FM vs IM Outpatient Clinic

[R Sterling]

I'm curious, is there a difference between the hours worked by a FM doc in private practice vs an IM doc in private practice? The threads on this forum all seem to agree that the hours in private practice is great since it's mostly outpatient. My primary, who is an IM doc, works around 12-15 hours a day, 6 days a week. He doesn't round at hospitals, and is always busy (his practice sees around 60 patients a day, with the help of 2 NPs. After hours, he's making calls to patients and going over labs). Is that typical for a FM physician with a private practive or is this an isolated case where someone is taking on a lot?

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[thethom]

If you want to work that much you can, any IM or FM doc could work 6 days a week or 3. The ONLY difference between outpt family medicine and outpt general internal medicine is we see kids as well (and prenatal care if you choose), IM cannot.

I make my calls and go over labs, phone notes, refills, etc during any down time I get in clinic, I get my notes done at the end of the day (or after a pt visit if the next room isnt full yet). This usually takes an additional 30 mins to an hour (bout 8 pts per half day in residency so far). I usually see my last patient at 4:30-4:45 so I'm out of the office by 5:30-6 most days.

What you describe above with 6 days a week and 12-15 hours a day is NOT the norm. I'm sure he's making well over $200k however...

 

[Bostonredsox]

Your primary is somewhat of a dying breed. There are very few outpatient/primary care IM anymore. About 50% of us enter a fellowship (GI, Cards, Pulm, etc.) and another 40%+ become hospitalist's. The number seeing patients in the clinic for primary care medicine is dwindling, putting an even heavier burden on our FP counterparts to shoulder the PCP workload. From the few I have met that do, the workload seems to be similar to most FPs with the caveat that all of our patients are non-pregnant adults. No kiddos. No preggos.

 

[staup]

Your primary is somewhat of a dying breed. There are very few outpatient/primary care IM anymore. About 50% of us enter a fellowship (GI, Cards, Pulm, etc.) and another 40%+ become hospitalist's. The number seeing patients in the clinic for primary care medicine is dwindling, putting an even heavier burden on our FP counterparts to shoulder the PCP workload. From the few I have met that do, the workload seems to be similar to most FPs with the caveat that all of our patients are non-pregnant adults. No kiddos. No preggos.

Yeah, this is completely not based on evidence.

There are tons and tons of IM's doing primary care.

 

[deleted87716]

Yeah, this is completely not based on evidence.

There are tons and tons of IM's doing primary care.

Most of whom will be retiring soon.

 

[staup]

Most of whom will be retiring soon.

and also completely incorrect.

 

[VA Hopeful Dr]

and also completely incorrect.

It might be region dependent. In my town, there is only 1 outpatient internist under 50.

So no, its not completely incorrect. It might just be so where you are.

 

[GoodmanBrown]

Your primary is somewhat of a dying breed. There are very few outpatient/primary care IM anymore. About 50% of us enter a fellowship (GI, Cards, Pulm, etc.) and another 40%+ become hospitalist's. The number seeing patients in the clinic for primary care medicine is dwindling, putting an even heavier burden on our FP counterparts to shoulder the PCP workload. From the few I have met that do, the workload seems to be similar to most FPs with the caveat that all of our patients are non-pregnant adults. No kiddos. No preggos.

Yeah, this is completely not based on evidence.

There are tons and tons of IM's doing primary care.

I dunno. This article (using 2003-2007 data) indicates Redsox and BD are pretty accurate. Only 23% of PGY-3 IM residents were interested in general medicine. 60% were doing fellowships, and 8.5% were interested in hospitalist positions. This was in the earlier days of hospitalist medicine, and that percent had risen from 0% in 2001. So, the percent of PGY-3 residents in 2011 who are interested in being hospitalists is likely higher than the 8.5% seen in the survey.

Also, just to assure you of the study's validity, the survey was tied to the IM-ITE and covered over 22,000 PGY-3 IM residents, meaning the survey was taken by over 75% of all US IM residents over that time period.

So, I don't know about current IM attendings in the field, but there's a clear and obvious trend among IM residents to not pursue primary care.

 

[staup]

I dunno. This article (using 2003-2007 data) indicates Redsox and BD are pretty accurate. Only 23% of PGY-3 IM residents were interested in general medicine. 60% were doing fellowships, and 8.5% were interested in hospitalist positions. This was in the earlier days of hospitalist medicine, and that percent had risen from 0% in 2001. So, the percent of PGY-3 residents in 2011 who are interested in being hospitalists is likely higher than the 8.5% seen in the survey.

