Free at Last! Free at Last!

Well, thats it for me at Duke. Today was my last day. I had a nice discussion with the most excellent Program Director (a gentleman who has been royally screwed and deserves better) turned in my ID, PDA, pager, scrub card, parking permit, dictaphone, gave my compliments to the nurses at the Family Medicine clinic, and that was that.

No point. Just that I'm glad to be done with it and even though I'm repeating intern year starting in July, have a big logistical exercise moving the family starting on Monday, and am teetering precariously on the brink of financial ruin what with the unanticipated expenses of moving I feel pretty optimistic.
 

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    Good luck with your new start. I'm glad you're getting the chance to finally pursue what you really wanted all along and I'm looking forward to reading about it. :)
     
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      Panda Bear said:
      Well, thats it for me at Duke. Today was my last day. I had a nice discussion with the most excellent Program Director (a gentleman who has been royally screwed and deserves better) turned in my ID, PDA, pager, scrub card, parking permit, dictaphone, gave my compliments to the nurses at the Family Medicine clinic, and that was that.

      No point. Just that I'm glad to be done with it and even though I'm repeating intern year starting in July, have a big logistical exercise moving the family starting on Monday, and am teetering precariously on the brink of financial ruin what with the unanticipated expenses of moving I feel pretty optimistic.
      Good luck. I'm also coordinating a big move and stressing out, but it's only me and my girlfriend (and her stuff). I can't imagine the complications kids and houses add.

      Glad you can start doing what you love.
       

      anxietypeaker

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        hey everyone. I was just on pandas blog about his experience in family medicine internship. And to put it bluntly, im actually kinda concerned about the quality of family medicine training in general compared to Internal medicine training. I've always thought family medicine is so cool as far as being able to see a little bit of everything. Moreover, family medicine seems to be the best PCP speciality (IN MY OPINION). Only the US and Canada have IM or peds also as PCPs. The UK, Korea, australia and others have IM and Peds as specialists. But with the kinda treatment/training that panda talked about and how FM is seen by med students/other docs, its kinda dissappointing.So for my questions:

        1) Do most FM residencies have equal resources/etc as IM residencies? I thought ACGME accreditation would make most programs more or less equal.

        2)What are some of the more prestigious (better) programs out there (im not asking for a ranking, just a few that have distinguished programs)?
         

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          anxietypeaker said:
          I was just on pandas blog about his experience in family medicine internship. And to put it bluntly, im actually kinda concerned about the quality of family medicine training in general compared to Internal medicine training.

          Please do not consider Panda Bear's comments to be in any way representative of the quality of family practice training anywhere except Duke (which doesn't really matter anymore, since they're history). He was the wrong guy in the wrong program at the wrong time.

          That being said, I wish him well in his new residency.
           
          KentW said:
          Please do not consider Panda Bear's comments to be in any way representative of the quality of family practice training anywhere except Duke (which doesn't really matter anymore, since they're history). He was the wrong guy in the wrong program at the wrong time.

          That being said, I wish him well in his new residency.

          I want to attest that I have friends in small, unopposed programs who get exceptional training. I wouldn't say we got bad training, just that the focus (in my opinion, dammit) was all wrong.

          I'm working on the third part of my article in which you will find my interpretation of this:

          http://www.annfammed.org/content/vol2/suppl_1/index.shtml

          This article is a blueprint of sorts for the future of Family Medicine and I think a lot of you will be somewhat horrified as to what is going to be expected of you in the future. I think it is a movement away from the old-school model of the doctor as, well, a physician and towards the idea of the physician as a busy-body and community activist.

          If you're into that kind of thing that's your business but I can't think of a way to make any specialty less popular than by reinforcing the things that drive people away from it.

          And no, I'm not writing an air-tight indexed and referenced refutation of the thing. It's page after page of psycho-babble and it was all I could do to read most of it once. I'm just going to give you my take on it in a broad sense and as usual your comments will be welcomed and appreciated.
           
          KentW said:
          Honestly, Gus, I would think you'd be more concerned with the future of emergency medicine at this point.

          http://www.iom.edu/CMS/3809/20313/17905.aspx

          It would certainly be a better use of your time.

          Look, it's my blog. It is a hobby. I like to write and I hope to improve my writing skills to the point where I can write a book. In a couple of months my time at Duke will be a dim memory. In the meantime I write about things that are interesting to me and that I think will be of interest to others.

          Also, as I have been on the receiving end of political correctness and creeping psycho-babble for my entire academic career this is one of my particular areas of interest, especially as I remember a time before institutional, pre-fabricated compassion.

          I am also a cynical old dog (some of the time) and I don't see why everything everybody writes or says has to be sanitized so as to be inoffensive. I'm just a guy, low on the totem pole, with an opinion or two.

          As for my time, well, I'm not doing much between now and July 1st. I am actually going to sign off for a while starting on Monday.
           

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            Not to fan the flames... but I find it interesting that Panda presumes he will be more of a "physician" in emergency medicine.

            How is that, exactly?

            The thing that continually amazes me about people's declarations on things like "how it's going to be" or "how you are trained" is that there are as many versions of that reality as there are physicians and physicians in training. I understand it's opinion, but conjecture about such things is pretty ridiculous (in my opinion,of course).

            PB was at an opposed program with a lot of problems. Many people are at great FM programs, unopposed, and get excellent training.

            As for the "future of family medicine"...I have been to the meetings and read the articles, too. There is no reason why you can adopt some of the more forward thinking ideas from that model without sacrificing one iota of the actual medical care you provide your patients.
             

