LiamNeesons

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Is it possible for a private practice family practitioner to become dual boarded in EM and to also do occasional appendectomies?
 

primadonna22274

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FM/EM double boards, yes.
Appys?! Not likely. That's surgery and while there are rural FM programs that train you to do appys, lap choles, C-sections and BTLs, unless you are truly backwoods RURAL it is unlikely you will do ALL of these things. I can't imagine why you would want to--not worth the risk and very low reimbursement IMO. And I'm someone with a lot of experience who enjoys a broad scope of practice and procedures....
 

emedpa

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if memory serves there are several unopposed fp residencies like ventura county which teach appys , trauma, c-sections, etc
 

notinkansas

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Having been in a general surgery residency I'd be very, VERY careful about trying to do things like appys as FM. Even C sections. There is a reason surgery is a different residency. Appys aren't like I&D. Yes, some are fairly straighforward. But what happens when you think it's appendicitis and it's not? What happens when there is a complication? Would you be prepared to chisel through a bunch of adhesions without perforating the bowel? Are you going to be able to find a surgeon to call in the middle of the night to happily come in and bail you out when you took a pt to the OR for an appy and they turned out to have a tumor causing a SBO? Remember, just because you can, (and because some people do) doesn't mean you should.

With Csections- unless you go to a very OB heavy program, you're unlikely to have enough numbers to give you adequate experience without doing a fellowship.
 

cabinbuilder

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Is it possible for a private practice family practitioner to become dual boarded in EM and to also do occasional appendectomies?
You won't have time to do everything in real practice. I doubt you will find an employer outside of Montana or the Dakotas what will even let you do appys and even with that how you would keep your numbers and skills up is another problem. Not seeing it. Sounds like you need to decide what is most important to you? Surgery, EM, or Full scope FP.
 
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LiamNeesons

LiamNeesons

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FP work in ERs all of the time. Is it really that difficult to remember how to do an appendectomy, complications included? I wouldn't necessarily want to utilize my full skill set on a weekly basis, but having the flexibility to focus on different areas if I get burned out is attractive. If you get rusty on a procedure can you observe a colleague until your comfortable again?
 

cabinbuilder

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FP work in ERs all of the time. Is it really that difficult to remember how to do an appendectomy, complications included? I wouldn't necessarily want to utilize my full skill set on a weekly basis, but having the flexibility to focus on different areas if I get burned out is attractive. If you get rusty on a procedure can you observe a colleague until your comfortable again?
FP work in ERs all of the time: this I know, it's how I make half of my living on a regular basis.

It really comes down to what your employer will let you do based on experience, how often you do the procedure and their malpractice policy. Being "rusty" on a procedure say colonoscopies is a huge difference than doing surgery. Even with colonoscopies if you haven't done so many in 2 years then you likely would have to go to CME, then be proctored by a surgeon (if there is one where you work) and this is IF the equipment and staff are available and your employer's malpractice will cover you. Plus, say you do a colonoscopy and you perforate the colon? Is there a general surgeon on site who can bail you out? Or will that person need to be shipped to the nearest facility that has a surgeon? Lots of factors that can determine what you can/can't do or what is feasible given potential complications and the availability of support staff.
 
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if memory serves there are several unopposed fp residencies like ventura county which teach appys , trauma, c-sections, etc
I'm a resident at Ventura, and just want to clarify some of the above. Like people have commented above, tons of FM docs work in ERs - our ER is predominantly staffed with FM folks, we do 4 x the ACGME requirement for ER hours in FM residency, and graduates are pretty competent in this area and can hit the ground running. We are also a trauma center, all get certified in Advanced Trauma Life Support during intern year, and have lots of experience running trauma codes, doing procedures during traumas, etc,- we're not trauma surgeons, of course, but we're first assist on all trauma surgeries. We are also the *primary* on all c-sections in the hospital with attendings serving as first assist for backup. Everyone here does some c-sections as part of their regular rotations, and people can sign up for extra call shifts for sections, so people graduate with a range of experience. There were a couple of people who were primary on around 100 sections by the time they graduated last year. (Whether or not this equates to getting privileges at a given hospital in the future is a separate question that depends on the hospital.) Some people go on to do OB fellowships for even more experience (we have an OB and a MCH fellowship here) or just go on to practice.

