FP and critical care medicine

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I have had this concern about how well a training I can get in critical care medicine as an FP resident.I read from one of the postings that it is difficult for FPs to get ICU priviledges. My concern came from the fact that everybody tend to believe that FP is same as ambulatory medicine, and that a lot of other primary care providers are moving outpatient-IM,PA,NPs.
I am no longer clear about the future of FP which I so much cherish. Last year there was a debate to add an additional year to the program because of the volume of info to learn in 3 yrs.
So can FP residents out there pls share their thoghts about how much hospital medicine FP gives and the fate of an FP who wants to be a hospitalist and possibly and Intensivist.

 

[mpp]

I am not a family medicine resident but I am somewhat interested in the field. One suggestion for someone interested in both family medicine ambulatory-type care along with a role in hospitalist critical care is doing an IM/Peds residency and a Critical Care fellowship. This seems like you could get the best of both worlds (how you'd find the time to do both once in practice is beyond me but I suppose it is possible). Of course IM/Peds is not family medicine, but I just don't understand what the role of a family medicine doctor would be in the ICU. Perhaps you could elaborate on what role you are looking for as a hospitalist and family practioner.

 

[edfig99]

FP is a great field, though I will admit where it's role is at this time is unclear. I can tell you that FP is the second largest collective group of physicians in the US - second only to internal medicine. I have heard that if you just counted the General Internists in the board of medicine, and excluded all subspecialists, then FP would surpass as the most numerous physician in the US.

There is still a role for FP in the ICU -- that is very much the case in most of rural America where there aren't tons of doctors running to serve. That being said, the ICU requirement in family practice residency is 4 weeks -- not nearly enough to take over the unit. If you are interested in being able to do critical care medicine and still be an FP, then you would have to do electives and probably work at an institution where there is at least an intensivist backup system that could be utilized.

The reality is that FP scope of practice is constantly being challenged by specialists all over the country...but these same specialists aren't going where the biggest need is...they do have a strong voice though. Geographically it is very difficulty to get privileges at some institutions (i am in the northeast, for example, and unless you work with a residency you are gonna have a hard time getting ob privileges). Malpractice is always a concern too...I mean, FP doing ICU does not equal the pay of a Cardiologist doing ICU, yet the insurance would be comparable. 🙁

The American Academy of Family Physicians has recognized that the existence of our specialty is in question right now, so much so they started the "Future of Family Medicine Project". This is being organized to answer the questions who are we, who needs us, what do we do, and how do we train others to do what we do... I recommend you check www.futurefamilymed.org for more info.

Med/Peds is a viable alternative - it allows you to subspecialize in one or both supspecialty boards (i.e. adult and peds cardio or icu or whatever). It isn't FP though...continuity of care is not expected in those fields, and neither is obstetrics. It's 4 years of training, mostly in the inpatient setting, with the emphasis being preparation for subspecialty training...not management of hypertension and ear infections.

the aafp website (www.aafp.org) also has many useful resources...you can look up rural fp residencies there.

hth,

 

[docrjay]

What about this fellowship. http://www.aafp.org/fellowships/10552.html

FP critical care/hospital medicine fellowship

Comments:
The critical care/hospital medicine fellowships designed to immerse the fellow in the ICU. Graduates would ideally practice in a rural hospital or serve as a hospitalist. Training is done in a 32-bed ICU with a full-time faculty intensivist. Hospital has excellent facilties and great specialty support. Fellows will regularly interact with family practice residents

FP is a great field, though I will admit where it's role is at this time is unclear. I can tell you that FP is the second largest collective group of physicians in the US - second only to internal medicine. I have heard that if you just counted the General Internists in the board of medicine, and excluded all subspecialists, then FP would surpass as the most numerous physician in the US.

There is still a role for FP in the ICU -- that is very much the case in most of rural America where there aren't tons of doctors running to serve. That being said, the ICU requirement in family practice residency is 4 weeks -- not nearly enough to take over the unit. If you are interested in being able to do critical care medicine and still be an FP, then you would have to do electives and probably work at an institution where there is at least an intensivist backup system that could be utilized.

