FM vs IM for practicing in the Southwest?

[UncreativeGenius]

Hey all. I'm an MS3 debating between FM and IM. After residency I'll definitely be looking to work in SoCal, Arizona, or Nevada (for family reasons) and I'm trying to figure out if being FM or IM would make a major difference when it comes to finding PCP jobs in those places. From my cursory search on Google, it seems like FM may be slightly more sought after? Am I totally off the mark? For reference, I would be looking at major metro areas like LA, PHX, LV etc.

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[surfnsnow]

The job market is wide open in both specialties! Don't use that to make your decision.
Do you like outpatient or inpatient ?
Do you want to see adults only or kids as well? Do you like women's health (OB/ gyn?)
Are you set on primary care? Or do you see yourself specializing? (IM has way more options)

I am FM but I have friends in IM as well. Both great options

 

[UncreativeGenius]

The job market is wide open in both specialties! Don't use that to make your decision.
Do you like outpatient or inpatient ?
Do you want to see adults only or kids as well? Do you like women's health (OB/ gyn?)
Are you set on primary care? Or do you see yourself specializing? (IM has way more options)

I am FM but I have friends in IM as well. Both great options

That definitely makes me feel better, thanks!

I'm pretty set on outpatient primary care at this point, and I enjoyed my peds and OBGYN rotations (but don't feel like I need both in the future). FM really sounds so flexible and versatile which is awesome. I think one of the things that concerns me about it though is, it seems hard to have to switch your mindset from patient to patient (e.g. going from an 85 year old well check to a 6 year old with constipation). It's like a completely different set of differentials/screening things to consider. Is that something that just gets better with time and experience during/after residency?

 

[AlbinoHawk DO]

Having trained in IM, I can hopefully give you some perspective on the IM side

I think in IM, it is better to pick a primary care track residency. The main advantage with IM is a better understanding of hospital management and more time spent in specialty clinics like rheumatology, nephrology, etc. This is not to say FM doesn't get this at all. It's just a difference of allotted time

On the FM side, on average, your time spent on PCP clinic is larger. It's also more common to get training in procedures. Then there's the obvious pediatrics and ob/gyn training. Although IM has the option to rotate in psychiatry, dermatology, and sports medicine, that training is core in FM instead of optional

The downside i think there is in the present day world for FM is that they are losing ground on pediatrics and obstetrics work (unless rural), so if your goal is those populations, just don't be surprised if your practice is more like 80% adult and 20% the other

The downside to IM is obviously the lack of peds and obstetrics and that you'll spend more time in hospital medicine than you probably care for with being outpatient PCP

I hope this helps

 

[UncreativeGenius]

Having trained in IM, I can hopefully give you some perspective on the IM side

I think in IM, it is better to pick a primary care track residency. The main advantage with IM is a better understanding of hospital management and more time spent in specialty clinics like rheumatology, nephrology, etc. This is not to say FM doesn't get this at all. It's just a difference of allotted time

On the FM side, on average, your time spent on PCP clinic is larger. It's also more common to get training in procedures. Then there's the obvious pediatrics and ob/gyn training. Although IM has the option to rotate in psychiatry, dermatology, and sports medicine, that training is core in FM instead of optional

The downside i think there is in the present day world for FM is that they are losing ground on pediatrics and obstetrics work (unless rural), so if your goal is those populations, just don't be surprised if your practice is more like 80% adult and 20% the other

The downside to IM is obviously the lack of peds and obstetrics and that you'll spend more time in hospital medicine than you probably care for with being outpatient PCP

I hope this helps

That is a really helpful point, thank you! I am definitely between IM-PC track and FM at this point. I was thinking that one aspect that might be more heavily emphasized in FM residency than even primary care track IM is urgent care/ED rotations. Is that true? I think I'd like to have acute/sick visits in my future theoretical practice, and I'm worried IM wouldn't provide enough exposure to handle run of the mill urgent complaints. But maybe I'm totally off?

 

[AlbinoHawk DO]

That is a really helpful point, thank you! I am definitely between IM-PC track and FM at this point. I was thinking that one aspect that might be more heavily emphasized in FM residency than even primary care track IM is urgent care/ED rotations. Is that true? I think I'd like to have acute/sick visits in my future theoretical practice, and I'm worried IM wouldn't provide enough exposure to handle run of the mill urgent complaints. But maybe I'm totally off?

Competlely off. The stuff you'd see in an urgent care would be things that would be very simple for any IM doctor. How could you handle an ICU patient but not someone with an urgent care complaint?

EM is not really helpful either. Any advanced skills you'd get from EM wouldn't translate to clinic work. The only reason you do EM for FM is to really understand what happens there when you send someone or someone who comes to your clinic after visiting one. The same is true for IM plus understanding what happens before your patient is admitted

You'll get enough walk-ins and urgent complaints in both IM and FM that it is a non factor

 

[AlbinoHawk DO]

Can't speak to IM training, but for FM most programs have 2 months of ER rotations. Most programs I looked at didn't have urgent care rotations but obviously YMMV. However the bulk of my acute/sick visits were in my own clinic. I'd say about 50% of my daily clinic schedule was acutes rather than wellness visits, OB, or chronic condition follow up - however our residency clinic also had a very underserved patient population that struggled with regular follow up for non-urgent issues and saw tons of kids, so those factors may have skewed things.

One month is required in IM. A second month is optional. You can't do more than 2 months, though.

There are no rotations in urgent care. It might be optional at some programs, but it's definitely not a requirement. You probably agree that really both our training is aimed at longitudinal care, so the urgent care thing is not emphasized

 

[VA Hopeful Dr]

Competlely off. The stuff you'd see in an urgent care would be things that would be very simple for any IM doctor. How could you handle an ICU patient but not someone with an urgent care complaint?

This shows an unfortunate lack of understanding about medicine.

To expand on this: what does handling an ICU patient have to do with fracture management? I'm sure you're great at vent management, but what about vaginal bleeding?

Being good at one area of medicine, no matter how acute or complicated, doesn't mean you're good at everything.

 

[cj_cregg]

Competlely off. The stuff you'd see in an urgent care would be things that would be very simple for any IM doctor. How could you handle an ICU patient but not someone with an urgent care complaint?