As far as appendectomies, part of the original question, I think it's fairly safe to say that Ventura is one of the most surgery-heavy programs, if not the most surgery-heavy. Historically, this is the place that people would come to learn open appys, choles, etc, and would go on to use those skills in the future. (an extreme example is this guy: http://bereadventisthospital.blogspot.com/, a graduate from a little while back who functions as a general surgeon in Chad.) HOWEVER, the standard of care in this country has changed over the last 10-20 years such that almost all appys & choles start out as laparoscopic and only some go on to become open procedures. Despite our desire to learn this skill set, we give our patients the best care, which means that we do way fewer open procedures than we did 2 decades ago. The important issue with this is that it takes a much larger number of procedures to initially become competent, and then a much larger number per year to remain competent, with lap vs open procedures. So it is no longer the case that a person could routinely come to Ventura and expect to graduate as a FM doc competent in open appys and choles. That world just doesn't exist any more, because it's not the best care for our patients. And I can't 100% guarantee it because I haven't trained everywhere, but I think it is reasonable to say that if that is the case in Ventura, it is probably the case everywhere in the U.S. for people in residency in this decade, because I'm not aware of places that do significantly more surgery training than we do.

That said, we still do do a lot of surgery, and we get really good at it. We are first assist on *all* general surgery cases - if we aren't there, there aren't really back up first assist people - we are it. We are first assist on all trauma cases. We are sometimes first assist on specialty cases depending on if we are available to scrub in. So we still get really solid surgery skills, but we are getting those skills in 2014 in the U.S. in the context of providing top of the line care to our patients.

Hope that clarifies a bit.
 

addy

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I'm a resident at Ventura, and just want to clarify some of the above. Like people have commented above, tons of FM docs work in ERs - our ER is predominantly staffed with FM folks, we do 4 x the ACGME requirement for ER hours in FM residency, and graduates are pretty competent in this area and can hit the ground running. We are also a trauma center, all get certified in Advanced Trauma Life Support during intern year, and have lots of experience running trauma codes, doing procedures during traumas, etc,- we're not trauma surgeons, of course, but we're first assist on all trauma surgeries. We are also the *primary* on all c-sections in the hospital with attendings serving as first assist for backup. Everyone here does some c-sections as part of their regular rotations, and people can sign up for extra call shifts for sections, so people graduate with a range of experience. There were a couple of people who were primary on around 100 sections by the time they graduated last year. (Whether or not this equates to getting privileges at a given hospital in the future is a separate question that depends on the hospital.) Some people go on to do OB fellowships for even more experience (we have an OB and a MCH fellowship here) or just go on to practice.

As far as appendectomies, part of the original question, I think it's fairly safe to say that Ventura is one of the most surgery-heavy programs, if not the most surgery-heavy. Historically, this is the place that people would come to learn open appys, choles, etc, and would go on to use those skills in the future. (an extreme example is this guy: http://bereadventisthospital.blogspot.com/, a graduate from a little while back who functions as a general surgeon in Chad.) HOWEVER, the standard of care in this country has changed over the last 10-20 years such that almost all appys & choles start out as laparoscopic and only some go on to become open procedures. Despite our desire to learn this skill set, we give our patients the best care, which means that we do way fewer open procedures than we did 2 decades ago. The important issue with this is that it takes a much larger number of procedures to initially become competent, and then a much larger number per year to remain competent, with lap vs open procedures. So it is no longer the case that a person could routinely come to Ventura and expect to graduate as a FM doc competent in open appys and choles. That world just doesn't exist any more, because it's not the best care for our patients. And I can't 100% guarantee it because I haven't trained everywhere, but I think it is reasonable to say that if that is the case in Ventura, it is probably the case everywhere in the U.S. for people in residency in this decade, because I'm not aware of places that do significantly more surgery training than we do.

That said, we still do do a lot of surgery, and we get really good at it. We are first assist on *all* general surgery cases - if we aren't there, there aren't really back up first assist people - we are it. We are first assist on all trauma cases. We are sometimes first assist on specialty cases depending on if we are available to scrub in. So we still get really solid surgery skills, but we are getting those skills in 2014 in the U.S. in the context of providing top of the line care to our patients.

Hope that clarifies a bit.
I'm sorry if this is a stupid question but---what's the appeal of being first assist on all general surgery cases if you're not going to be making anything of that OR experience?
 

eddieberetta

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I'm sorry if this is a stupid question but---what's the appeal of being first assist on all general surgery cases if you're not going to be making anything of that OR experience?
Nil
 

MadHopsMD

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Is it possible for a private practice family practitioner to become dual boarded in EM and to also do occasional appendectomies?
Its really neat to have surgical privileges to do C-sections or even appies. But the question is WILL you find a JOB that lets you do all this? There are just few jobs out there that let you have hospital privileges to do surgery.

