know the garbage arguments and false argument techniques employed.

 

[smq123]

I invite you to go back and read the thread. I'm sure not going to do it. I already know the garbage arguments and false argument techniques employed.

I have been reading the thread, and just went back to re-read it. I have not seen much of the "garbage arguments" or "false argument techniques" that you mention, but I HAVE noticed an undercurrent of hostility and defensiveness in your posts. This undercurrent has, in all honesty, detracted from an otherwise civil and interesting discussion.

I have no problem admitting that having mandatory Pulm/CC backup for all patients, and even a closed ICU, is probably beneficial. And that, honestly, even I, as an FM resident, would be a little hesitant to have a loved one cared for by a non-CC trained family doc while in an ICU.

My sister did IM, followed by Pulm/CC. There are things she will do better than me - bronchs, caring for ICU patients, etc. And there are things I will do better than her - even as an intern, my knowledge of peds and OB was better. I can insert IUDs and do colpos better than she can. There are things that FM does better, and things that CC does better. There is no shame in saying that, and your insistence that you can handle the average ICU patient just as well as a fellowship trained CC guy can makes us FM guys look bad.

 

[MedicineDoc]

I have been reading the thread, and just went back to re-read it. I have not seen much of the "garbage arguments" or "false argument techniques" that you mention, but I HAVE noticed an undercurrent of hostility and defensiveness in your posts. This undercurrent has, in all honesty, detracted from an otherwise civil and interesting discussion.

I have no problem admitting that having mandatory Pulm/CC backup for all patients, and even a closed ICU, is probably beneficial. And that, honestly, even I, as an FM resident, would be a little hesitant to have a loved one cared for by a non-CC trained family doc while in an ICU.

My sister did IM, followed by Pulm/CC. There are things she will do better than me - bronchs, caring for ICU patients, etc. And there are things I will do better than her - even as an intern, my knowledge of peds and OB was better. I can insert IUDs and do colpos better than she can. There are things that FM does better, and things that CC does better. There is no shame in saying that, and your insistence that you can handle the average ICU patient just as well as a fellowship trained CC guy can makes us FM guys look bad.

I suggest that only obgyns should do ob and colposcopy because they are "better at it than FM" there is no shame in admiiting that and you should stick to the things "we FMs" do well. No one in my program does colposcopy. Does that help you realize how ignorant you sound? My aunt is an ob does that help you see how knowledgeable and qualified I am to be telling you this? After all you are making us look bad doing this ob gym stuff. Look there are FMs that do alot of cc obviously you're not one of them. Who are you to tell anyone what area they should practice. I like many of the residents in my program am signed as a hospitalist. Many others in my program work in the ER along side board certified ER docs. We don't do colposcopies. We don't do IUDs and don't give a crap about them.You sound as immature as they do. You're not an expert on this subject so why are you so vocal? They are barely out of residency themselves. You are doing a fine job of "looking bad" and don't need anyone to help you "look bad" rest assured.

 

[smq123]

I suggest that only obgyns should do ob and colposcopy because they are "better at it than FM" there is no shame in admiiting that and you should stick to the things "we FMs" do well. No one in my program does colposcopy. Does that help you realize how ignorant you sound? My aunt is an ob does that help you see how knowledgeable and qualified I am to be telling you this? After all you are making us look bad doing this ob gym stuff. Look there are FMs that do alot of cc obviously you're not one of them. Who are you to tell anyone what area they should practice. I like many of the residents in my program am signed as a hospitalist. Many others in my program work in the ER along side board certified ER docs. We don't do colposcopies. We don't do IUDs and don't give a crap about them.You sound as immature as they do. You're not an expert on this subject so why are you so vocal? They are barely out of residency themselves. You are doing a fine job of "looking bad" and don't need anyone to help you "look bad" rest assured.

A more appropriate analogy would be if I had said that there is little value in doing an OB residency, which is not what I said. I never said that I could do a colposcopy just as well as an OB/gyn could, although you've basically been saying that you can do critical care as well as a fellowship-trained critical care doctor.

If a patient has LGSIL or ASCUS with HPV on pap, I can do the routine colpo. If they have HGSIL (or worse), I would send them to OB/gyn, though. If they need a LEEP or a cone, they should go to the specialist.

I can do a routine IUD in a woman with a normal uterus. If she has a uterine anomaly, or wants something more permanent (i.e. Essure), then I would refer her to an OB. Again, I didn't say that I "just as good" as an OB, but that I can do routine stuff.

I can manage a routine vaginal delivery. There is NO WAY that I'd manage twins, patients with known history of shoulder dystocia, etc.

I don't doubt that you could manage a moderately sick ICU patient. But, I think it is disingenuous to suggest that you can do critical care "as well as" a Pulm/CC boarded physician. I'm not saying that you shouldn't do any critical care at all, so don't accuse me of telling you what not to practice. But claiming that FPs can do CC "as well as" someone who is in critical care is, like I said, naive and a little disingenuous. And a little dangerous.

Finally, my first point to you was to please go back and REREAD YOUR OWN POSTS. Your tone is a lot more hostile and angry than you seem to realize. While things have (sort of) remained civil so far, if they don't stay that way then the thread should get locked.

 

[MedicineDoc]

I said that I believe that our icu patients get as good care or better than those patients in a closed icu. I didn't say I thought I was a critical care specialist and that is what it reads above. Let's say we have joeblow critical care "genius" managing the patients maybe he doesn't consult pulmonology where I would have or maybe he feels super strong and doesn't consult anybody because he is the all knowing critical care fellow. Who gets the better care? I am capable of getting my patients what they need with the help of consultants that is what I said and no matter how many times you or anyone else put words in my mouth that is still what it says above.