EM is not really helpful either. Any advanced skills you'd get from EM wouldn't translate to clinic work. The only reason you do EM for FM is to really understand what happens there when you send someone or someone who comes to your clinic after visiting one. The same is true for IM plus understanding what happens before your patient is admitted

You'll get enough walk-ins and urgent complaints in both IM and FM that it is a non factor

Disagree. The skill set/knowledge base for acute visits is completely different from ICU patients. Knowing how to manage septic shock or a stroke doesn't mean you automatically know how to manage an ear infection or a foot fracture.

One month is required in IM. A second month is optional. You can't do more than 2 months, though.

There are no rotations in urgent care. It might be optional at some programs, but it's definitely not a requirement. You probably agree that really both our training is aimed at longitudinal care, so the urgent care thing is not emphasized

I agree that a portion of my training is geared towards longitudinal care, but I think acute complaints are equally important/emphasized when it comes to clinic.

 

[Ironheme]

I would add that what I see in clinic does translate to urgent care. ICU rotation alone would not have helped me at all in UC.

EM/ICU helps you develop your radar for how sick patients really are when you see them in the office.

 

[Splenda88]

This shows an unfortunate lack of understanding about medicine.

To expand on this: what does handling an ICU patient have to do with fracture management? I'm sure you're great at vent management, but what about vaginal bleeding?

Being good at one area of medicine, no matter how acute or complicated, doesn't mean you're good at everything.

If you are a surgeon, the hospital staff (especially nurses) think you are smarter or know more than the other docs. Lol

 

[Splenda88]

With some hospitals hiring IM only for hospital medicine, I think IM is a safer bet even if you want to do outpatient primary care.

For instance, my hospitalist PD interviewed a graduating FM resident this year and the FM resident asked me to put in some good words for her, which I did.

Ironically, my PD who is an FM doc told me straight he will not hire her because she is an FM doc. I said to myself: You are an FM doc and why did you let the recruiter schedule her for the interview?

 

[VA Hopeful Dr]

With some hospitals hiring IM only for hospital medicine, I think IM is a safer bet even if you want to do outpatient primary care.

For instance, my hospitalist PD interviewed a graduating FM resident this year and the FM resident asked me to put in some good words for her, which I did.

Ironically, my PD who is an FM doc told me straight he will not hire her because she is an FM doc.

I disagree. Job market for outpatient FM is way better than for outpatient IM.

 

[Splenda88]

I disagree. Job market for outpatient FM is way better than for outpatient IM.

You might be right, but if someone is in the fence between outpatient vs inpatient, IM is probably a safer bet IMO.

 

[AlbinoHawk DO]

This shows an unfortunate lack of understanding about medicine.

To expand on this: what does handling an ICU patient have to do with fracture management? I'm sure you're great at vent management, but what about vaginal bleeding?

Being good at one area of medicine, no matter how acute or complicated, doesn't mean you're good at everything.

No misunderstanding of medicine. Maybe you're just projecting your inadequacies? If you can handle ICU patients, it means you have worked your way through all the differentials that got them there in the first place and are able to treat appropriately each step of the way. Do you think vaginas don't bleed in the ICU? If you think ICU doctors can manage a vent and are just too confused on how to treat a simple pneumonia or a foot rash, you are lost

I agree being good at one area doesn't mean you're good at another, but you are talking about a specialty that directly builds upon another. Your argument is like saying you can't assume that being good at calculus means you know anything about algebra

Are you trained in internal medicine or critical care medicine? As someone trained in IM, I can speak to CCM beyond the 1 month FM doctors do intern year

I disagree. Job market for outpatient FM is way better than for outpatient IM.

Based on what data? The only times I've seen FM come ahead is for urgent care or emergency medicine shifts in rural areas

 

[AlbinoHawk DO]

Disagree. The skill set/knowledge base for acute visits is completely different from ICU patients, as someone who went to a program with an open ICU. Knowing how to manage septic shock or a stroke doesn't mean you automatically know how to manage an ear infection or a foot fracture.


I agree that a portion of my training is geared towards longitudinal care, but I think acute complaints are equally important/emphasized when it comes to clinic.

I went to an open ICU program as well, and I disagree with you. If you get a patient to the point of ICU, you have worked through everything else. There's a reason you need an IM background to become an intensivist. You cannot appropriately treat ICU patients without a clear understanding of the foundations and what it takes to be there. Do you honestly believe that an intensivist can't treat an ear infection or a foot fracture?

Most longitudinal care comes from acute complaints. I think half of my patients when I was in residency were people that came with an acute complaint and then I got them to continue coming for screenings and other things. The other half are longitudinal patients that intermittently come with acute complaints. Was your training any different than this?

 

[VA Hopeful Dr]

No misunderstanding of medicine. Maybe you're just projecting your inadequacies? If you can handle ICU patients, it means you have worked your way through all the differentials that got them there in the first place and are able to treat appropriately each step of the way. Do you think vaginas don't bleed in the ICU? If you think ICU doctors can manage a vent and are just too confused on how to treat a simple pneumonia or a foot rash, you are lost

I agree being good at one area doesn't mean you're good at another, but you are talking about a specialty that directly builds upon another. Your argument is like saying you can't assume that being good at calculus means you know anything about algebra

Are you trained in internal medicine or critical care medicine? As someone trained in IM, I can speak to CCM beyond the 1 month FM doctors do intern year



Based on what data? The only times I've seen FM come ahead is for urgent care or emergency medicine shifts in rural areas

Looking at Practice link for one (I know it's not the end all be all but it's a data point) since it allows you to specify IM or hospitalist and FM or urgent care. The EM job market for FM is pretty bad at the moment.

I also keep an eye on job postings in my specific state, and the FM outpatient jobs absolutely dwarf the outpatient IM jobs. Maybe SC is wildly different from the rest of the country in this regard but I'd be kinda surprised.

Now this isn't me saying the IM job market is bad by any stretch, just that FM is better at the moment for outpatient jobs.

As for the rest, are you seriously trying to tell me that extra ICU time makes you better at outpatient medicine? IM and FM both have 3 years of training post med school. Every extra ICU month you have compared to us is one fewer month in something else, and at least 10 years ago this was usually some combination or Ortho, GYN, or urgent care/outpatient clinic. I distinctly remember in residency trying to persuade my IM hospitalist attendings NOT to consult GYN for every vaginal bleeding/discharge.