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              anxietypeaker said:
              hey everyone. I was just on pandas blog about his experience in family medicine internship. And to put it bluntly, im actually kinda concerned about the quality of family medicine training in general compared to Internal medicine training.

              Internists are trained in the care of adults. Family medicine trains you to care for the whole family. Why are you interested in making comparisons?

              If you are interested in doing more inpatient care, as internists do, you should go to an unopposed program in an urban area that has high volume, where you ARE the internist, the OB/GYN, the pediatrician, etc.

              Most opposed programs train you adequately for outpatient care where you will be doing a lot of referring.
               

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                sophiejane said:
                As for the "future of family medicine"...I have been to the meetings and read the articles, too. There is no reason why you can adopt some of the more forward thinking ideas from that model without sacrificing one iota of the actual medical care you provide your patients.

                Agree. The FFM project is largely an abstraction, and provides little in the way of specifics. Most FPs are still trying to wrap their brains around how they can apply it to their practices, or even if they should. I doubt that Gus is going to be able to offer much of substance after a single cursory read, particularly without any real-world experience in the practice of family medicine.

                A miserable year spent as a reluctant FP intern does not an expert make.
                 
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                KentW said:
                Agree. The FFM project is largely an abstraction, and provides little in the way of specifics. Most FPs are still trying to wrap their brains around how they can apply it to their practices, or even if they should. I doubt that Gus is going to be able to offer much of substance after a single cursory read, particularly without any real-world experience in the practice of family medicine.

                A miserable year spent as a reluctant FP intern does not an expert make.

                And yet, I have a finely tuned chicken-**** detector and the FFP project pegs the needle all the way to the right. My cursory read also allowed me to come to the same conclusion as you, namely that it is largely an abstraction and that there is some question whether any of it can or should be applied.

                Also, since I have been on the cutting edge, now dull and dented, of the application of some of the proposals in the FFM, I think I am in a tolerable position to report on some of the results.

                If you read my blog, I am not ant-family practice and you know that, aside from a little joking around, I respect what you guys do. This may be typical of many organizations but your leadership has goals that are probably at odds with those of most of the rank-and-file.
                 

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                  Panda Bear said:
                  And yet, I have a finely tuned chicken-**** detector and the FFP project pegs the needle all the way to the right.

                  The same can be said of pretty much any white paper. Nothing unique about the FFM report in that respect.

                  The only section of the FFM report that you could even reasonably comment on is the report of the Task Force on Medical Education: http://www.annfammed.org/cgi/content/full/2/suppl_1/s51

                  Even so, you cannot accurately claim that Duke's ill-fated program was the embodiment of the FFM project goals, as "community medicine" barely garners a mention, and there is certainly nothing in the report that recommends marginalizing the training of family physicians in favor of midlevel providers. If any links to the FFM project were claimed by the faculty at Duke, they are, at best, a faulty interpretation.
                   

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                    Panda Bear said:
                    Where did I say that, exactly?

                    Panda Bear said:
                    This article is a blueprint of sorts for the future of Family Medicine and I think a lot of you will be somewhat horrified as to what is going to be expected of you in the future. I think it is a movement away from the old-school model of the doctor as, well, a physician and towards the idea of the physician as a busy-body and community activist.

                    What IS going to be expected of us in the future?

                    A movement away from being a physician and toward being a busy-body?

                    Your implications are clear that you believe you will be sheltered from such expectations in emergency medicine.

                    Correct me if I'm wrong, but in EM it seems to me that you will be doing urgent care/FP type medicine 90% of the time, unless you are in a big trauma center.

                    To each his own.
                     

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                      sophiejane said:
                      Internists are trained in the care of adults. Family medicine trains you to care for the whole family. Why are you interested in making comparisons?

                      If you are interested in doing more inpatient care, as internists do, you should go to an unopposed program in an urban area that has high volume, where you ARE the internist, the OB/GYN, the pediatrician, etc.

                      Most opposed programs train you adequately for outpatient care where you will be doing a lot of referring.

                      That question is ridiculous to ask. To say that FM and IM aren't compared by medical students going into practice is ridiculous. Moreover, the faculty at some universities even make these comparisons themselves. In fact, there has been research articles comparing the two fields, and ONLY the two fields, in JAMA and some other fairly prestigious medical journal. If you dont think that the two fields are compared by most people, then you are extremeley out of it. However, if you meant that the two fields SHOULD not be compared, then thats your opinion. However, the reason taht i made this comparison was because Panda was talking about the superior training IM got. Now, to say that medical students would pick FM over IM because they like the breadth is fine. But if the training is inferior compared to IM, then I am sure more people will shift over to IM or Peds. Please dont ask questions and get defensive based off your own emotions. Some people here truly are just asking. Moreover, you say that IM = adults and FM = everyone...does that justify FM having inferior training???? If the training is inferior, no matter how much a person wants to do FM, he/she will think second about it. Thats why i asked. All you did in your statement was cater to your own ego and manipulate the question into a frame that would quench your own paranoida. Answer the questions or just ignore them. Dont change the question as you see fit. Youd make a good lawyer...or maybe not :laugh:
                       