Even in really rural places, more and more OB/GYN and Surgeons are being placed there. I have visited many programs across the country during the interview season, and jobs to do C-Sections for example as FM are very hard to come by. I know more than a few FM who did OB fellowship who do not have surgery privileges. They are disappointed by it, because its almost a waste of a fellowship. THe reason they cant perform C-section is not only politics in the hospital or malpractice insurance rates, but in order to keep your skills up you need to do at least 2-3 csections a week...that volume is just isn't there at least in the US. If you want to work overseas, then I do not know.

As for EM. Yes after you finish your FM rotation you can work in EMs. But again, if you are looking to work in a relative large city, you might not get paid the same amount as board certified ER physician who work in the hospital. In order to get paid you might have to do a fellowship.
 
Jan 18, 2013
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I'm sorry if this is a stupid question but---what's the appeal of being first assist on all general surgery cases if you're not going to be making anything of that OR experience?
It's not a stupid question at all, and there are several different things I'd say about it, and probably other people have comments too.

In the first place, in any specialty there will be things that you do in residency that you don't do later, and that's not a problem. That's the same here as it is anywhere - some but not all of our graduates go on to work in ICUs, and some but not all go on to deliver babies - but having had positions of responsibility in those areas helps inform the roles that we do take on in the future, and especially as family medicine docs, gives us insight into many of the health care experiences our patients have as full human beings beyond the direct care that we provide for them, and can help us give them perspective on the advice they get from surgical specialists in the future. Some folks here, like the guy I linked to above, actually do go on to do lots of surgery.

Second, residency is more interesting when you are actually *doing stuff* rather than looking on from the sidelines. All FM residents are required to do at least some surgery by the ACGME or AOA, and I'd much rather be first assist than standing around twiddling my thumbs or limiting myself to scut work and post op checks. I think that's probably true of all my fellow residents. Doing things while you're a resident is more interesting even if you plan to work just in outpatient private practice in the suburbs in the future.

Third, getting comfortable with bodies and instruments while developing a deeper sense of confidence and anatomical acumen helps in other areas of medicine. Maybe I won't be taking out gall bladders single-handedly in the future. But I can say with certainty that my time first assisting on general surgery cases has contributed dramatically to my ability to walk into an OR and competently be the primary surgeon on a cesarean delivery, which is absolutely something that I do plan to do in the future. It also means that I am more comfortable in the ER trauma bay putting in a chest tube - or as a few of us (but not me) have done, open a chest in the ER to perform direct cardiac massage. Even with simple things like suturing lacerations in the Urgent Care are easier because our role in the OR builds our skills and competence with our hands. There is a cross over in what you learn there to areas that you (or at least I) will likely be practicing in the future.

And lastly, being first assist in the OR maybe makes more of a difference here than in many other residencies in the country, because we send people out in the world who actually DO do this stuff, whether it's in Chad or China or Honduras or Nepal, or super rural Alaska or Idaho out on a First Nations reservation in the Southwest - places where having a second set of skilled hands (or in some cases, the only set of skilled hands) can make an enormous impact. Not everyone who trains here aspires to that kind of work, and not everyone who aspires to it will do it, but there is a role in the world for full spectrum family medicine, and we aim to train people in that to prepare them to walk into those roles if they so chose. And part of that training is surgical, and so it is much more meaningful to be first assist.

Probably other people have other perspectives on you (not stupid) questions, but for me, that's what I value about our surgical experience here.
 
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cabinbuilder

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Excellent!!!! VenturaResident. A LOT of what you said holds true to what I do out in the wilds. Confidence is the KEY especially when you are out there alone for 100's of miles.
 

naranoth

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sorry to post a little late on a thread, but I found this one very interesting. As a surgery resident that has performed numerous resident only (R2+R3) open appis at a county hospital, I cannot imagine feeling comfortable doing the procedure without the knowledge that an ex lap is possible if there is any suspicion for bowel injury/cancer.

The real reason I wanted to comment though is to second what venturaresident is saying...getting familiar with other specialties makes you a much better doctor. I remember being a surgery intern and being forced by an attending to consult medicine/FM for glucose mgmt in a patient with an A1c of 5 and a postop glucose of 270 on D5 and off home meds...I'm assuming some of you have been on the receiving end of that consult. In the same grain, seeing a patient in the ER at 2am with an incidental finding of gallstones on an ultrasound 2 weeks ago for diffuse abdominal pain who was sent in by her PCP hurts.
 
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From your other posts, you appear to be either a practicing or an aspiring radiologist. That makes me not very convinced of your insight into (and not very interested in your perspective on) full spectrum family medicine. But if I have any radiology questions I'll be sure to shoot them your way, thanks.
What's the pay like for being first assist on a surgery, is it worthwhile.