Full Scope Rural Family Medicine

[AFMD]

I'm a 3rd medical student, and I'm interested in what a rural family medicine physician might feel comfortable managing or doing that his urban counterpart may not. What procedures do they often know that other family physicians might not? For example, would they do more laceration repair or fracture management? Are there really that many rural family physicians that have a practice and do scopes, vasectomies, or C-sections? And enough of them to keep up the skill? What does "full scope" really mean anyway? Is it simply being competent in an array of procedures, or is it being comfortable managing more complicated OB/peds/ER/inpatient cases, or is it more complicated than that?

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[VA Hopeful Dr]

I'm a 3rd medical student, and I'm interested in what a rural family medicine physician might feel comfortable managing or doing that his urban counterpart may not. What procedures do they often know that other family physicians might not? For example, would they do more laceration repair or fracture management? Are there really that many rural family physicians that have a practice and do scopes, vasectomies, or C-sections? And enough of them to keep up the skill? What does "full scope" really mean anyway? Is it simply being competent in an array of procedures, or is it being comfortable managing more complicated OB/peds/ER/inpatient cases, or is it more complicated than that?

My partner in my first practice out of residency did rural for 15 years before coming to a regular old outpatient office. Things he did in his old job...

Splinting/casting, delivered babies (no sections), vasectomies, scopes for the first 10 years, inpatient all ages (hospital was 30 beds so no real ICU), more complicated lacs than I felt good doing. Basically, he had to handle anything that came in that didn't require an OR.

 

[styphon]

I'm a 3rd medical student, and I'm interested in what a rural family medicine physician might feel comfortable managing or doing that his urban counterpart may not. What procedures do they often know that other family physicians might not? For example, would they do more laceration repair or fracture management? Are there really that many rural family physicians that have a practice and do scopes, vasectomies, or C-sections? And enough of them to keep up the skill? What does "full scope" really mean anyway? Is it simply being competent in an array of procedures, or is it being comfortable managing more complicated OB/peds/ER/inpatient cases, or is it more complicated than that?

To me a full scope is a FM doctor who does in/outpt w/ OB as opposed to the array of procedures.

It depends on their residency training. C/sections are not taught in most eastern/western states for FM and require a fellowship to get the numbers needed for hospital privledges. That being said, if you have the number (usually 200-250 as primary surgeon) most hospitals will certify you.

Scopes woudl be easier to get, you still need a certain number. If you can find a GI/surgeon to show you during residency, and take 1-2 electives in it...

Vasectomies - problem is getting enough pt's in residency.. If you can find a urologist willing to help you - which did happen in my program.

Laceration repair/fracture management - do ER electives/Ortho electives and you will be very comfortable.

 

[PMRMD2B]

I just finished a rotation in rural FM. They are trained more in colons, endo's, colpos, C-sections, etc.. but I think it is very rare for them to do it in real practice. Out of the 9 MDs on faculty there, only 2 still do c-sections, 2 do scopes, limited ob mostly because of malpractice rates and time, limited scopes because of not getting paid for them. Most hospitals will not credential a FM docs to do C-sections. None of them do a lot of casting, vasectomies, or ER work. I think it is fun to train that way, but you will be hard pressed to find an area where you will have a comprehensive practice model like that.

 

[apoptoaster]

...Most hospitals will not credential a FM docs to do C-sections.

Not sure where you got that from. Most in metropolitan areas are much less likely to credential FP's to do c-sections, and in general, most FP's don't have nearly enough experience or training in residency or beyond to be able to do c-sections. FP's involvement in C-sections is extremely dependent on a lot of factors, such as the need/availability of OB specialists, geographic location, culture at the hospital, malpractice rates of the state (which vary a lot state by state), and most importantly - the FP's desire to do OB and their level of training to do it. Being on call for c-sections adds a significant toll on a physician's lifestyle, and I think that's a large part of why a lot of FP's shy away from it.

The OP might find this article from the AAFP helpful:
http://www.aafp.org/about/policies/all/cesarean-delivery.html

If it's something you want to be able to do, there are plenty of opportunities. I think it largely depends on what part of the country you want to live in and exactly how rural you want to get.

 

[NurWollen]

Isn't it pretty much the norm for rural hospitals to have FM docs helping to cover the ED?

 

[PMRMD2B]

I stated the fact about FM credentialing to address the broad scope the OP was asking about. Even with a one-year OB fellowship after FM, many hospitals will not give a family physician privileges for C-sections or most scoping procedures.

I am on the board of directors for a federally qualified health center, so I am very familiar with rural medicine. Even in the rural hospitals I've visited as a student and as a professional (formally in hospital admin), most of them now have BC ER physicians and FM is becoming less common in the ER.

Unless you are in a very rural area, you will most likely not have this comprehensivist (term being coined by rural programs) approach, due to liability, malpractice, lack of keeping current with all skills, and availability of other specialists who are better trained and reimbursed for these procedures.

 

[NurWollen]

I stated the fact about FM credentialing to address the broad scope the OP was asking about. Even with a one-year OB fellowship after FM, many hospitals will not give a family physician privileges for C-sections or most scoping procedures.