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                        anxietypeaker said:
                        That question is ridiculous to ask. To say that FM and IM aren't compared by medical students going into practice is ridiculous. Moreover, the faculty at some universities even make these comparisons themselves. In fact, there has been research articles comparing the two fields, and ONLY the two fields, in JAMA and some other fairly prestigious medical journal. If you dont think that the two fields are compared by most people, then you are extremeley out of it. However, if you meant that the two fields SHOULD not be compared, then thats your opinion. However, the reason taht i made this comparison was because Panda was talking about the superior training IM got. Now, to say that medical students would pick FM over IM because they like the breadth is fine. But if the training is inferior compared to IM, then I am sure more people will shift over to IM or Peds. Please dont ask questions and get defensive based off your own emotions. Some people here truly are just asking. Moreover, you say that IM = adults and FM = everyone...does that justify FM having inferior training???? If the training is inferior, no matter how much a person wants to do FM, he/she will think second about it. Thats why i asked. All you did in your statement was cater to your own ego and manipulate the question into a frame that would quench your own paranoia. Answer the questions or just ignore them. Dont change the question as you see fit. Youd make a good lawyer...or maybe not :laugh:

                        You want to bring out the snob in someone? Ask an IM/Peds resident what the difference between them and an FM resident is - especially in practice, when an FM doc is part of a group that doesn't do Ob.

                        IM/Peds definitely look down on FM, even as they do the same job in primary care.
                         

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                          thats a good point that i wasnt aware of. But EVEN with that, im not referring to reputation/etc that does actually tend to matter with most. ALL i was focusing on was training. And my question was whether fm gets inferior teaching because of whatever reason. I think that question is very fair, sophiejane. thanks though for the additional input apollyon and adding to the thread.
                           

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                            What do you define as inferior teaching? What do you define as teaching? Bedside teaching, Noon conferences, Morning report, Patient census, patient load, senior resident teaching intern, attending teaching intern and senior resident? I think first you need to define what the standard is. If you are comparing FM to Peds, FM to IM, FM to OB/GYN, or FM to any other rotation you must think about the level of responsibility that is given to the FM resident and how they are treated by those off service personnel. The teaching is only as strong as those off service rotations. It is obvious that the amount of exposure is inferior when compared to those specialties but that doesn't mean the teaching is. Is it beneficial to have an FM resident spend ample time in all subspecialties like those in IM or Peds. What is the value of a rotation if you are never going to perform those duties in clinical practice? I think it is beneficial to ask why the different cirriculums are structured the way they are. On the flip side is it reasonable to ask if the cirruculum and/or teaching in IM is inferior to FM if the internest pursues primary care.
                            I think these are real questions not meant as a response to inflame anyone. I am just curious as to what others think the answers might be.
                             
                            sophiejane said:
                            What IS going to be expected of us in the future?

                            A movement away from being a physician and toward being a busy-body?

                            Your implications are clear that you believe you will be sheltered from such expectations in emergency medicine.

                            Correct me if I'm wrong, but in EM it seems to me that you will be doing urgent care/FP type medicine 90% of the time, unless you are in a big trauma center.

                            To each his own.

                            Whoa. Every medical specialty is shackled to paperwork and bureaucracy to some degree or another as well as to service requirements that are not strictly speaking, medically related. There is also such a thing as pay for performance (I believe it is called) but there is a huge difference between the requirements for EM and FM. By definition almost an EM physician is not going to be tracking his patient's HGBA1C or blood pressure as a performance metric.

                            If you bothered to wade through the FFM report you are going to be horrified (or not depending on whether you are into that kind of thing). DFM was definitely trying to implement a lot of the recommendations which goes to show you that you can have a large group of very intelligent, sincere people propose a solution to a problem which will never work when applied in practice.
                             

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                              KentW said:
                              The same can be said of pretty much any white paper. Nothing unique about the FFM report in that respect.

                              The only section of the FFM report that you could even reasonably comment on is the report of the Task Force on Medical Education: http://www.annfammed.org/cgi/content/full/2/suppl_1/s51

                              Even so, you cannot accurately claim that Duke's ill-fated program was the embodiment of the FFM project goals, as "community medicine" barely garners a mention, and there is certainly nothing in the report that recommends marginalizing the training of family physicians in favor of midlevel providers. If any links to the FFM project were claimed by the faculty at Duke, they are, at best, a faulty interpretation.

                              Listen, all the FFM project was was a marketing report published by a marketing firm who went out and surveyed people on how FP's are doing in the community at the request of the AAFP et al. It's not uncommon for, say, Microsoft or Walmart or Merck to do that from time to time just to ask, "Hey, how are we doing out there?" It's not Gospel and it certainly may not even reflect your patients' or community's sentiments. No one can predict the Future of Anything; I don't care how many papers they publish. At the same time, physicians aren't as skilled as Fortune 500 firms in doing market assessment and formulating strategies. This was our chance to see what's out there. But like anything, broad paint strokes tend to miss the finer details. I imagine the community in which you practice (the market conditions) will dictate your position, and how you run your business will dictate how that envirnoment will embrace you or reject you.
                               
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                                anxietypeaker said:
                                That question is ridiculous to ask. To say that FM and IM aren't compared by medical students going into practice is ridiculous. All you did in your statement was cater to your own ego and manipulate the question into a frame that would quench your own paranoida. Answer the questions or just ignore them. Dont change the question as you see fit. Youd make a good lawyer...or maybe not :laugh:


                                Now, now. I didn't get emotional nor did I sling insults. No need for you to stoop to that level. I simply asked why you were interested in comparing the two.

                                I'm not sure you are a medical student yet (forgive me if I'm wrong), and if you are, I'd be surprised to hear people asking that question a lot where you are in school. They certainly don't ask it where I am. People who are interested in IM have their reasons, as do people interested in FM. I've never heard of someone choosing one or the other due to "inferior" or "superior" training.