 

[Reductio]

I said that I believe that our icu patients get as good care or better than those patients in a closed icu. I didn't say I thought I was a critical care specialist and that is what it reads above. Let's say we have joeblow critical care "genius" managing the patients maybe he doesn't consult pulmonology where I would have or maybe he feels super strong and doesn't consult anybody because he is the all knowing critical care fellow. Who gets the better care? I am capable of getting my patients what they need with the help of consultants that is what I said and no matter how many times you or anyone else put words in my mouth that is still what it says above.

It appears that you don't know what an Intensivist is, nor do you know what a "closed ICU is"

first of all - Said "critical care genius" probably isn't getting a Pulm consult because there is a 90% chance that said critical care genius is also a BC/BE Pulmonologist.

Intensivists don't consult?? Have you EVER worked with an Intensivist in your life? The only consult an intensivist might not regularly request is Pulmonlogy. For the rationale behind this, see above.

You're capable of getting your "patients what they need with the help of consultants". Who are these consults? You said you "would have" consulted Pulmonology. If so, guess what? You've essentially just consulted an intensivist (see above). If an Intensivist doesn't consult Pulm, see above for the rationale. Who else.... Cardiology? ID?, Nephro? Realize, that's no different than what the Intensivist would have done. Except, YOU, cost the patient another few-hundred$ by requesting a separate Pulm consult.

Closed vs. Open ICUs... You're suffering from butt-hurt because you have to hand off the patient to another Primary in the Closed ICU. (I believe that "butt-hurt" is the technical term here on the SDN). That IS the only real difference between closed and open ICUs, you know. But that's OK, you're a good FP that wants to be involved as the PCP, I'll give you that. Just remember that the Intensivist is also a BC/BE GENERAL INTERNIST.

If you don't believe the LeapFrog data... can we agree on the data coming from Primary Care? Theres a lot of talk these days about coordinated care, and the patient-centered medical home. If the PCP, Pulmonologist, and the specialist who's managing the Pressors, CVVH, and Sepsis - whether thats the Cards/Nephro/ID, or a CC... if all 3/4/5 of those where the SAME PERSON... Doesn't it make sense that the care would be more coordinated?

A good solution for you, would simply be to work in a system with an open ICU. Then, you could remain as the PCP, and consult all you want. You could even consult a Pulm/CC doc, and still be the Primary. Problem solved.

 

[jdh71]

Clearly you have either self esteem issues or reading comprehension issues. No where did I state any of the above. My only observation of you is that you're an angry defensive doc who apparently has issues with critical care folk.

What I like about the closed intensivist run model is that were avaiable at a seconds notce to address issues, we can stay up to date on all the literature, and frankly, sometimes a pt needs a doc who doesn't have other obligations to stay at theirs bedside to make multiple adjustments each day, of more importantly to have detailed end of life discussions with family.

The part time available fm/Im docs who ran the models I've seen can do none of that with consistency

I agree, especially the data demonstrating the benefit from an inhouse intensivist overnight. You simply cannot take as good of care of a patient at home from bed as you can from the hospital, or from the clinic.

By analogy a guy who's spent his training and career doing critical care will not be as good at ambulatory medicine, even if he can consult the **** out of every other service. Someone needs to keep all the pieces of the puzzle together, and that someone should be a person who is most familiar.

Morbidity, mortality, length of stay, and cost . . . these are not abstract or odd end points. They matter.

While I agree everyone got to do what they got to do, I think a little humility is in order.

 

[EdibleEgg]

smq123--- I understand the gist of your original statement, but you are on a slippery slope. You should be "just as good as" an OB at any procedure you do. If you are not, then you should refer. You are held to the same standard. By the way, if not the best, then one of the best colposcopists in the US is an FP.

There is definitely value in a CC fellowship. Most Intensivists I know are sharp. Closed ICU's are crap, though. I know when I need help.

The sort of argument laid out in this thread is always funny to me. Be as proud as you want, if you practice long enough, there will at least be a moment when you wish there was an intensivist around. But on the other hand, I'm always amazed at how much more capable I am managing vents and pressors at three in the morning when the patient has no insurance that I am at noon with an insured patient.

 

[MedicineDoc]

:


OK, you're a good FP that wants to be involved as the PCP, I'll give you that. Just remember that the Intensivist is also a BC/BE GENERAL INTERNIST.


A good solution for you, would simply be to work in a system with an open ICU. Then, you could remain as the PCP, and consult all you want. You could even consult a Pulm/CC doc, and still be the Primary. Problem solved.

First off "BC/BE internist" does not impress me" We are both IM and FM at our institution. We consult when needed and not for pressors in sepsis or any other easily handled situations. Yes I consult for vent management if they are super sick. Yes I consult cards if there is an underlying cardiac issue like an mi knowing full well that the answer will be if the patient is septic "get him better and we will deal with the cad when he is over his infection. The fact is the surviving sepsis campaign is more a way to die than a way to live, no one even does swans anymore as they haven't been shown to improve outcomes and I'm perfectly able to choose antibiotic therapy and dose it renaly or whatever the need may be. Fancy vent modes have not been shown to improve mortality. As long as the plateau pressure is doing okay and there is mo autopeep or other problems I can wean the patient based on abgs. I can most of the time guess what our pulmonologist will do. I look over what is being done and sometimes consult nephrology or whatever just to get a fresh mind whom I know and respect to take a look at the patient if they aren't doing well and stay away from obnoxious specialist attendings who don't want any part of a sick patient unless they are on call and I absolutely need their specialty then i.e. the patient is likely septic and needs a stent to drain the kidney of pus backed up behind a stone. If we don't have the specialist needed I get them the hell out of there ( I.e. One of my pts that had A dissecting thoracic aneurysm or a patient with a bone marrow transplant with pericarditis/cardiac tamponade after having cards draining the tamponade) and likely graft vs host