I asked my IM-trained wife what she thought of this. She recalls consulting GYN for inpatient vaginal bleeding 99% of the time (the exceptions were patients who said "my period was due to start today"). She also still isn't particularly comfortable with ortho complaints (which is a huge component of acute outpatient medicine).

I also think you're not necessarily aware of what all presents to urgent care. As I said, I'm sure you're quite good at ICU/hospital level care but do you know what you would do in the outpatient setting with a broken ankle? Or the first steps in new onset menorrhagia? Keeping in mind the a GYN appointment is 3 weeks away and ortho is booked 1 week out.

Not sure why you're taking this the way you are either. There's no shame in admitting that you don't know everything in medicine. There is way too much for any one person to know, that's why different specialties exist in the first place. I don't think I'm superior to a psychiatrist because I can manage diabetes much better than they can. My Ob/GYN father-in-law doesn't think he's a better doctor than I am because I don't know how to manage a pregnancy as well as he does. In this case, generally speaking IM-training doesn't get you the same experience with acute outpatient care as FM does. In the same vein, FM training doesn't get nearly as much inpatient training as IM does.

 

[AlbinoHawk DO]

Looking at Practice link for one (I know it's not the end all be all but it's a data point) since it allows you to specify IM or hospitalist and FM or urgent care. The EM job market for FM is pretty bad at the moment.

I also keep an eye on job postings in my specific state, and the FM outpatient jobs absolutely dwarf the outpatient IM jobs. Maybe SC is wildly different from the rest of the country in this regard but I'd be kinda surprised.

Now this isn't me saying the IM job market is bad by any stretch, just that FM is better at the moment for outpatient jobs.

As for the rest, are you seriously trying to tell me that extra ICU time makes you better at outpatient medicine? IM and FM both have 3 years of training post med school. Every extra ICU month you have compared to us is one fewer month in something else, and at least 10 years ago this was usually some combination or Ortho, GYN, or urgent care/outpatient clinic. I distinctly remember in residency trying to persuade my IM hospitalist attendings NOT to consult GYN for every vaginal bleeding/discharge.

I asked my IM-trained wife what she thought of this. She recalls consulting GYN for inpatient vaginal bleeding 99% of the time (the exceptions were patients who said "my period was due to start today"). She also still isn't particularly comfortable with ortho complaints (which is a huge component of acute outpatient medicine).

I also think you're not necessarily aware of what all presents to urgent care. As I said, I'm sure you're quite good at ICU/hospital level care but do you know what you would do in the outpatient setting with a broken ankle? Or the first steps in new onset menorrhagia? Keeping in mind the a GYN appointment is 3 weeks away and ortho is booked 1 week out.

Not sure why you're taking this the way you are either. There's no shame in admitting that you don't know everything in medicine. There is way too much for any one person to know, that's why different specialties exist in the first place. I don't think I'm superior to a psychiatrist because I can manage diabetes much better than they can. My Ob/GYN father-in-law doesn't think he's a better doctor than I am because I don't know how to manage a pregnancy as well as he does. In this case, generally speaking IM-training doesn't get you the same experience with acute outpatient care as FM does. In the same vein, FM training doesn't get nearly as much inpatient training as IM does.

Most of the time, the person is able to apply to the same outpatient jobs. They put FM on these because it is usually FM that is seeking these jobs

I never said that extra ICU time would make you better at outpatient or should replace other rotations. The conversion was regarding acute complaints. The point i was making was regarding that acute outpatient complaints aren't particularly difficult when your training is overall more in-depth

Where i trained, both IM and FM had to consult nearly 100% of the time for vaginal bleeding in the inpatient setting because that's just protocol for hospitalist rotations. If your training site had a separate FM service that allowed you to do peds and gyn, that's a product of your training. Everyone in IM is required to do one month of gynecology, which is the same requirement by FM, although many FM programs choose to go beyond that

I'm not sure why your wife has trouble with ortho complaints. My program had a sports medicine rotation. Maybe hers didn't, or she decided not to take it or didn't have enough exposure in her outpatient clinic. By the same token, we have multiple months of specialty clinic in cardio, renal, rheumatology, ID, etc. In my expediency, FM has few of these IM-specialty clinics. Are you uncomfortable with these complaints because you didn't do these rotations?

I have no problem in saying what i don't know. I'm sure you know significantly more about obstetrics and pediatrics. Simply, i don't see my skillset lacking for the things mentioned previously

 

[VA Hopeful Dr]

Most of the time, the person is able to apply to the same outpatient jobs. They put FM on these because it is usually FM that is seeking these jobs

That has not been my experience since IM-trained PCPs can't take call on pediatric patients below a certain age (16 seems to be what I've seen most commonly). Combined FM/IM groups seem pretty rare in my area. This could be region dependent as I haven't worked everywhere.

I never said that extra ICU time would make you better at outpatient or should replace other rotations. The conversion was regarding acute complaints. The point i was making was regarding that acute outpatient complaints aren't particularly difficult when your training is overall more in-depth

Where i trained, both IM and FM had to consult nearly 100% of the time for vaginal bleeding in the inpatient setting because that's just protocol for hospitalist rotations. If your training site had a separate FM service that allowed you to do peds and gyn, that's a product of your training. Everyone in IM is required to do one month of gynecology, which is the same requirement by FM, although many FM programs choose to go beyond that

If that's hospital policy, fair enough. That was not the case where I did residency, med school, or where my wife did residency or where she worked as a hospitalist.

Your point is still, I believe, incorrect. Explain to me like I'm 5 how doing a pulm/CC fellowship helps you deal with a broken ankle in an outpatient setting.

Everyone in IM is not required to do a month of gynecology best I can see. My wife didn't do that and the ACGME IM residency requirements don't mention gynecology. None of the 3 programs in SC require GYN (or ortho/sports med for that matter). There is plenty of elective time so the option is there but its not a requirement.

I'm not sure why your wife has trouble with ortho complaints. My program had a sports medicine rotation. Maybe hers didn't, or she decided not to take it or didn't have enough exposure in her outpatient clinic. By the same token, we have multiple months of specialty clinic in cardio, renal, rheumatology, ID, etc. In my expediency, FM has few of these IM-specialty clinics. Are you uncomfortable with these complaints because you didn't do these rotations?