                                Internists are trained to be internists. Superior IM programs produce superior internists. FPs are trained to be FPs. Superior FP programs produce superior FPs. Saying that internists receive "superior" training to FPs doesn't make any sense. Does the OB/GYN receive superior training to the internist? Yes, as it pertains to their specialty. Do you see where I'm going with this?

                                If your question really was, do internists get better training in the care of adults with serious chronic illness? Perhaps, at some programs. But there are some pretty bad IM programs out there and some pretty superior FP programs, and I wouldn't doubt that the FPs from the superior programs could do a better job caring for adults with chronic illness than the internists from the inferior programs. But ont the other hand, would you take your kid to an internist? Of course not. But both you and your child could see the same family physician as your primary care provider.

                                And it's really not just the programs. It's also the individual. There are terrible internists and fabulous FPs and vice versa.

                                Answering the question you posed would be difficult because it is so broad and there are so many factors involved.
                                 

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                                  Apollyon said:
                                  You want to bring out the snob in someone? Ask an IM/Peds resident what the difference between them and an FM resident is - especially in practice, when an FM doc is part of a group that doesn't do Ob.

                                  IM/Peds definitely look down on FM, even as they do the same job in primary care.


                                  Exactly.

                                  And I would add that people who make their decision about choosing a specialty based on who does and does not look down upon them are in for an interesting ride.
                                   

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                                    anxietypeaker said:
                                    hey everyone. I was just on pandas blog about his experience in family medicine internship. And to put it bluntly, im actually kinda concerned about the quality of family medicine training in general compared to Internal medicine training. I've always thought family medicine is so cool as far as being able to see a little bit of everything. Moreover, family medicine seems to be the best PCP speciality (IN MY OPINION). Only the US and Canada have IM or peds also as PCPs. The UK, Korea, australia and others have IM and Peds as specialists. But with the kinda treatment/training that panda talked about and how FM is seen by med students/other docs, its kinda dissappointing.So for my questions:

                                    1) Do most FM residencies have equal resources/etc as IM residencies? I thought ACGME accreditation would make most programs more or less equal.

                                    2)What are some of the more prestigious (better) programs out there (im not asking for a ranking, just a few that have distinguished programs)?


                                    1 year into residency, my advice is when you're looking at FM programs is to look at:

                                    1) Experience - which is (Responsibility^Call Frequency) x (Patient Volume + Procedure Volume)
                                    2) Teaching - which is (Didactic) + (Experience x Supervision) + (Faculty Commitment)
                                    3) Hospital capabilities - which is (Ancillary support + Technology)
                                    4) Quality of Life - which is (Resident Satisfaction x Hospital Capabilities + Faculty Support) / (Experience)

                                    There's no perfect program or training, and prestige plays NO part in the above factors. And you'll realize that some attendings are good at some things but not others. What you want is to optimize those 4 variables, and ask yourself "Am I going to make the most out of my training".

                                    Yeah, will Internal Med have more training than FMed in Internal Med? Sure.
                                    But does OB make you sharper in Pedi? Yes.
                                    Or does Surgery help on your Medicine patients? Yes.
                                    Does learning how to cut and sew on Surgery and Derm help you in FM Clinic? Yes.
                                    What about putting together Ortho, Neuro, those damned Nursing Home Visits with Sports Med, Occupational Med & Therapy, and Physical Therapy/Rehab? Hell yeah.

                                    The beauty of Family Medicine is being able to put it all together. If you're the type of PERSON who gets easily frustrated because you don't know the answer, then Family Medicine is not for you. The toughest part in my past year is making the best of my time with every case and every opportunity. And I think every intern (who cares) runs into this problem. This is a specialty where you have to be strong enough to See One, Do One, and Teach One. You simply don't have the time to See 400, Do 200, and Ask 5 bagillion questions. If you can't handle that, you have a problem. You have a failure to learn. And so you need to find a program that will fit your needs (whatever the hell they are). I mean, I've had drinks with a couple of practicing pediatrician and residents who say that their training at the prestigious Texas Children's Hospital (Baylor) did NOT prepare them for what they wanted to do, which was Primary Care Pedi. Makes no damned sense to me. But I'm guessing that they were in the minority... they picked the wrong program.

                                    I don't think asking questions is pissing anyone off. If there's concern that your training is going to be inferior, QUIT NOW because you will NEVER have the confidence in yourself to do the right thing for your patients. Your colleagues can see it, and your patients can SMELL it.

                                    I personally am happy that Duke shut down. It's good for Family Medicine that ******ed programs disappear and good programs stick around (and hopefully, not the other way). And I'm even happier that Panda's around to present the M&M for the rest of us to learn from it.
                                     

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                                      sophiejane said:
                                      Now, now. I didn't get emotional nor did I sling insults. No need for you to stoop to that level. I simply asked why you were interested in comparing the two.

                                      I'm not sure you are a medical student yet (forgive me if I'm wrong), and if you are, I'd be surprised to hear people asking that question a lot where you are in school. They certainly don't ask it where I am. People who are interested in IM have their reasons, as do people interested in FM. I've never heard of someone choosing one or the other due to "inferior" or "superior" training.

                                      Internists are trained to be internists. Superior IM programs produce superior internists. FPs are trained to be FPs. Superior FP programs produce superior FPs. Saying that internists receive "superior" training to FPs doesn't make any sense. Does the OB/GYN receive superior training to the internist? Yes, as it pertains to their specialty. Do you see where I'm going with this?

                                      If your question really was, do internists get better training in the care of adults with serious chronic illness? Perhaps, at some programs. But there are some pretty bad IM programs out there and some pretty superior FP programs, and I wouldn't doubt that the FPs from the superior programs could do a better job caring for adults with chronic illness than the internists from the inferior programs. But ont the other hand, would you take your kid to an internist? Of course not. But both you and your child could see the same family physician as your primary care provider.

