FP's and surgery

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sdude

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Hello,

I'm a grad student planning a possible medical career, and I am pretty sure I would find being a FP in a rural/small town area to be very rewarding. (I come from a rural background)

I'm really excited about the challenge of becoming a first-rate diagnostician in every area, being able to intelligently advocate for my patients with any specialist, and developing the competence to take care of most things myself.

The one thing I'm concerned about is surgical/ob issues. I'm fascinated by surgery, have a lot of nerve, and become very cool and focused in critical situations. I also have pretty unusual manual dexterity, and I'm sure I could do any procedure well as long as I had adequate training.

The issue is training--I would never bill myself as a surgeon or an ob, but if I'm the only doc on call in a rural hospital, I will (probably regularly) be forced into situations where there was no time to transfer and I would have the choice of operating or watching the patient die. Women (possibly without any previous prenatal care) will go into labor and come to the ER and I'll have to deal with it.

How do rural FP's get advanced procedual training? I wish there were FP fellowships available in operative gyn, emergency vascular surgery, appendectomies, etc. Is it possible to design your own "advanced FP" PGY-4?

Are there any FP residencies that are known for being very "high-level" in emphasizing advanced procedures and specialist-level diagnostic ability, possibly with a 4th year available?

Thanks in advance for any advice!

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It seems to me that you're jumping the gun a bit.....but

As far as OB goes I'm a fourth year medical student and the place that I am currently training is somewhat "rural"-actually it's a regional referral center, but not an academic center. Thus far I delivered appx. 30 babies, sewed the epis myself etc. I've 1st assisted on countless C sections, was primary surgeon on 2 of them. I've done an Above the knee amputation, put in chest tubes, done an appy, have done countless intubations in the OR. Basically I'm the only student on every service (no residents either). I feel pretty confident that right now beginning my fourth year I could do any of the things you are talking about and get by. Granted my procedural training has been better that most but if you really stick your nose in and really try to do a lot you can. (I'm not saying I'm ready to practice on my own and I do make a lot of mistakes, but you know what I'm saying)
Take things one step at a time. If you work your but off, stick your nose in in clinical training then you will get to do a lot and things come quicker than you might think.
 
there are many programs that teach sections, trauma, etc to fp residents. to name a few
california: ventura county, contra costa county, natividad
oregon: klamath falls/ohsu rural track
washington: tacoma family med, spokane rural option
colorado: greeley program
there are also numerous fp fellowships in high risk operative obstetrics. check out the fellowship page at www.aafp.org for details. good luck
here they are:
Fellowship Programs in Obstetric
Univ. of Alabama - Huntsville Huntsville AL
USC/CHMC Family Medicine Los Angeles CA
Santa Clara Valley Medical Center San Jose CA
Sutter Medical Center of Santa Rosa FPRP Santa Rosa CA
Florida Hospital FPRP Orlando FL
West Suburban Health Care Oak Park IL
Memorial Hospital FPR South Bend IN
St. Elizabeth FPC Edgewood KY
LSU Medical Center FPRP Lafayette LA
Department of Family Medicine New Brunswick NJ
University of Nevada School of Med Las Vegas NV
University of Rochester Rochester NY
Univ Hospitals of Cleveland Cleveland OH
Memorial Hospital of RI Pawtucket RI
Spartanburg Family Med Residency Spartanburg SC
University of Tennessee Memphis TN
University of Tennessee at Memphis Memphis TN
Department Family Medicine Nashville TN
Brackenridge Hospital Austin TX
Christus Spohn Hospital Memorial Corpus Christi TX
School of Medicine - Univ. of UT Salt Lake City UT
Swedish Family Medicine Residency Seattle WA
tacoma family medicine, tacoma wa
Fellowship Directory | AAFP Home Page
 
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Thanks! :)

Esp. about the Colorado and CA programs--looks awesome!

(Ventura co.: Learning FP while being able to SURF again? Makes me want to pass out!)
 
There's an interesting fellowship at Maricopa in Phoenix for 2 years for extended hospital training for FPs.

http://www.medprodoctors.com/Training.htm

My question is does this happen in real life? Call me faithless, but when one goes out into the real world of private practice with real malpractice, real hospital administrators granting priviledges, etc, is it just a pipe dream? Maybe i've joined the dark side of the force and believe that it might be more prudent to leave some things to those more competent. As an US IMG I seriously doubt that I'd be looked at in the better programs. In fact the Northern Colorado program goes out of its way to say "If you're an IMG don't bother applying until you've done 2 years of post-grad training" or to that effect.