I have no problem in saying what i don't know. I'm sure you know significantly more about obstetrics and pediatrics. Simply, i don't see my skillset lacking for the things mentioned previously

I am, but I'll be the first to admit that my wife is my superior in the care of adult medical patients for exactly those reasons.

If you did extra gyn and ortho/sports med rotations in residency then you probably would be fine to set up in an urgent care. But, IM training doesn't require those. FM does so speaking in generalities if you want to do outpatient acute care medicine, FM prepares you better at baseline.

 

[AlbinoHawk DO]

That has not been my experience since IM-trained PCPs can't take call on pediatric patients below a certain age (16 seems to be what I've seen most commonly). Combined FM/IM groups seem pretty rare in my area. This could be region dependent as I haven't worked everywhere.

If that's hospital policy, fair enough. That was not the case where I did residency, med school, or where my wife did residency or where she worked as a hospitalist.

Your point is still, I believe, incorrect. Explain to me like I'm 5 how doing a pulm/CC fellowship helps you deal with a broken ankle in an outpatient setting.

Everyone in IM is not required to do a month of gynecology best I can see. My wife didn't do that and the ACGME IM residency requirements don't mention gynecology. None of the 3 programs in SC require GYN (or ortho/sports med for that matter). There is plenty of elective time so the option is there but its not a requirement.

I am, but I'll be the first to admit that my wife is my superior in the care of adult medical patients for exactly those reasons.

If you did extra gyn and ortho/sports med rotations in residency then you probably would be fine to set up in an urgent care. But, IM training doesn't require those. FM does so speaking in generalities if you want to do outpatient acute care medicine, FM prepares you better at baseline.

There are very few places where PCPs see a significant volume of pediatric patients. The majority of patients go to a pediatrician. I have never seen an IM doctor turned down for an outpatient job except urgent care. The majority of IM people simply don't go the outpatient route anymore or simply do a single clinic day as part of larger clinical duties

In my hospital, medical school, and everywhere I've seen, vaginal bleeding needs to be consulted to gynecology. This is not uncommon or not knowing what to do. For example, at my hospital, i had to consult cardiology for atrial fibrillation, but i know and manage it anyway

I never said you needed to do a fellowship in ICU to do outpatient management. You're setting up not only strawman argument but you are being ridiculously reductionist. As i mentioned previously, the steps that take to be able to get to manage ICU necessitate that you learn the basics, which are the simple acute complaints you see in a clinic

It's a requirement of internal medicine and the ABIM/AOBIM to do "women's health," which is just another word for gynecology. Ortho or sports medicine is optional. I never said it was required

FM doesn't prepare you better for adult medicine. IM is the specialty for all adult medicine, inpatient and outpatient. As previously mentioned, you don't do the same volume of specialty outpatient clinics such as cardio, renal, pulm, etc. FM is a generalist if you wish to do children and obstetric care.

 

[Splenda88]

FM doesn't prepare you better for adult medicine. IM is the specialty for all adult medicine, inpatient and outpatient. As previously mentioned, you don't do the same volume of specialty outpatient clinics such as cardio, renal, pulm, etc. FM is a generalist if you wish to do children and obstetric care.

Interesting.

I am an IM and I would hope FM are better equipped right out of residency to be better at outpatient than IM. If not, what the point of FM residency then because most (again most) FM docs don't do peds and/or GYN.

 

[cj_cregg]

I have no idea where y'all are getting this idea that so many FM docs don't see kids or gyn. In my medical school and residency/fellowship, I do not know a single family medicine doc that doesn't see kids or isn't perfectly happy to manage at least routine gynecologic care (paps, STI/vaginitis type stuff, contraception/family planning, and management of menopausal symptoms at a minimum).

 

[VA Hopeful Dr]

Interesting.

I am an IM and I would hope FM are better equipped right out of residency to be better at outpatient than IM. If not, what the point of FM residency then because most (again most) FM docs don't do peds and/or GYN.

Not even close. A study early last year had just over 80% of FPs who participated in ABFM board certification activities in 2017-2019 see children in their practices. I know in my office of 7 FPs pediatric patients make up right at 12% of our practice.

Harder to find numbers on GYN care, but I personally don't know a single outpatient FP who doesn't do at least basic GYN work.

 

[VA Hopeful Dr]

There are very few places where PCPs see a significant volume of pediatric patients. The majority of patients go to a pediatrician. I have never seen an IM doctor turned down for an outpatient job except urgent care. The majority of IM people simply don't go the outpatient route anymore or simply do a single clinic day as part of larger clinical duties

So that first part is just completely untrue, see my post above this one.

I've seen IM people turned down from jobs listed as just FM jobs several times. Almost always because of the pediatric issue.

In my hospital, medical school, and everywhere I've seen, vaginal bleeding needs to be consulted to gynecology. This is not uncommon or not knowing what to do. For example, at my hospital, i had to consult cardiology for atrial fibrillation, but i know and manage it anyway

That sucks. That seems wasteful in general and does trainees a significant disservice. The IM program where I went to med school had an unwritten policy of only consulting when they needed a procedure done or just had no idea what was going on.

I never said you needed to do a fellowship in ICU to do outpatient management. You're setting up not only strawman argument but you are being ridiculously reductionist. As i mentioned previously, the steps that take to be able to get to manage ICU necessitate that you learn the basics, which are the simple acute complaints you see in a clinic

I never said that either. For the third time, how does ICU training help you manage ankle fractures?

It's a requirement of internal medicine and the ABIM/AOBIM to do "women's health," which is just another word for gynecology. Ortho or sports medicine is optional. I never said it was required

I just checked the 2020 ACGME requirements for IM residency. Nothing about women's health or gynecology is mentioned. The ABIM says office gynecology may be taught but isn't required. Nothing else about GYN or women's health is mentioned that I could find.

FM doesn't prepare you better for adult medicine. IM is the specialty for all adult medicine, inpatient and outpatient. As previously mentioned, you don't do the same volume of specialty outpatient clinics such as cardio, renal, pulm, etc. FM is a generalist if you wish to do children and obstetric care.

I'm starting to think you aren't even reading my posts. I didn't say FM prepared one better for adult medicine. I said this:

"FM does so speaking in generalities if you want to do outpatient acute care medicine, FM prepares you better at baseline."