                                      And it's really not just the programs. It's also the individual. There are terrible internists and fabulous FPs and vice versa.

                                      Answering the question you posed would be difficult because it is so broad and there are so many factors involved.

                                      Thats a great reply. Thanks for the info.
                                       

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                                        sophiejane said:
                                        Exactly.

                                        And I would add that people who make their decision about choosing a specialty based on who does and does not look down upon them are in for an interesting ride.

                                        Totally agree. At the end of the day, it's the quality of your patient care that will speak for itself. Not whatever group you belong to.

                                        On a side note, if Med/Peds was so great, why aren't there more of them? If Internal Medicine (or Pedi for that matter) was so great, why is everyone specializing?
                                         

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                                          anxietypeaker said:
                                          thats a good point that i wasnt aware of. But EVEN with that, im not referring to reputation/etc that does actually tend to matter with most. ALL i was focusing on was training. And my question was whether fm gets inferior teaching because of whatever reason. I think that question is very fair, sophiejane. thanks though for the additional input apollyon and adding to the thread.


                                          Man, it's just so hard to say. CHF is CHF. Pneumonia is pneumonia. I mean, the FAQ on this bulletin says it all, when it comes to bread-and-butter stuff, it's all the same.

                                          That said, it probably wouldn't matter anyways because treatment/guidelines/diagnostics/technology change all the time that whatever you learn in residency will probably be irrelevant in a couple of years anyways. The key is to be able to practice Evidence-based Medicine. If you practice Evidence-based Medicine, there should be no difference across fields for a given patient.

                                          At the same time, you can only diagnose what you know. And for me, it ain't much. And so you gotta make an effort to learn by whatever means necessary all the time. Just by showing up for work and brain farting your way through your rotations ain't gonna cut it .

                                          What you DON'T want is a program where some f*cking ***** triages patients to you. That's a training disaster. "Oh, that's a 'complicated' patient, it needs to go to Internal Medicine and not Family Medicine." My favorite is "Oh, it's a Gyn issue and you're a guy, so it needs to go to a woman doctor". At my med school, the ER would triage all pancreatitis to General Surgery. ALL pancreatitis. So there's a generation of Medicine residents who don't know how to manage pancreatitis. ******ed. Of course, if a patient is critical and needs to be in the ICU, that's one thing. Or if the patient needs a surgical procedure, go to Surgery. At the same time, you don't want every CP r/o MI on your service. It's a fine balance and some FM programs got it figured out while others... Triaging away good learning cases and dumping huge volume of bullsh*t on your Family Medicine service is a bad sign. Don't go to that program... let those die a Duke death.
                                           

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                                            Panda Bear said:
                                            DFM was definitely trying to implement a lot of the recommendations which goes to show you that you can have a large group of very intelligent, sincere people propose a solution to a problem which will never work when applied in practice.

                                            Remember the old saying - "a camel is a horse built by committee"?
                                             

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                                              lowbudget said:
                                              On a side note, if Med/Peds was so great, why aren't there more of them? If Internal Medicine (or Pedi for that matter) was so great, why is everyone specializing?

                                              I can't speak for the rest of the country, but in my (very large) state, the one and only meds-peds program has gone belly up.

                                              I'm not sure why...but I don't think the idea of the "super specialist" (FP-EM, Meds-Peds, FP-IM, etc.) is really catching on.

                                              And to answer anxietypeaker's question further...I think the vast majority of people who go into IM do so because they want to specialize, not because they get superior training.
                                               
                                              IM residents are much better trained for adult medicine than Family Medicine residents because that's all they do. They don't do any pediatrics, OB/gyn, or any of the fuzzy stuff. The IM residents also don't do as many outpatient rotations and spend more time in house dealing with patients who are sick enough to be hospitalized.

                                              I did one month of medicine wards in intern year and as we didn't have an inpatient service that, cardiology, and MICU were the extent of my adult medicine for this year. We also had two months of outpatient pediatrics which was nice because it was a nine-to-five rotation but not extremely high yield as most of the patients had viral URIs, viral diarrhea, ringworm, eczema, or were just there for a well-child check.

                                              Same with newborn nursery of which we had one month. A week would have been enough.
                                               

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                                                Panda Bear said:
                                                I did one month of medicine wards in intern year and as we didn't have an inpatient service

                                                That's definitely not typical.

                                                I must reiterate that your experiences at a sub-par FP residency program do not qualify you to make blanket statements about the adequacy of family medicine training elsewhere.

                                                In my experience, a quality family medicine residency program will prepare its residents better for the outpatient care of adults than most internal medicine programs, and equally as well for inpatient care.
                                                 
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                                                lowbudget

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                                                  Panda Bear said:
                                                  IM residents are much better trained for adult medicine than Family Medicine residents because that's all they do. They don't do any pediatrics, OB/gyn, or any of the fuzzy stuff. The IM residents also don't do as many outpatient rotations and spend more time in house dealing with patients who are sick enough to be hospitalized.

                                                  I did one month of medicine wards in intern year and as we didn't have an inpatient service that, cardiology, and MICU were the extent of my adult medicine for this year. We also had two months of outpatient pediatrics which was nice because it was a nine-to-five rotation but not extremely high yield as most of the patients had viral URIs, viral diarrhea, ringworm, eczema, or were just there for a well-child check.

                                                  Same with newborn nursery of which we had one month. A week would have been enough.