Also, just to assure you of the study's validity, the survey was tied to the IM-ITE and covered over 22,000 PGY-3 IM residents, meaning the survey was taken by over 75% of all US IM residents over that time period.

So, I don't know about current IM attendings in the field, but there's a clear and obvious trend among IM residents to not pursue primary care.

Of course there is, that's not being argued. But to argue "there are very few" IM generalists is completely inaccurate.

Every residency I know of has people going into primary care, not to mention 1/3 of all medicine residencies are dominated by IMGs, with most of them not having a chance of matching into fellowship if their life depended on it.

To make a statement declaring there won't be any more IM generalists is just ignorant.

 

[Reductio]

In this years Match, there were 5,121 categorical IM positions, while there were only 2708 FP positions. A smaller percentage of IM residents might be going into primary care, but by raw numbers it seems that there are quite a few internists in primary care.

I'm surprised that there are so few FP positions in comparison....

 

[Captopril]

1/3 of all medicine residencies are dominated by IMGs, with most of them not having a chance of matching into fellowship if their life depended on it.

To make a statement declaring there won't be any more IM generalists is just ignorant.

Pot, kettle, black.

 

[lowbudget]

In this years Match, there were 5,121 categorical IM positions, while there were only 2708 FP positions. A smaller percentage of IM residents might be going into primary care, but by raw numbers it seems that there are quite a few internists in primary care.

I'm surprised that there are so few FP positions in comparison....

And?... out of the 5,121, how many go into subspecialties?

From Frieda in 2009, I counted fellows graduated per year:
cards 790,
crit care 87,
endo 275,
422 gi,
heme 16,
heme onc 458,
ID 345,
nephro 395,
onc 46,
pulm 44,
pulm/crit 428,
transplant liver 15,
rhemu 200,
A/I 141

Total: 3362

Assuming everyone graduated were the same as those entering fellowship and assuming these numbers are generally stable over time, playing with round numbers, we're talking about 71.5% going into subspecialties (3362 div by 5121)... (that number comes close to GoodmanBrown's cited article)...

That leaves 1759 in general medicine...

(and out of 1759, how many are pure hospitalists who do zero outpatient primary care?... and out of those how many don't accept Medicare?...)

I'm sure you can pull more raw acute numbers, but the point is that half to more-than-half go in subspecialties; which is consistent with what researchers have been saying.

 

[lowbudget]

In this years Match, there were 5,121 categorical IM positions, while there were only 2708 FP positions. A smaller percentage of IM residents might be going into primary care, but by raw numbers it seems that there are quite a few internists in primary care.

I'm surprised that there are so few FP positions in comparison....

The other way to look at it would be, what would happen to the geographical coverage if we were to withdrawal all family physicians from primary care? Or, put another way, if we left primary care to be served by only internists, pediatricians, and gynecologists alone, what would states look like?

Here's the answer:
http://www.graham-center.org/online/graham/home/tools-resources/maps/maps/hpsamaps.html

 

[naus]

And?... out of the 5,121, how many go into subspecialties?

From Frieda in 2009, I counted fellows graduated per year:
cards 790,
crit care 87,
endo 275,
422 gi,
heme 16,
heme onc 458,
ID 345,
nephro 395,
onc 46,
pulm 44,
pulm/crit 428,
transplant liver 15,
rhemu 200,
A/I 141

Total: 3362

Assuming everyone graduated were the same as those entering fellowship and assuming these numbers are generally stable over time, playing with round numbers, we're talking about 71.5% going into subspecialties (3362 div by 5121)... (that number comes close to GoodmanBrown's cited article)...

That leaves 1759 in general medicine...

(and out of 1759, how many are pure hospitalists who do zero outpatient primary care?... and out of those how many don't accept Medicare?...)

I'm sure you can pull more raw acute numbers, but the point is that half to more-than-half go in subspecialties; which is consistent with what researchers have been saying.

Yeah and also don't leave out the plethora of academic "general" internists who do maybe a day of outpatient clinic a week. Ultimately, not very many new IM grads today end up in private primary care practice. The academic internists may not make a lot of salary, but the excellent benefits and free college tuition for the kids make up for that.