The generalities are our required time in Ortho, sports med, gynecology, and pediatrics. IM training can do all of those except the last if you choose to use elective time in those areas but since it's optional then, again speaking in generalities, we are going to be better trained in outpatient acute care medicine which was the question that originally set this discussion off in the first place.

 

[AlbinoHawk DO]

Interesting.

I am an IM and I would hope FM are better equipped right out of residency to be better at outpatient than IM. If not, what the point of FM residency then because most (again most) FM docs don't do peds and/or GYN.

Exactly. The reason the specialty exists is because people would be general practitioners before with just one year of training. People who were experts at adult medicine were internal medicine, which most easily comparable is to say they are the pediatrics of adults. Then, at some point, general practitioners created a specialty called family practice because they didn't want to be left behind their colleagues who trained more

Supposedly, the point was to have a generalist who could do a little bit of everything without necessarily being the expert at one thing. They could meet the need in communities without specialists. Before, many FM doctors did colonoscopies. Now, outpatient is simply the best place to practice because everyone else has a place in the hospital in most cities

 

[VA Hopeful Dr]

Exactly. The reason the specialty exists is because people would be general practitioners before with just one year of training. People who were experts at adult medicine were internal medicine, which most easily comparable is to say they are the pediatrics of adults. Then, at some point, general practitioners created a specialty called family practice because they didn't want to be left behind their colleagues who trained more

Supposedly, the point was to have a generalist who could do a little bit of everything without necessarily being the expert at one thing. They could meet the need in communities without specialists. Before, many FM doctors did colonoscopies. Now, outpatient is simply the best place to practice because everyone else has a place in the hospital in most cities

Pretty much this. FPs saw their own patients in the hospital until hospitalists became a thing. Same thing with patients in the ED and EPs becoming wide spread. A fair number still did OB until the early/mid-90s.

 

[AlbinoHawk DO]

So that first part is just completely untrue, see my post above this one.

I've seen IM people turned down from jobs listed as just FM jobs several times. Almost always because of the pediatric issue.

That sucks. That seems wasteful in general and does trainees a significant disservice. The IM program where I went to med school had an unwritten policy of only consulting when they needed a procedure done or just had no idea what was going on.

I never said that either. For the third time, how does ICU training help you manage ankle fractures?

I just checked the 2020 ACGME requirements for IM residency. Nothing about women's health or gynecology is mentioned. The ABIM says office gynecology may be taught but isn't required. Nothing else about GYN or women's health is mentioned that I could find.

I'm starting to think you aren't even reading my posts. I didn't say FM prepared one better for adult medicine. I said this:

"FM does so speaking in generalities if you want to do outpatient acute care medicine, FM prepares you better at baseline."

The generalities are our required time in Ortho, sports med, gynecology, and pediatrics. IM training can do all of those except the last if you choose to use elective time in those areas but since it's optional then, again speaking in generalities, we are going to be better trained in outpatient acute care medicine which was the question that originally set this discussion off in the first place.

Don't get me wrong. We have to do the entire workup and everything, but we have to consult so they sign off due to liability issues. The one thing we definitely cannot do is admit pregnant patients. We can be consulted on their care

I don't know what you think is so hard about using the Ottawa ankle rules that an ICU doctor can't figure out. People with ankle fractures also get admitted to the ICU. Again, the point i was making was that if you get to the point of your training to be signed off to do open ICU, it means you've worked through all the more simple complaints

I went back to the rules, and it appears that you're right. It must have been a requirement of my program where you couldn't graduate without a month of women's health (office gynecology) and perform at least 5 pap smears, but again, the boards itself does have women's health as they do ophthalmology, dermatology and other subspecialty skills

We will have to agree to disagree. I don't think the IM training doesn't prepare you for acute outpatient complaints. The only thing i did see people at my FM program being stronger was ob/gyn, pediatrics, and small procedures

I think overall FM is better if you want to see everything, but i don't think IM is lacking in comparison to acute complaints of adults. Of course, maybe this is all because of where I've trained and what i have seen. Maybe in other places IM treats outpatient training as a formality

 

[VA Hopeful Dr]

Don't get me wrong. We have to do the entire workup and everything, but we have to consult so they sign off due to liability issues. The one thing we definitely cannot do is admit pregnant patients. We can be consulted on their care

I don't know what you think is so hard about using the Ottawa ankle rules that an ICU doctor can't figure out. People with ankle fractures also get admitted to the ICU. Again, the point i was making was that if you get to the point of your training to be signed off to do open ICU, it means you've worked through all the more simple complaints

I went back to the rules, and it appears that you're right. It must have been a requirement of my program where you couldn't graduate without a month of women's health (office gynecology) and perform at least 5 pap smears, but again, the boards itself does have women's health as they do ophthalmology, dermatology and other subspecialty skills

We will have to agree to disagree. I don't think the IM training doesn't prepare you for acute outpatient complaints. The only thing i did see people at my FM program being stronger was ob/gyn, pediatrics, and small procedures

I think overall FM is better if you want to see everything, but i don't think IM is lacking in comparison to acute complaints of adults. Of course, maybe this is all because of where I've trained and what i have seen. Maybe in other places IM treats outpatient training as a formality

It sounds like your training was more comprehensive in terms of outpatient medicine than what I've used to in my area (that fact that you even know about the Ottawa rules is way above what I'm used to seeing from internists). Its pretty rare for IM grads in SC to go the outpatient route out of residency. The only one who did from my wife's entire class went straight to opening up a Suboxone clinic. Make of that what you will. Lots of them will leave hospital medicine after some years and go outpatient, but there is significant skill atrophy (same would happen if I tried to do hospital medicine at this point in time).

I still think you're downplaying "the simple complaints" and the difference between dealing with issues in the ICU compared to an outpatient clinic, but as you say we'll have to agree to disagree on that one.

With decently balanced training, I would agree that outpatient internists can handle adult acute visits about as well as we can. The minor office procedures can be quite useful but as long as you can handle lacerations (which y'all should be good at) and joint aspirations (and a decent rheum rotation should do OK for that one) then I don't think you'd be doing your patients a disservice on acute care.

 

[Gastrapathy]

My group makes no distinction between FM and IM for adult primary care jobs. Peds does kids. The main reason to do IM over FM is when you discover you’d rather do Rheum.