                                                  IM residents aren't IM attendings. And IM physicians who don't get specialty training are after all generalists just like FM doctors. And like FM residents, many of IM residents train if things that they don't care about or intend to ever see ever again. The fact that they don't do as many outpatient rotations or even spend time in their own outpatient continuity clinic should signal to you that if a resident desires to be an outpatient doctor, their training is incongruent with their career goals. Call it inferior or superior training, but if your training doesn't match what your patients need, who cares? They're off the mark.

                                                  Same goes with Pedi. What you described is what exactly outpatient pedi is. For many med students, that's what they want. If you say to everyone that they need to do 3 years of inpatient Pedi so that they can graduate and do a lifetime of outpatient Pedi, that's crazy. From a patient's point of view, this doctor's training was inferior because it wasn't appropriate.

                                                  In med school, I had a CRITICAL CARE attending who had done moonlighting in the ER, thinking that it was a cake walk. No ma'am. She realized that she was in over her head and stopped doing that because the things she saw just weren't the things she was trained to do. It wasn't the intubations, the lines, the chest tubes or the crashing patient that she didn't know how to manage. She considered that stuff EASY. It was the easy simple stuff that she considered difficult.

                                                  There's one brilliant resident at my program who did 1 year of ER residency quit and went into FM. Why? Makes no sense right? He really liked the chaos in the ER and the adrenaline, but he hated how he had to move his cases and never manage a patient from beginning to end. So he never got feedback as to whether or not his initial diagnosis or management was right. (Most ER residents would say, who cares? But this guy is very conscientious.)

                                                  Just because you're training in the management of common (arguable simple) diseases, doesn't make the training inferior. It makes the training appropriate considering that's how patients present and these are their problems. I mean, FM can take care of the majority (90%) of the things that ails people. If you're interested in taking care of the 10%, then subspecialize and squat around in these academic centers trying to get air time at conferences, CNN, and Discovery Health. If you like being 1 block away from your house, taking care of the kids in your neighborhood and their multi-generational families and being the most respected guy on your part of town, the one people call as "my doctor who takes care of me", then FM is the way to go.

                                                  Hey, sure, family medicine or primary care for that matter isn't being played on Top 40 radio these days, but who cares? I sure don't. I was never really into chasing popularity or what other people thought anyways. It's all about learning how to be a bad ass, how to be kind and compassionate, how to be great co-worker, and how to have fun doing it. Fame, fortune, free time, it'll all follow.
                                                   

                                                  skypilot

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                                                    lowbudget said:
                                                    Just because you're training in the management of common (arguable simple) diseases, doesn't make the training inferior. It makes the training appropriate considering that's how patients present and these are their problems. I mean, FM can take care of the majority (90%) of the things that ails people. If you're interested in taking care of the 10%, then subspecialize and squat around in these academic centers trying to get air time at conferences, CNN, and Discovery Health. If you like being 1 block away from your house, taking care of the kids in your neighborhood and their multi-generational families and being the most respected guy on your part of town, the one people call as "my doctor who takes care of me", then FM is the way to go.

                                                    Hey, sure, family medicine or primary care for that matter isn't being played on Top 40 radio these days, but who cares? I sure don't. I was never really into chasing popularity or what other people thought anyways. It's all about learning how to be a bad ass, how to be kind and compassionate, how to be great co-worker, and how to have fun doing it. Fame, fortune, free time, it'll all follow.

                                                    Wow, great post.

                                                    Often what looks easy, the skill of managing patients, is not easy and
                                                    what looks difficult, following a protocol to perform a procedure over and over again, is not difficult.
                                                     

                                                    Blue Dog

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                                                      lowbudget said:
                                                      Hey, sure, family medicine or primary care for that matter isn't being played on Top 40 radio these days, but who cares? I sure don't. I was never really into chasing popularity or what other people thought anyways. It's all about learning how to be a bad ass, how to be kind and compassionate, how to be great co-worker, and how to have fun doing it. Fame, fortune, free time, it'll all follow.

                                                      skypilot said:
                                                      Often what looks easy, the skill of managing patients, is not easy and what looks difficult, following a protocol to perform a procedure over and over again, is not difficult.

                                                      :) :thumbup:
                                                       

                                                      RuralMedicine

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                                                        I probably shouldn't respond to this because I'm one of those dreaded Med-Peds types. Yes I considered FP and specifically opted for Med-Peds because I felt that it would prepare me more for the acute care and inpatient challenges needed in a rural area. Now into practice I think I made a wise choice.

                                                        I will certainly agree that residency programs vary in resources, attitudes and certainly quality. I recognize that not all FP programs are like the one at Duke or like the one at the institution where I trained (where the residents actually received less pediatric training than Kent presumed was atypical at the now closed Duke program). There definitely are stronger FP programs out there but in reality unless things have changed radically in the past 6 years I would say that there are more FP programs like the Duke program or the FP program at the institution I trained at than the strong unopposed FP programs that are held up as the yardstick. Even if you limit the discussion to the strongest FP programs I would challenge that the pediatric training in a lower tier pediatric residency is stronger. The disparities seem to be less if you compare strong unopposed FP with lowest tier IM.

                                                        I think it all comes down to knowing your limits, knowing who/ what is your back up and proceeding forward. You can't and shouldn't try to be all things to everyone. In reality if your three years of residency got you sufficient OB exposure/ experience to be proficient there then you scrimped on something else. (This may be ok if you realize where you did and set your limits accordingly.)