I feel the idealist inside me saying go for rural FP, but my head says specialize. Sigh...
 
dj_smooth said:
There's an interesting fellowship at Maricopa in Phoenix for 2 years for extended hospital training for FPs.

http://www.medprodoctors.com/Training.htm

My question is does this happen in real life? Call me faithless, but when one goes out into the real world of private practice with real malpractice, real hospital administrators granting priviledges, etc, is it just a pipe dream? Maybe i've joined the dark side of the force and believe that it might be more prudent to leave some things to those more competent. As an US IMG I seriously doubt that I'd be looked at in the better programs. In fact the Northern Colorado program goes out of its way to say "If you're an IMG don't bother applying until you've done 2 years of post-grad training" or to that effect.

I feel the idealist inside me saying go for rural FP, but my head says specialize. Sigh...


I know what you mean, I'm an older (29) guy, and have worked in the healthcare field, and have chewed on this issue a lot.

My problem is that I admire the competence of good specialists (and their lifestyle is pretty nice), but they often seem diminished as physicians. My internist won't dare remove a mole and has no knowlege or interest in my issues as an athlete, the psychiatrist I see for depression literally turned white when I came down with an obvious bacterial infection (colored mucus, etc), I couldn't get into see the internist, and asked (as a one-time favor) if he could prescribe antibiotics. Don't even get me started on the dermatologist... A healthy guy in Houston can easily wind up with seven doctors! It's ridiculous.

FP's from smaller towns have always impressed me the most, and the ones I've known combine the best qualities of doctors (IMO): compassion, nerve, and competence.

I'm lived in different parts of Texas (Houston right now), and have driven across the country a few times, and it's pretty obvious that the "ideal" of always getting referred to a specialist simply isn't an option in huge parts of the country. The number of people who don't get any kind of competent health care is unbelieveable, even in urban areas. Passing an indigent patient on to an ob on the other side of town (or fifty miles away) you know will turn her away, or referring a depressed teenager to a psychiatrist you know his parents won't pay for and he'll never see really seems to me a form of negligence.

It's a really difficult issue, period. My understanding though, is that in rural areas hospitals are more lenient in granting privileges simply because they have to. I wish everyone who needed surgery could get it at Methodist from Baylor faculty (like I would), and that all ER's were staffed by board-certified emergency physicians--but as our society becomes more stratified I'm afraid there are increasingly going to be two "worlds" of medicine, with the lower level coming to resemble "Doctors Without Borders" in Africa.

It's pretty discouraging.
 
sdude said:
My problem is that I admire the competence of good specialists (and their lifestyle is pretty nice), but they often seem diminished as physicians. My internist won't dare remove a mole and has no knowlege or interest in my issues as an athlete, the psychiatrist I see for depression literally turned white when I came down with an obvious bacterial infection (colored mucus, etc), I couldn't get into see the internist, and asked (as a one-time favor) if he could prescribe antibiotics. Don't even get me started on the dermatologist... A healthy guy in Houston can easily wind up with seven doctors!

Great perspective. It is very discouraging when the generalists want to refer you to a specialist for even the simplest problems.

Sheesh, can't they give it the "Old College Try" before referring the patient to a specialist?

I am sure reimbursement has something to do with this. If they can't handle it in 5 minutes they refer it out. That way they can continue to see 40 patients per day.
 
Many small towns need surgeons. You hear a lot about FPs being broadly trained to provide for rural communities simply because there are not a lot of specialists out there who can provide those services. But if you're someone who wants to live out in small towns, why not be the area's local surgeon? I think you'll find it just as rewarding (financially and otherwise) as the town's general surgeon who's trained to handle a lot of issues, both surgical and primary care... doing surgeries beyond urban surgery. There's a lot of General Medicine in Surgery... so don't pass up surgery just because you're thinking about living in a small town. There's a lot of demand for them out there handling a variety of cases (pedi, trauma, burns, and general stuff)...

If you're that interested in procedural training, do surgery and move to a small town. The need is much greater and you can always be an non-certified general practitioner when you don't want to operate anymore.
 
lowbudget said:
Many small towns need surgeons. You hear a lot about FPs being broadly trained to provide for rural communities simply because there are not a lot of specialists out there who can provide those services. But if you're someone who wants to live out in small towns, why not be the area's local surgeon? I think you'll find it just as rewarding (financially and otherwise) as the town's general surgeon who's trained to handle a lot of issues, both surgical and primary care... doing surgeries beyond urban surgery. There's a lot of General Medicine in Surgery... so don't pass up surgery just because you're thinking about living in a small town. There's a lot of demand for them out there handling a variety of cases (pedi, trauma, burns, and general stuff)...

If you're that interested in procedural training, do surgery and move to a small town. The need is much greater and you can always be an non-certified general practitioner when you don't want to operate anymore.