 

[Splenda88]

Don't

I think overall FM is better if you want to see everything, but i don't think IM is lacking in comparison to acute complaints of adults. Of course, maybe this is all because of where I've trained and what i have seen. Maybe in other places IM treats outpatient training as a formality

Bingo.

Outpatient primary care in many IM programs is just a formality. I remember less than a handful of my co-residents enjoyed going to our primary care clinic. Almost all of us hated it.

I only did 5 pap, spent 1 wk in a sport medicine (ortho) clinic.

 

[sanfran256]

Bingo.

Outpatient primary care in many IM programs is just a formality. I remember less than a handful of my co-residents enjoyed going to our primary care clinic. Almost all of us hated it.

I only did 5 pap, spent 1 wk in a sport medicine (ortho) clinic.

I am IM going into outpatient primary care.
Signed off on all inpatient procedures (LP, para, A lines, central lines).
I have done 50 + paps
Can do skin biopsies, thyroid nodule biopsies, have done probably 50 + joint injections/aspirations at this point (via a few rheum and sports med rotation, as well as inpatient), tons of suturing on my ED rotation, I/Ds

Realistically, I feel like most of my procedural competence came from US guided procedures in the hospital. Outpatient procedures are super easy if you can do those - just takes a few times for someone to teach you.

The only thing I wish IM trained is IUD/nexplanon placement . Oh well

 

[AlbinoHawk DO]

Bingo.

Outpatient primary care in many IM programs is just a formality. I remember less than a handful of my co-residents enjoyed going to our primary care clinic. Almost all of us hated it.

I only did 5 pap, spent 1 wk in a sport medicine (ortho) clinic.

Most of us disliked our general clinic, but it was mostly because it got in the way of inpatient work. The outpatient specialty clinics were interesting

 

[AlbinoHawk DO]

I am IM going into outpatient primary care.
Signed off on all inpatient procedures (LP, para, A lines, central lines).
I have done 50 + paps
Can do skin biopsies, thyroid nodule biopsies, have done probably 50 + joint injections/aspirations at this point (via a few rheum and sports med rotation, as well as inpatient), tons of suturing on my ED rotation, I/Ds

Realistically, I feel like most of my procedural competence came from US guided procedures in the hospital. Outpatient procedures are super easy if you can do those - just takes a few times for someone to teach you.

The only thing I wish IM trained is IUD/nexplanon placement . Oh well

Nexplanon is not too bad. I had the opportunity to join the FM class, learning it during my women's health month. They brought the company rep, and we did it in an afternoon. How this translates into doing it on a real person, i don't know. It shouldn't be a problem to learn if you asked the company to teach you

 

[smq123]

Bingo.

Outpatient primary care in many IM programs is just a formality. I remember less than a handful of my co-residents enjoyed going to our primary care clinic. Almost all of us hated it.

I only did 5 pap, spent 1 wk in a sport medicine (ortho) clinic.

When I was helping to interview-hire physicians for the FQHC that I used to work at, this was a real problem. Many of the IM trained people did not want to do paps. Many had done less than a dozen in residency, and those were done only with great reluctance. When your reimbursement is tied to what percentage of your patients are compliant with their Pap smears, this was clearly suboptimal. You can’t refer to gyn, as they’re too busy, and many of our patients were transient and unreliable and couldn’t be counted on to go anyway. Getting records from an outside gyn was a nightmare, too.

 

[Splenda88]

I am IM going into outpatient primary care.
Signed off on all inpatient procedures (LP, para, A lines, central lines).
I have done 50 + paps
Can do skin biopsies, thyroid nodule biopsies, have done probably 50 + joint injections/aspirations at this point (via a few rheum and sports med rotation, as well as inpatient), tons of suturing on my ED rotation, I/Ds

Realistically, I feel like most of my procedural competence came from US guided procedures in the hospital. Outpatient procedures are super easy if you can do those - just takes a few times for someone to teach you.

The only thing I wish IM trained is IUD/nexplanon placement . Oh well

Wow... I did not do all these things. but I did para, thora, a-line, central lines.

I guess your program was very heavy in procedures.

Your outpatient skills will be as good as the skills of FM residents

 

[Splenda88]

When I was helping to interview-hire physicians for the FQHC that I used to work at, this was a real problem. Many of the IM trained people did not want to do paps. Many had done less than a dozen in residency, and those were done only with great reluctance. When your reimbursement is tied to what percentage of your patients are compliant with their Pap smears, this was clearly suboptimal. You can’t refer to gyn, as they’re too busy, and many of our patients were transient and unreliable and couldn’t be counted on to go anyway. Getting records from an outside gyn was a nightmare, too.

Most people in my residency class wanted to do the minimum of pap required by ACGME and be done with it. All of us have gone into inpatient medicine or do a fellowship.

 

[sanfran256]

Wow... I did not do all these things. but I did para, thora, a-line, central lines.

I guess your program was very heavy in procedures.

Your outpatient skills will be as good as the skills of FM residents

I just asked and said yes to as many procedures as I could in residency!
As far as paps I have a young predominantly female patient population...

 

[SLC]

…Where i trained, both IM and FM had to consult nearly 100% of the time for vaginal bleeding in the inpatient setting because that's just protocol for hospitalist rotations.

Where you trained sounds like it may have stifled learning then? At my program, IM consulted us for Gyn complaints on inpatients because we were always there (we had distinct FM service, as well as multiple IM services). But then we taught the IM residents and walked them through any procedures needed.

And then we turned around and staffed the “medicine service” at the Women’s hospital as Moonlighters in our spare time, and for extra money, where the Gyns consulted us for all the non Vaginal issues. The only IM folks there were a few Hospitalist attendings, and an “OB medicine” fellow. But the FM residents did most of the shifts.

Everyone in IM is required to do one month of gynecology, which is the same requirement by FM, although many FM programs choose to go beyond that.

There apparently isn’t a Gyn requirement for IM. At my FM residency however we had a TON of gyn: 6 months of maternal-fetal rotations (2 each year). Outpatient Gyn, tons of women’s health in our continuity clinic, and Family Planning clinic duties. I think I’d placed 90 IUD’s by graduation, and about as many Nexplanons. We didn’t even count Pap’s, but every resident had done tons by graduation. PD said “we don’t track them, but the assumption when you’re out there applying for privileges is that you’ll be competent in basic office Gynecology if you’ve graduated from an FM program”.