                                                        I agree that Medicine is not learned in a vacuum and it's a process and a continuum. In my program strong Med-Peds residents easily held there own (and often had attendings commenting on how we were stronger) with categorical IM or Peds residents at the same PGY level (although our training in the specific field was only half of their training technically). Ironically there were moments when I shone as an internist because of my pediatric training and vice versa. Still I spent 4 years training in two disciplines and FPs pursue training that is one year shorter yet in theory has sufficient training to be proficient in four or more disciplines. It really comes down to recognizing where your limits are but if you are setting your limits as indentical to board certified providers in those disciplines then either you are superhuman or not that skilled in self assessment.

                                                        Ideally we could all work together to take care of patients rather than creating an FP-Med/Peds turf battle. Still the turf battle is being waged across the country especially in geographic regions where Med/Peds is less established. Interestingly I'm the lone Med/Peds in a community with another pediatrician, three internists, and now 2 FPs. When I first came here I tried to sit down with my FP colleagues and discuss potential for collaboration. It had sounded like a good idea at the time (and I still believe in a different community it might be). By their own admission none of them (there were 3 initially) feel comfortable with pediatrics yet for some reason they still see kids in their practices. They also do not have peds privileges at our hospital (a combination of hospital policy and their desire to have less call) so I (or the other pediatrician) do end up doing their inpatient work but since they usually don't ask for help until everything else has failed and the kid needs to be admitted they usually end up eroding the parents' confidence to the point that they end up switching to a pediatrician at which point the FPs get very defensive and claim that they should be allowed to take care of kids and it isn't fair. In reality if we could communicate I wouldn't mind doing their inpatient stuff and trying to then transition the child back into their outpatient practice. We could discuss what patients should go back to them and what patients perhaps should have a pediatrician following them. This continues to be my approach but instead I often get caught in between the frustrated parents and the angry FP. No one can do everything, recognize your limits, ask for help when you need it, and communicate
                                                         

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                                                          RuralMedicine said:
                                                          I recognize that not all FP programs are like the one at Duke or like the one at the institution where I trained (where the residents actually received less pediatric training than Kent presumed was atypical at the now closed Duke program).

                                                          I didn't say anything about peds. I was referring to his single month of adult inpatient medicine. Peds was not the subject under discussion.

                                                          You can't and shouldn't try to be all things to everyone.

                                                          No? Then explain the attraction of IM-peds.
                                                           

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                                                            Panda Bear said:
                                                            Well, thats it for me at Duke. Today was my last day. I had a nice discussion with the most excellent Program Director (a gentleman who has been royally screwed and deserves better) turned in my ID, PDA, pager, scrub card, parking permit, dictaphone, gave my compliments to the nurses at the Family Medicine clinic, and that was that.

                                                            No point. Just that I'm glad to be done with it and even though I'm repeating intern year starting in July, have a big logistical exercise moving the family starting on Monday, and am teetering precariously on the brink of financial ruin what with the unanticipated expenses of moving I feel pretty optimistic.

                                                            Interesting blog I must admit. I find it crazy you have 5 dogs, a wife and kids on an intern salary. That is insane. How do you sleep?
                                                             

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                                                              anxietypeaker said:
                                                              Arent hospitalists according to the NEJM and JAMA offer superior patient care...so regardless of what specialty, people have told me for the best inpatient care, its SAFEST to go with a hospitalist...

                                                              I'm not sure what articles you're referring to, but "quality" in hospital care these days tends to be measured by length of stay (shorter=better) and adherence to protocols. Arguably, both are more readily attainable with in-house staff, which explains why hospitals like hospitalists. I haven't read any articles showing that hospitalists actually provide safer care.
                                                               
                                                              LADoc00 said:
                                                              Interesting blog I must admit. I find it crazy you have 5 dogs, a wife and kids on an intern salary. That is insane. How do you sleep?


                                                              I sleep very well. We have been teetering on the knige edge of financial ruin for so long that I accept it as a state of affairs as common as the sunrise. My dogs are pretty well trained and obedient so they're not a problem. My kids are young enough where this move is a big adventure where they'll get to eat Burger King for the next week. My long-suffering wife owns my medical degree so hopefully there will be a good income at the end of this ordeal.

                                                              But you kind of see why I don't relish the prospect of being a low-payed barefoot doctor taking care of the underserved out of the goodness of my heart. That was definitely the problem with the DFM model of care, namely that all of the ancillary stuff helping the indigent overcome their barriers to care probably doesn't pay very much.

                                                              As to training issues, while it is true that in clinic most of what you see is pretty simple, that's no reason to decrease the number of inpatient rotations you do during training. I think these rotations are where you learn your core knowledge. Maybe you'll never do any critical care once you go into practice, for example, but what you learned will form a deep background of knowledge. Same with medicine rotations.

                                                              To say that a FM physician doesn't require this depth of knowledge is to concede that maybe a medical degree is not required to be an FP and is selling your specialty short. DFM certainly doesn't think the physician is necessary, except of course as an administrator.
                                                               

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                                                                Panda Bear said:
                                                                I don't relish the prospect of being a low-payed barefoot doctor taking care of the underserved out of the goodness of my heart.

                                                                Ironic, as you'll probably be doing more charity care in emergency medicine than you ever would have done in family medicine. :rolleyes:
                                                                 

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                                                                  Panda Bear said:
                                                                  IM residents are much better trained for adult medicine than Family Medicine residents because that's all they do. They don't do any pediatrics, OB/gyn, or any of the fuzzy stuff.