 

[staup]

Pot, kettle, black.

what does that even mean?

 

[staup]

And?... out of the 5,121, how many go into subspecialties?

From Frieda in 2009, I counted fellows graduated per year:
cards 790,
crit care 87,
endo 275,
422 gi,
heme 16,
heme onc 458,
ID 345,
nephro 395,
onc 46,
pulm 44,
pulm/crit 428,
transplant liver 15,
rhemu 200,
A/I 141

Total: 3362

Assuming everyone graduated were the same as those entering fellowship and assuming these numbers are generally stable over time, playing with round numbers, we're talking about 71.5% going into subspecialties (3362 div by 5121)... (that number comes close to GoodmanBrown's cited article)...

That leaves 1759 in general medicine...

(and out of 1759, how many are pure hospitalists who do zero outpatient primary care?... and out of those how many don't accept Medicare?...)

I'm sure you can pull more raw acute numbers, but the point is that half to more-than-half go in subspecialties; which is consistent with what researchers have been saying.

that's certainly true, but each medicine residency is also about 3x the size of family residencies; there are many more internal medicine residents than family residents.

 

[deleted87716]

Most internal medicine residents are poorly prepared for primary care.

http://www.hopkinsmedicine.org/news...nts_graduate_unprepared_for_primary_care_jobs

 

[VA Hopeful Dr]

that's certainly true, but each medicine residency is also about 3x the size of family residencies; there are many more internal medicine residents than family residents.

The post you are quoting is talking about numbers of residents, not number of programs.

 

[staup]

The post you are quoting is talking about numbers of residents, not number of programs.

as am I.

 

[staup]

Most internal medicine residents are poorly prepared for primary care.

http://www.hopkinsmedicine.org/news...nts_graduate_unprepared_for_primary_care_jobs

thanks for unneeded, irrelevant newsflash genius. I think everybody in IM has been aware of this for a long time which is why they have been restructuring the residencies for the last 5 years.

 

[lowbudget]

as am I.

IM is 3x larger but 2/3 go into subspecialties.

 

[staup]

IM is 3x larger but 2/3 go into subspecialties.

which is exactly what we have said here about 4 times already.

 

[VA Hopeful Dr]

as am I.

Then I'll just admit I'm completely lost. What was your point in that post?

 

[deleted87716]

thanks for unneeded, irrelevant newsflash genius. I think everybody in IM has been aware of this for a long time which is why they have been restructuring the residencies for the last 5 years.

Guess they aren't doing a very good job of it, as that article is only six months old. Genius. 🙄

 

[staup]

Then I'll just admit I'm completely lost. What was your point in that post?

I have no idea what you're writing about. There are much more internal medicine residents than family residents. Even with 2/3 of IM residents going into sub specialty, there are still a lot of IM residents entering primary care. What else do you want me to write?

 

[staup]

Guess they aren't doing a very good job of it, as that article is only six months old. Genius. 🙄

I wrote "Genius" because I am not sure why you even included that point. We are writing about the numbers of residents entering primary care, not the quality of care.

 

[deleted87716]

We're not just making this stuff up, "genius." You want numbers? You got 'em.

http://www.mtinternist.org/uploads/IM_workforce_data_1998-2009.doc

 

[staup]

We're not just making this stuff up, "genius." You want numbers? You got 'em.

http://www.mtinternist.org/uploads/IM_workforce_data_1998-2009.doc

Numbers for what? Something we have been talking about the entire time, how most IM residents go into sub specialty? Who are you disagreeing with here?

I'm done with this, you're just stupid and want to argue. go back to clinic.

 

[deleted87716]

Who are you disagreeing with here?

I might ask you the same thing. The only thing you've yet to offer, aside from insults, is your unqualified assertion that there are "tons and tons of IM's doing primary care."

I'm done with this, you're just stupid and want to argue. go back to clinic.

Grow up.

 

[smq123]

Everyone can just SIMMER DOWN. IF this discussion can't continue in a civil manner, it'll be closed.

Thanks.