Now in practice I do almost all the non-operative Gyn for my patients. A few have established with an OBGyn for that (out of preference for a female provider, which I am not). My panel is overwhelmingly young, and probably 65% female, so I do a fair bit of that type of thing though. Clinic tomorrow is already 2 well woman exams, a vaginitis, IUD placement. Yesterday was breast/pain, OCP management, and a bunch of peds.

I don’t do OB, as an attending, but that’s by personal preference. I could (and I’m urban/suburban), but it never appealed to me to be in the delivery room. I do a TON of peds though. It’s a byproduct of seeing young families. A patient becomes pregnant, I send her off to my OB colleague, and then I see the baby once born. I’ve developed a professional relationship with a local OBGyn clinic, and they send me their patients for general medical complaints, and I tend to send them all my OB’s and operative Gyn cases. This has been skewing my panel toward female as well.

 

[AlbinoHawk DO]

Where you trained sounds like it may have stifled learning then? At my program, IM consulted us for Gyn complaints on inpatients because we were always there (we had distinct FM service, as well as multiple IM services). But then we taught the IM residents and walked them through any procedures needed.

And then we turned around and staffed the “medicine service” at the Women’s hospital as Moonlighters in our spare time, and for extra money, where the Gyns consulted us for all the non Vaginal issues. The only IM folks there were a few Hospitalist attendings, and an “OB medicine” fellow. But the FM residents did most of the shifts.



There apparently isn’t a Gyn requirement for IM. At my FM residency however we had a TON of gyn: 6 months of maternal-fetal rotations (2 each year). Outpatient Gyn, tons of women’s health in our continuity clinic, and Family Planning clinic duties. I think I’d placed 90 IUD’s by graduation, and about as many Nexplanons. We didn’t even count Pap’s, but every resident had done tons by graduation. PD said “we don’t track them, but the assumption when you’re out there applying for privileges is that you’ll be competent in basic office Gynecology if you’ve graduated from an FM program”.

Now in practice I do almost all the non-operative Gyn for my patients. A few have established with an OBGyn for that (out of preference for a female provider, which I am not). My panel is overwhelmingly young, and probably 65% female, so I do a fair bit of that type of thing though. Clinic tomorrow is already 2 well woman exams, a vaginitis, IUD placement. Yesterday was breast/pain, OCP management, and a bunch of peds.

I don’t do OB, as an attending, but that’s by personal preference. I could (and I’m urban/suburban), but it never appealed to me to be in the delivery room. I do a TON of peds though. It’s a byproduct of seeing young families. A patient becomes pregnant, I send her off to my OB colleague, and then I see the baby once born. I’ve developed a professional relationship with a local OBGyn clinic, and they send me their patients for general medical complaints, and I tend to send them all my OB’s and operative Gyn cases. This has been skewing my panel toward female as well.

As mentioned previously, you can do the workup but you need to still get gynecology on-board for inpatient. The same is for FM residents doing inpatient service. I never felt my learning was stifled. If anything, the opposite because I'd either get confirmation that what was done was okay per the consultant or I'd see what I missed

Yes, apparently a rotation is not required (even though it was at my program), but the ABIM does require women's health as part of board certification: https://www.abim.org/Media/h5whkrfe/internal-medicine.pdf

 

[BigPikachu]

Ultimately, if it’s within your scope of practice and you have the experience and training to care for the patient, it doesn’t really matter if you’re an Internist or Family Physician. Internist may be better at the hospital inpatient care and adult internal medicine especially with elderly patients with complex co-morbidities. Family Physicians would be better with the primary outpatient care and with paediatrics and obstetrics/gynaecology cases. Internists can more easily sub-specialise in a field of adult medicine they gravitate an interest to, such as cardiology or nephrology, etc. Family Physicians tend to stick to family medicine, primary care practice with some secondary care in hospitals, and develop extended skills in paediatrics, dermatology, obgyn, minor surgery, or even mental health.

I would like to believe I’m a reasonably experienced Family Physician and I’m quite happy with managing patients with a variety of problems under my care and trying my best to care for them in the inpatient or outpatient setting, but I don’t let my ego and arrogance get in the way of consulting or handing over care to another specialist if the problem is beyond my scope of practice and capabilities. I can manage someone with COPD reasonably well and initiate them on ABs/Steroids/Inhalers and even start BiPAP, but I would be remiss not to consult or transfer care to my Internist or Respiratory Physician colleagues. I can manage someone with Post-Partum Bleeding following a complicated delivery, but I would be remiss not to consult or transfer care to my Intensivist and ObGyn colleagues.

 

[SLC]

As mentioned previously, you can do the workup but you need to still get gynecology on-board for inpatient. The same is for FM residents doing inpatient service. I never felt my learning was stifled. If anything, the opposite because I'd either get confirmation that what was done was okay per the consultant or I'd see what I missed

Yes, apparently a rotation is not required (even though it was at my program), but the ABIM does require women's health as part of board certification: https://www.abim.org/Media/h5whkrfe/internal-medicine.pdf

You need to get Gyn on board where you trained? Because where I trained we were never “required” to consult anyone. We consulted when we needed a non-FM procedure, or needed some teaching on a challenging case. But there were no rules that stated I had to consult Gyn, or any other specialty, ever.

 

[AlbinoHawk DO]

You need to get Gyn on board where you trained? Because where I trained we were never “required” to consult anyone. We consulted when we needed a non-FM procedure, or needed some teaching on a challenging case. But there were no rules that stated I had to consult Gyn, or any other specialty, ever.

Yes, for inpatient purposes we had to. We also couldn't admit pregnant patients. FM couldn't admit patients into the open ICU without consulting CCM, while IM could.

 

[SLC]

Ahh, see we (FM) could admit to the ICU and step down unit, admit pregnant patients, etc. basically we had the run of the hospital, and called in consultants when needed, rather than being required to do them by default.

There’s a lot of learning that can be had from calling a quality consult; but there’s also a lot of learning to be lost if your consultant sucks, or you never get the chance to do the things you’re trained to do.