                                                                  The "fuzzy stuff"? Right, like outpatient medicine, which internists do the most of in real life and the least of in residency? Or do you mean fuzzy as in listening to patients, or holding a hand now and then? If that's fuzzy, and if internists can't handle it or are too busy for it, God help their patients, or lack thereof...

                                                                  Some of the best internists I've worked with are the best listeners and hand holders. They were totally fuzzy and proud of it.

                                                                  If fuzzy is bad and you aim to avoid it in the ER, then perhaps Duke prepared you better than you thought for your new career, where the whole object of the game appears to be getting patients the hell out of the ER as fast as possible.
                                                                   

                                                                  lowbudget

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                                                                    RuralMedicine said:
                                                                    When I first came here I tried to sit down with my FP colleagues and discuss potential for collaboration. It had sounded like a good idea at the time (and I still believe in a different community it might be). By their own admission none of them (there were 3 initially) feel comfortable with pediatrics yet for some reason they still see kids in their practices. They also do not have peds privileges at our hospital (a combination of hospital policy and their desire to have less call) so I (or the other pediatrician) do end up doing their inpatient work but since they usually don't ask for help until everything else has failed and the kid needs to be admitted they usually end up eroding the parents' confidence to the point that they end up switching to a pediatrician at which point the FPs get very defensive and claim that they should be allowed to take care of kids and it isn't fair. In reality if we could communicate I wouldn't mind doing their inpatient stuff and trying to then transition the child back into their outpatient practice. We could discuss what patients should go back to them and what patients perhaps should have a pediatrician following them. This continues to be my approach but instead I often get caught in between the frustrated parents and the angry FP. No one can do everything, recognize your limits, ask for help when you need it, and communicate

                                                                    Very interesting post and I appreciate you speaking up. Man, I guess I'm going to have to do more Pedi with my elective time because I sure hell want to keep my practice a good mix of young and old and not some 100% Medicare HMO practice where you have 15 minutes in clinic to address 7 complicated issues for $25 with the constant need to redirect the patient ("No, it was 4 days ago, oh wait, maybe 4 months ago because I remember I was eating chicken when Sally came to visit me... or was it cashews? I don't know. It's in the chart", referring to that monster holding up the exam table.) Oh. My. God. They say the answer is in the history & physical... but faculty always forget to add, *IF* you can GET a history or a physical.

                                                                    Quick question RuralMed:
                                                                    So... which one is it? Is your hospital barring FP's from having admitting privileges because they're FP's? Or is it because FP's don't want to admit Pedi's at all? What's the story?

                                                                    I just find it funny that the people who weren't even invited to the party in the first place are the same ones who said "Well I didn't want to go anyways." Uh-huh.
                                                                     
                                                                    sophiejane said:
                                                                    The "fuzzy stuff"? Right, like outpatient medicine, which internists do the most of in real life and the least of in residency? Or do you mean fuzzy as in listening to patients, or holding a hand now and then? If that's fuzzy, and if internists can't handle it or are too busy for it, God help their patients, or lack thereof...

                                                                    Some of the best internists I've worked with are the best listeners and hand holders. They were totally fuzzy and proud of it.

                                                                    If fuzzy is bad and you aim to avoid it in the ER, then perhaps Duke prepared you better than you thought for your new career, where the whole object of the game appears to be getting patients the hell out of the ER as fast as possible.

                                                                    Well, how about "drama therapy?" Fuzzy enough for ya'? Or instruction on how to give the appearance that you are listening empathetically? You know, hand on chin, bob yer' head every few seconds to indicate compassion and understanding.

                                                                    Or how about cultural competancy classes built on the premise that one is a racist because you lock your car doors in the ghetto?

                                                                    I use the word "fuzzy" as a shorthand for "mind-numbingly stupid to the point of nausea."

                                                                    You got to remember that I didn't just shoot out of the vagina yesterday. I know when someone needs their hand held or a little comforting but I also know that his kind of thing can't be taught, at least not by the kind of people doing the teaching around here.
                                                                     

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                                                                      lowbudget said:
                                                                      you have 15 minutes in clinic to address 7 complicated issues for $25

                                                                      Actually, it's more like $66.28-$101.57 for a 99214, or $98.12-$144.64 for a 99215 (depending on local rates) for Medicare as of Jan. 1, 2006. If you're good (and fast), you can do a 99214 and a procedure (e.g., joint injection) in the same visit (code the procedure with a modifier 25). ;)

                                                                      And you know why some of us actually find taking care of those oldsters with full-page problem lists challenging? Because it is. I love a good challenge. They make you think. They make you pay attention. They make you apply all that stuff you learned in pharmacology, pathophysiology, etc. And you know what? They appreciate what you do a lot more than the younger folks.

                                                                      Anyone who says primary care doesn't require much thought or isn't rewarding is clearly doing it wrong.
                                                                       

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                                                                        Panda Bear said:
                                                                        Well, how about "drama therapy?" Fuzzy enough for ya'? Or instruction on how to give the appearance that you are listening empathetically? You know, hand on chin, bob yer' head every few seconds to indicate compassion and understanding.

                                                                        Or how about cultural competancy classes built on the premise that one is a racist because you lock your car doors in the ghetto?

                                                                        Is this what they were teaching at Duke? If so, it's another nail in their coffin, and it also discredits pretty much all of your broad declarations about how family physicians are trained in the US, because it underscores how atypical and dismal was your experience as an FM resident.

                                                                        As Kent continues to say...your experience is NOT typical and anyone reading your posts should keep that in mind. Maybe you should put a little disclaimer in your signature so that people don't assume you are an expert on graduate medical education, because the types of statements you make certainly imply that YOU think you are.
                                                                         
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