<stalks off back to clinic>

 

[deleted87716]

Even with 2/3 of IM residents going into sub specialty, there are still a lot of IM residents entering primary care.

http://aleksandreia.wordpress.com/2011/04/30/desperately-seeking-primary-care-internist/

I spoke with an internist who taught at the program and practiced at the hospital. He had it on good authority that this year, 2011, only 175 physicians would enter the work force as general internists after completing residencies. 175 new primary care internal medicine doctors for the whole US. I reviewed what data is available online and found that his numbers could not be far off. There are about 3000 internal medicine residents in each year at the programs around the country and of those, 80% go on to become specialists such as cardiologists or oncologists, and of the remaining 20% more than half go on to practice pure hospital medicine. So at best there might be 300 new primary care internists. When I was a resident, nearly half of the internal medicine residents went into primary care, so attrition undoubtedly significantly outpaces replacement.

http://www.acponline.org/advocacy/where_we_stand/policy/im_workforce.pdf

General internists are leaving practice sooner than other physician specialties at the same time that fewer medical students are choosing to make the practice of general internal medicine and primary care their central career goal. Approximately 21% of physicians who were board certified in the early 1990s have left internal medicine, compared to a 5% departure rate for internal medicine subspecialists.

 

[VA Hopeful Dr]

I have no idea what you're writing about. There are much more internal medicine residents than family residents. Even with 2/3 of IM residents going into sub specialty, there are still a lot of IM residents entering primary care. What else do you want me to write?

I guess I just didn't see the point behind saying that IM programs are bigger than FM programs, when the raw numbers of residents from this year's match had already been posted. In that same post, as was stated, we have no idea what percentage of those general internists go into hospitalist positions.

If we assume 1 in 5 general internists becomes a hospitalist (not unreasonable, I think), the the number of outpatient internists becomes approximately half of the number of family doctors. Still a respectable number, but my belief is that this represents a growing shift of internists away from primary, outpatient care leaving most of that work to us.

 

[lowbudget]

In the past 25 years, academic leaders and accreditation bodies in internal medicine and pediatrics have made multiple efforts to increase residents' exposure to ambulatory primary care medicine, to bring hospital-based residency training more in line with the career paths of graduates. Current proposals continue the trend of increasing ambulatory exposure through providing more clinical hours in the outpatient setting as a pedagogic strategy to improve residents' practical skills in providing quality care in outpatient settings. Resident clinics, however, are often understaffed and dysfunctional. Under these circumstances, the work environment encourages some residents to learn only that providing high-quality primary care is a frustrating and unrewarding form of labor. Leaders in medicine have used innovative organizational strategies to improve residents' outpatient experiences. Model primary care residency programs and clinics have been created. The diffusion of model primary care clinical practices and structures is, however, limited by the strain of generating sufficient clinical revenue to run an academic medical center efficiently and reliably in the current environment. Increased outpatient exposure, without attention to the quality of practice settings, is potentially counterproductive, generating an unintended consequence that is the opposite of the goals of policy: it may reinforce residents' interest in subspecialty practice.

Academic Medicine:
May 2008 - Volume 83 - Issue 5 - pp 498-502
http://journals.lww.com/academicmed...ctive__The_Unintended_Consequences_of.16.aspx

 

[staup]

This thread is so ridiculous. Some of you guys are just children.

My assertion is that General IM is not dissapearing. Is there is less of a trend for IM residents to enter primary care, certainly, which I've agreed with many times in this thread.

But as your data shows, there are hundreds or more entering primary care every year, so it's not dissapearing to nothing. Is that a low number compared to the number of IM residents, yes, but it may be larger that any single subspecialty of IM.

I don't know where you come from, but I am at a major academic center in the northeast. There are a lot of general internists in this city, and to insist that they will dissapear is just ignorant.

You just need to calm down and understand what someone is saying before you keep disagreeing.

 

[aylwang]

even FPs, many of my friends are going into urgent care and some are going into hospitalist, i am doing occupational medicine...... i'd say about 1/2 end up in primary care

 

[michaelrack]

Most internal medicine residents are poorly prepared for primary care.

http://www.hopkinsmedicine.org/news...nts_graduate_unprepared_for_primary_care_jobs

Interesting article:
"Doctors who have completed training in internal medicine are in general poorly prepared for jobs as primary care physicians, most notably lacking the knowledge to best care for patients with chronic conditions such as diabetes, hypertension and high cholesterol"

That wasn't exactly my experience in IM residency training. I felt that I was well prepared to manage chronic medical illness, especially in the elderly. I wasn't well prepared to take care of things like sports injuries in young adults- FM probably prepares its residents better to manage things like knee injuries, as well as to perform musculoskeletal procedures such as joint aspiration.