 

[AlbinoHawk DO]

Ahh, see we (FM) could admit to the ICU and step down unit, admit pregnant patients, etc. basically we had the run of the hospital, and called in consultants when needed, rather than being required to do them by default.

There’s a lot of learning that can be had from calling a quality consult; but there’s also a lot of learning to be lost if your consultant sucks, or you never get the chance to do the things you’re trained to do.

It depends how your program treats consults. My program treated consults as a fail-safe. It didn't use it as a means of avoiding a workup. As I mentioned previously, we did everything, but the other service had to be onboard

It would serve OP to really investigate programs they applied to because at your program (FM) could admit pregnant and manage ICU solo, but at my program (FM) couldn't admit pregnant or manage ICU solo while in-patient. They could admit pregnant only as part of their OB rotation

 

[SLC]

It depends how your program treats consults. My program treated consults as a fail-safe. It didn't use it as a means of avoiding a workup. As I mentioned previously, we did everything, but the other service had to be onboard

It would serve OP to really investigate programs they applied to because at your program (FM) could admit pregnant and manage ICU solo, but at my program (FM) couldn't admit pregnant or manage ICU solo while in-patient. They could admit pregnant only as part of their OB rotation

Yep, and at my program, OB wouldn’t admit anyone unless for labor and delivery. They recognized they weren’t equipped for medical work. They’d have us admit and offer to consult if desired. Even the OB residents consulted us on most Gyn case they had admitted at the womens hospital with complicated medical comorbidities.

I remember one case I was consulted on as a senior resident. 50’ish year old woman admitted for bartholin abscess. Started on Oral BactrimDS the night before upon admission. Their plan was to take her in, drain the abscess under anesthesia, then discharge later that day.

This was at the women’s hospital, we had our L&D service there, along side the OBGyn residency so when we were on our MFM rotations, we were also the medicine team for the hospital. They consulted me (and my extension, my FM attending) for surgical clearance prior to taking her to the OR, and for recs on managing her insulin dependent DM while admitted. I visited with the patient, room smelled like necrotic diabetic foot. Vulva was red and swollen with black eschar.

I suggested they get a CT, that they probably had something other than bartholin cyst. Sure enough, she had Necrotizing Fasciitis. Gas all through the perineum, lower abdominal wall, glutes, upper thighs. We rushed her to the referral center next door where they had general surgery, and into their surgical ICU. She underwent a huge debridement, a few weeks inpatient, but she survived.

So getting OB on board for a pregnant patient admitted to medicine in our other hospitals wouldn’t have been that useful. They had no problem admitting they weren’t well trained for that. They wanted to be consulted for surgeries, or Gyn issues FM didn’t feel comfortable with. Unless it was that, they would have deferred to FM.

 

[AlbinoHawk DO]

Yep, and at my program, OB wouldn’t admit anyone unless for labor and delivery. They recognized they weren’t equipped for medical work. They’d have us admit and offer to consult if desired. Even the OB residents consulted us on most Gyn case they had admitted at the womens hospital with complicated medical comorbidities.

I remember one case I was consulted on as a senior resident. 50’ish year old woman admitted for bartholin abscess. Started on Oral BactrimDS the night before upon admission. Their plan was to take her in, drain the abscess under anesthesia, then discharge later that day.

This was at the women’s hospital, we had our L&D service there, along side the OBGyn residency so when we were on our MFM rotations, we were also the medicine team for the hospital. They consulted me (and my extension, my FM attending) for surgical clearance prior to taking her to the OR, and for recs on managing her insulin dependent DM while admitted. I visited with the patient, room smelled like necrotic diabetic foot. Vulva was red and swollen with black eschar.

I suggested they get a CT, that they probably had something other than bartholin cyst. Sure enough, she had Necrotizing Fasciitis. Gas all through the perineum, lower abdominal wall, glutes, upper thighs. We rushed her to the referral center next door where they had general surgery, and into their surgical ICU. She underwent a huge debridement, a few weeks inpatient, but she survived.

So getting OB on board for a pregnant patient admitted to medicine in our other hospitals wouldn’t have been that useful. They had no problem admitting they weren’t well trained for that. They wanted to be consulted for surgeries, or Gyn issues FM didn’t feel comfortable with. Unless it was that, they would have deferred to FM.

That sounds like a better model for training than the one we had. At my institution OB/Gyn would admit all patients that were pregnant and had to consult us if they wanted medical management. On the other hand, we admit everything else but had to consult them if there was any ob/gyn issue, so the bartholin cyst case would have fallen under our service first. I'm assuming part of the reason things are setup this way is because the FM program is small and doesn't have enough attendings and coverage inpatient. I'm also thinking it was done like this because most hospitalists are IM and don't want the liability similarly as to why we sometimes have to consult cardio (eg, new onset afib) even though we've done everything and the patient can be discharged

 

[BigPikachu]

Hospital administration and executive should make it clear when they recruit and onboard a new (attending) physician what they're credentialled for, including scope of practice, in addition to educating them what their governance and policies are around managing complex cases that may involve multi-systems. At the end of the day, just imagine if you're been questioned by a lawyer or coroner, and often they'll be asking if you had the training, experienceand if you should have asked for more specialist advice or care. There are some cases where you'll be comfortable sitting on and others not; keep to your scope-of-practice and don't be afraid to ask for help from your specialist colleagues if needed.

 

[CluvK]

At one point in my IM internship, I was very into outpatient medicine/PCP, and wished I could do FM residency instead of IM because I would have more exposure to outpatient procedures, peds, gyn, optho, etc. I was seriously thinking about switching to FM.

Then I wanted to subspecialize so stayed in IM.

If you are pretty sure you want to be PCP, go FM.

 

[BigPikachu]

I'm obviously biased, but I believe FM Physicians are the true generalist medical practitioners; jack of all trades but master of none, care for patients and their families of all ages from cradle to grave; we are mostly experts in primary community/outpatient care, but can partake in secondary hospitalist care if required.

IM Physicians are the true hospitalists and experts in general adult medicine. As a FM, I typically refer and/or consult a IM if an adult patient has multiple complex and comorbid medical (non-surgical) issues and will benefit from their specialist expertise in the inpatient or outpatient setting. Although I typically find working with a local IM Physician with additional specialist/fellowship training, such as in Cardiology or Endocrinology or others, to be more beneficial.