Thanks for the thoughtful advice. I have been very impressed with the surgeons I've known, and it's definitely one of my most admired branches of medicine. Surgery appeals to me a lot, but I'm pretty confident I wouldn't want to be a full-time surgeon. I think I would be happiest dealing with different age groups, healthy people with minor problems, teenagers who need someone to talk to (who isn't a shrink :)), hospice patients with distressing yet treatable symptoms--things like that.

I guess my issue (may not be a problem in FP) is that I'm strongly interested in most branches of medicine, and know from experience that I get the most satisfaction from being able to use my skills to help people directly, even in relatively mundane ways.

A limited surgical practice would be exciting, though...I'll just see how things work out.

Thanks for the ideas.
 
minime said:
It seems to me that you're jumping the gun a bit.....but

I've 1st assisted on countless C sections, was primary surgeon on 2 of them. I've done an Above the knee amputation . . .

Is that right :wow: ? As a fourth year med student you've been the primary surgeon doing a C-section???????


Judd
 
I would think several factors have led to FPs being more willing to farm out....

Reimbursements have dropped significantly for procedures. On my inpt IM a central line was reimbursed for approx $70, rads would get $300+.

Technology has dramatically changed medicine where it should be used when available, i.e. u/s guidance for above procedure by rads.

Followed by the lawsuit, where if you botched the central line, the question that you would be asked is, why didn't you use u/s guidance for the central line? It was available 2 floors down at your hospital.

I saw a staff physician get burned by this exact scenario. He did the central line so the icu pt didn't have to wait for the rads schedule to open up, had a complication, and lost the lawsuit. He swore that he'd never do another bedside central line after this wonderful medical/legal experience. Check your local hospitals in big cities and see how many FPs are credentialled to deliver, it will likely be a short list due to the liability issue of having a FP vs an OB doing the procedure, even though both are trained.
 
r90t said:
I would think several factors have led to FPs being more willing to farm out....

Reimbursements have dropped significantly for procedures. On my inpt IM a central line was reimbursed for approx $70, rads would get $300+.

Technology has dramatically changed medicine where it should be used when available, i.e. u/s guidance for above procedure by rads.

Followed by the lawsuit, where if you botched the central line, the question that you would be asked is, why didn't you use u/s guidance for the central line? It was available 2 floors down at your hospital.

I saw a staff physician get burned by this exact scenario. He did the central line so the icu pt didn't have to wait for the rads schedule to open up, had a complication, and lost the lawsuit. He swore that he'd never do another bedside central line after this wonderful medical/legal experience. Check your local hospitals in big cities and see how many FPs are credentialled to deliver, it will likely be a short list due to the liability issue of having a FP vs an OB doing the procedure, even though both are trained.


I'd never do a central line without ultrasound, but I definitely understand your point about big cities. At major hospitals invasive procedures by FP's don't seem to be wise or practical, whatever the quality of the FP's training. I'm thinking along the lines of a rural practice/small hospital, where specialty interventionalists simply aren't available.
 
This is off the OP's post, but would anyone be interested in forming an interest group for a Family Practice Surgery Fellowship? This kind of fellowship was already mentioned in this thread, and is something I've thought about for quite awhile.

Here's some ideas about how the fellowship could look:

1. Training could focus on the most important surgeries for underserved areas: appy's, chole's, hernias, C-sections, basic trauma, possibly splenectomies, possibly breast lump/mastectomies. The fellow would essentially function for a year as the equivalent of a 2nd or 3rd year surgical resident. Ideally they would have trained in a residency that already had offered them significant numbers of C-sections and appy's (like some of the places already mentioned).

2. Training would be offered at hospitals where a fellow could reasonably expect to get the numbers necessary for them to attain privleges at most hospitals in the US with the exception of the major U centers.

3. The FP-surgeon model (also mentioned above) in Canada, also gets extra training in psychiatry because this is another specialty that is totally maldistributed from urban to rural populations. Psych is already a longitudinal focus of many FP programs, but it could be an additional focus in the fellowship.

4. Obviously, this fellowship would best suit FP's who intend to practice in underserved US locations and overseas. However, a good case can be made for why a FP in any location should do a C-section over an OB, which is continuity of care. Patient anxeity and fear, as well as personalized care are worse when the patient is handed off from doctor to doctor who doesn't know them. The inhumanity of allopathic medicine is the ultimate - and most prevalent - criticism leveled at the entire profession today. "Alternative" forms of medical care exist everywhere, and Americans spent as much on them as they did on allopathic care last year. FP's are as threatened with extinction as the entire profession is; every specialty should take heed.