The reality is that FP scope of practice is constantly being challenged by specialists all over the country...but these same specialists aren't going where the biggest need is...they do have a strong voice though. Geographically it is very difficulty to get privileges at some institutions (i am in the northeast, for example, and unless you work with a residency you are gonna have a hard time getting ob privileges). Malpractice is always a concern too...I mean, FP doing ICU does not equal the pay of a Cardiologist doing ICU, yet the insurance would be comparable. 🙁

The American Academy of Family Physicians has recognized that the existence of our specialty is in question right now, so much so they started the "Future of Family Medicine Project". This is being organized to answer the questions who are we, who needs us, what do we do, and how do we train others to do what we do... I recommend you check www.futurefamilymed.org for more info.

Med/Peds is a viable alternative - it allows you to subspecialize in one or both supspecialty boards (i.e. adult and peds cardio or icu or whatever). It isn't FP though...continuity of care is not expected in those fields, and neither is obstetrics. It's 4 years of training, mostly in the inpatient setting, with the emphasis being preparation for subspecialty training...not management of hypertension and ear infections.

the aafp website (www.aafp.org) also has many useful resources...you can look up rural fp residencies there.

hth,

 

[DropkickMurphy]

I read from one of the postings that it is difficult for FPs to get ICU priviledges

There is a valid reason for that. It's called patient safety.

 

[deleted87716]

I have had this concern about how well a training I can get in critical care medicine as an FP resident.

It depends on the residency. Where I trained, we routinely cared for patients in the ICU on several different rotations. I felt pretty comfortable taking care of ICU patients by the time I finished residency.

I read from one of the postings that it is difficult for FPs to get ICU priviledges.

I suggest you take most of what you read on these forums with a large grain of salt, and always consider the source. 😉

When granting privileges, hospitals will inquire about your credentials and training. If you have sufficient training to care for patients in the ICU, you should have no trouble obtaining privileges.

I am no longer clear about the future of FP which I so much cherish.

I would recommend you continue to broaden your experience, as there is actually little question as to the viability of family medicine as a specialty. If anything, family physicians are going to be increasingly in demand in coming years.

Last year there was a debate to add an additional year to the program because of the volume of info to learn in 3 yrs.

Actually, this is nothing new. The same subject has arisen in other fields, as well (emergency medicine, for example, which already has programs of varying length, from 3-4 years). The fact that something is discussed doesn't necessarily indicate a problem. Personally, I think a three-year program is appropriate.

Hope this helps,
Kent

 

[deleted87716]

The reality is that FP scope of practice is constantly being challenged by specialists all over the country

Actually, no...it isn't. Feel free to provide examples, if you can, but I can assure you that as an FP, I have never felt the least bit threatened by any of my specialist colleagues (and they are colleagues, by the way). They have little desire to do what I do, and vice versa. Patient care is a team effort.

 

[lateness]

It depends on residency mostly. On where you do it, and medicine is regional, every program is a little different, and can be flexible. I think if you do residency in a mostly unopposed program, then you will care for the inpatient more, and you wont have any turf battles with other specialties taking care of the same patient. But I have heard of some FPs in some rural areas, doing inpatient medicine. You could also do another year or two fellowship, as a hospitalist, and/or critical care. Then you could do it alot more, and hopefully there will be more fellowships created in the years to come.

 

[dksamp]

Hello,
Interesting topic. Let me give you my input from the PRIVATE PRACTICIONER’S perspective. First, let me start off with a phrase I have said ZILLIONS of times, and that is MEDICINE IS REGIONAL: What goes down in one part of the country may not be acceptable in another part. This is the deal with the ICU:
First of all, there are 2 types of ICUs: Open & Closed.
Open ICU - Anyone can admit there and call their own consults. In many cities, if an FP admits a patient to the ICU, and if the patient spends longer then 24 hours there, then a specialist should be on the case as per hospital bylaws. In my location, I can admit to the ICU myself, however, there is an expectation that you will call the appropriate specialist when warranted (i.e. Vent, unstable patient, etc.).
Closed ICU – There is usually an intensivist group that runs the ICU with different intensivists taking turns. There are a few hospitals in my area that have that. Basically, if a patient IRRESPECTIVE of the attending or the consultants goes to the ICU, the intensivist takes over the case and becomes the attending while the patient is in the ICU. As a result, the former attending can still see the patient, write a note and BILL for his visit, however, the BULK of the orders/management will be done by the intensivist. When the patient gets transferred out of the ICU back to med/surg or telemetry, it then goes back to the original attending and the intensivist backs off.
That being said, if you want to do this type of management as an FP, you would do better in a RURAL area because FP’s and even IM's who don't have fellowship training in critical care doing a bunch of ICU related management and procedures DOES NOT FLY in the big cities. If you want that type of action in the big cities, you are better off doing internal medicine and a fellowship in critical care. Here’s one caveat: be careful of wanting more duties and privileges than you need when you will take on ALL THE LIABILITY, and less reimbursement…some food for thought ;-)
Here is a list of FP fellowships that do provide some advanced hospital training:

http://www.aafp.org/fellowships/10428.html
http://www.aafp.org/fellowships/10552.html
http://www.aafp.org/fellowships/10591.html


Even if you were to go through this training, the REGION you wind up in will determine what you ultimately can or can’t do. Hope this helps. PEACE!

-Derek

 

[Eidolon6]

Critical care has matured to its own "specialty" rather than a natural off-shoot of surgery, internal medicine, anaesthesiology and peds. Myriad reasons exist for this but some of the big ones include...ballooning evidence and information in the field, physicians who cannot afford to spend all their time with critically ill patients when they have a busy practice, and growing evidence that closed ICU models with trained/certified intensivists improves outcomes and reduces costs. Currently EM is trying to petition for critical care privileges and some hybrid EM/CCM fellowships exist. This may be folly if we start liberalizing rather than standardizing our critical care training. Currently, in the adult sector, critical care certification can be acheived via IM/IM subspecialty, surgery or anaesthesia....and within those strata, there are significant practice variations/philosophies. Addition of independent EM or FP critical care programs may further complicate a growing marass of inconsistent knowledge bases and expertise variance. So far one of the truths that are being born out in ICU medicine is that standardized approaches and practice patterns improve outcomes and patient care...and we are perhaps being hypocritical if we continue to mass stratify, decentralize and support nonstandardized training in critical care medicine. I agree with Derek's post and from my experience as a critical care physician...indeed be careful what responsibilities and knowledge set you ask for...as those required of a true CCM physician are substantial and merit the specialization of critical care medicine.

 

[zippy81]

You get plenty of ICU exprience at many programs that in addition to the required 4 weeks also alow you when on inpt services to follow pts that are transferred to the ICU. Same goes for peds, find a community program that has a PICU and allows you to follow pts there. This training will definitely prepare you for a small hospital ICU where very sick pts will be transferred at some point even with intensivists around...

 

[shemozart]

I agree with what one of the above posters wrote - it's VERY regional. I'm training in the Midwest in a town of about 200,000 in a "community hospital" with about 300 beds - FP residency is unopposed. We do 6-8 weeks of straight ICU our first year, and 4 weeks each our second and third year. We also follow our own FP clinic patients in the unit while on regular adult medicine rotations - so additional patients above and beyond the devoted ICU time above. I haven't heard of any graduates that have stayed in the Midwest or small towns and have NOT been able to get ICU privileges. (Haven't heard of any that went elsewhere and tried, though)....and there's many community docs (both FP and IM) that follow their own patients in the unit in our hospital, as well as others that just have IM hospitalists and intensivists follow their own patients. However, the unit at the big academic center in town has a separate ICU team with residents and intensivists providing all care, and NO community docs of any kind can manage care. So that would be a difference as well....what kind of medical center you're interested in providing care at and what hospitals you're admitting to.

If you want to do some ICU in the future, anything is possible, but you won't be able to do it just anywhere. And you need the training and procedures to back you up! But if you're interested, there's a way! 🙂

 

[CambieMD]

as an FP doc I saw my patients who were in the unit. It can de difficult to manage patients in the unit and have a busy outpatient practice. At times I made multiple trips to the hospital to complete my rounds. there was a lot of pressure to move your patients out of the high rent district. Because of time constraints I ended up let a hospitalist group handle all of my in-patients. I just didn't feel that I had the time to do both.
Unfortunately, there are those who think that FPs should not be allowed to treat ICU patients. FPs as group should not be locked out of ICU care. This should be looked at on a case by case basis.


CambieMD