I'm not proposing anything revolutionary here. The Ventura FP program (which emphasizes surgery and ER) already claims that their doctors can treat over 90% of their patient's problems, and the Canadian system is already producing doctors with this type of training...with less training time. I'm just proposing that a group of interested students and current FP's get together and take the next logical step.

I personally think that the major impediment to the specialty of FP today for medical students, is the perception that they actually don't DO anything. Although this really isn't true even in the most limited FP office, if there was an opportunity to care for all aspects of a person's medical and emotional needs, I think more people would be attracted to the specialty.

Oh, the the insurance thing? Well, most OB's can't afford to do C-sections these days either. The back of the entire medical system will soon break in this current environment, and everyone knows it. Thus, it stands to reason that in the next few years, the system will be adjusted to something more rational (like lawsuit damage limits to 250k). In an environment where million-dollar lawsuits don't pile up like leaves, anyone with enough experience should be able to do procedures and surgeries within a reasonable overhead framework.

Further thoughts and/or PM's appreciated.
 
I couldn't agree with you more. That is precisely the type of training I would want to have if I went into FP.

You are exactly right about the "passing the patient" issue. Naturally, one wants top quality care, but freqently referrals seem to be a way to evade responsibility while greatly increasing patient anxiety, dissatisfaction, and the possibility of medical errors. FP needs to have a place both for those who are happy with general ambulatory care, and those who can and want to do more.

I agree with you on the insurance issue...sooner or later the whole system will collapse and health care reform will have to take place whether we want to deal with it or not.

Ventura sounds better all the time. Surgery AND surfing? ahhhhhhh.....
 
sdude said:
Thanks! :)

Esp. about the Colorado and CA programs--looks awesome!

(Ventura co.: Learning FP while being able to SURF again? Makes me want to pass out!)


Just wear a 4mm or thicker suit.
 
A 3/2 is fine for surfing in Ventura - trust me (with exception of La Nina and winter off-shores).

I'm doing a 4th year rotation there in September and I'm looking fwd to it. However, EVERYONE applies to Ventura, so they're reputed to be the most competitive FP residency in the country. I'm not pinning much hope on getting in there.

Plus, housing costs are unbelievable. Median house price is (no joke) a half-million bucks. A crummy 2-bd in an ugly neighborhood is well over 300k. Rent is commensurate.

So, it's a good program (especially if you surf), but it probably isn't as great as everyone makes it sound. There's quite a few great programs that focus on surgery and procedures, you just have to find them. The list above left out the Wesley program in Wichita, which lets you do a trauma surgery rotation during your training, and the New Mexico programs give you lots of procedures too. There's also some intense surgery training at a program in Texas, but I don't remember where at the moment.
 
You can do OB/GYN fellowships for C-section, however, major cities won't likely credential you. There are some programs out there that my friends applied to, specifically designed for the FP grad to be a one man show in the sticks of Montana. One is in Pocatello, ID. Don't know where the rest are.
 
secretwave101 said:
A 3/2 is fine for surfing in Ventura - trust me (with exception of La Nina and winter off-shores).

I'm doing a 4th year rotation there in September and I'm looking fwd to it. However, EVERYONE applies to Ventura, so they're reputed to be the most competitive FP residency in the country. I'm not pinning much hope on getting in there.

Plus, housing costs are unbelievable. Median house price is (no joke) a half-million bucks. A crummy 2-bd in an ugly neighborhood is well over 300k. Rent is commensurate.

So, it's a good program (especially if you surf), but it probably isn't as great as everyone makes it sound. There's quite a few great programs that focus on surgery and procedures, you just have to find them. The list above left out the Wesley program in Wichita, which lets you do a trauma surgery rotation during your training, and the New Mexico programs give you lots of procedures too. There's also some intense surgery training at a program in Texas, but I don't remember where at the moment.

The rental prices (for holes) in CA are really unbelievable. I tried living in Orange County for a while, and after a month of housing nightmares and an apparently non-existent job market (for NETWORK admin, if you can believe it--evidently everyone in CA is already in that field) I wasn't too sorry to head back to Texas. The one thing I really miss is San Onofre State Beach (Trail 5).

I also found the people in OC to be very strange and cliquish. SoCal in general was depressing because you could really see that it probably was paradise on earth at one time.

I got a real kick out of the Ventura FP residency's website--it actually seemed deliberately targeted to wave-starved med students!

I wonder if Ventura's reputation is due in part to the fact that every surfer in med school (who would probably be into FP anyway) puts it down as first choice. Non-surfers then get attracted to its selectivity, and want to go too, and the reputation starts to snowball...

I'm glad there are other residencies with a procedural emphasis. If you remember what that Texas program is please let me know. (Also places near snow-covered hills, world class skateparks, etc.)
 
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