I am on the board of directors for a federally qualified health center, so I am very familiar with rural medicine. Even in the rural hospitals I've visited as a student and as a professional (formally in hospital admin), most of them now have BC ER physicians and FM is becoming less common in the ER.

Unless you are in a very rural area, you will most likely not have this comprehensivist (term being coined by rural programs) approach, due to liability, malpractice, lack of keeping current with all skills, and availability of other specialists who are better trained and reimbursed for these procedures.

You realize that you're basically saying that full-scope rural family medicine does not exist. I may just be an MS2, but I could point you to a dozen thread on this forum, and, much more importantly, a dozen real-life physicians who indicate otherwise.

 

[PMRMD2B]

I am saying that it does exist and it is a dying field. When a physician can't get paid for certain procedures (lets be honest, who do you want sticking a scope up your butt, a family doc or a GI doc) or your malpractice is too high to cover the little bit you get paid for something, they stop doing it. And not to be a butt about it (because this will come off that way).. but I spent 10 years in upper level hospital admin in 3 states, overseeing urban and rural practices.. my division?.. yep, primary care. I am also on the board of directors for a federally qualified health center and a state rural medicine society. So, I think I have a little more idea of the real world than someone who is just learning about Starling's forces and gram negative bacteria.

Maybe we are at odds on what you consider to be "full scope". There are very few family physicians who regularly practice full OB with C-section, vasectomies, and scoping procedures, etc. In fact, anyone who has been in residency will tell you that you can't be proficient in all these areas. Even rural programs who focus more on this comprehensive approach will tell you that their doctors can't do it all.

 

[VA Hopeful Dr]

I am saying that it does exist and it is a dying field. When a physician can't get paid for certain procedures (lets be honest, who do you want sticking a scope up your butt, a family doc or a GI doc) or your malpractice is too high to cover the little bit you get paid for something, they stop doing it. And not to be a butt about it (because this will come off that way).. but I spent 10 years in upper level hospital admin in 3 states, overseeing urban and rural practices.. my division?.. yep, primary care. I am also on the board of directors for a federally qualified health center and a state rural medicine society. So, I think I have a little more idea of the real world than someone who is just learning about Starling's forces and gram negative bacteria.

Maybe we are at odds on what you consider to be "full scope". There are very few family physicians who regularly practice full OB with C-section, vasectomies, and scoping procedures, etc. In fact, anyone who has been in residency will tell you that you can't be proficient in all these areas. Even rural programs who focus more on this comprehensive approach will tell you that their doctors can't do it all.

My partner at my last job, who did those things minus c-sections, would disagree.

 

[PMRMD2B]

So, he doesn't do this "full scope" then.. if he doesn't do C-sections.. so how can he disagree. He is 1 out of 1,000. He may have a broad scope, but it is limited.

 

[galactus]

Where I did residency (university based, opposed), we did a lot of OB. A LOT. All residents trained in c-sections. We had 6 attendings and 2 rural attendings that did c-sections, and the rest of the faculty did non-operative OB. 2nd year FM residents would be primary for the sections if they wanted. There was no need for a rural or OB fellowship. We always had a few residents graduate every year who go out to do rural, which includes surgical OB privileges. Some went to become 100% hospitalists. Half the ER docs at the level 1 hospital where I trained were all FM trained. We even had a few private FM guys who had surgical OB privilege in the hospital! I know it's rare to see that in an FM program, especially at an opposed setting, but we were trained to become rural physicians and we generated plenty every year. Rural medicine, and esp FM docs who practice OB, still exists!

 

[VA Hopeful Dr]

So, he doesn't do this "full scope" then.. if he doesn't do C-sections.. so how can he disagree. He is 1 out of 1,000. He may have a broad scope, but it is limited.

Surgical procedures requiring an OR have not been considered "full scope" family medicine, historically speaking. This is like you saying that since there are some FPs in Cali that still take out tonsils, that anyone not doing that isn't practicing full scope.

Traditionally, full scope just meant that all of your patients that needed to be in the hospital were under your care while there - vaginal deliveries, newborn nursery, inpatient adult/peds care, ER.

 

[PMRMD2B]

In my state, there are only two known hospitals that will credential FM docs to do C-Sections, even if they completed an Ob fellowship. Additionally, I don't know of many hospitals that will credential a FM doc to do endoscopies or colonoscopies in their facilities.. which now includes hospital owned "private" practice settings.

 

[VA Hopeful Dr]

In my state, there are only two known hospitals that will credential FM docs to do C-Sections, even if they completed an Ob fellowship. Additionally, I don't know of many hospitals that will credential a FM doc to do endoscopies or colonoscopies in their facilities.. which now includes hospital owned "private" practice settings.

In my state, I know of at least 6 hospitals that will let FPs do c-sections and I don't know of any who outright forbid FPs doing vaginal deliveries. I also know of several hospitals, including 2 teaching hospitals and a level 1 trauma center that will allow FPs to do scopes.

 

[th286]

I'm an intern in Family Medicine and I looked all around the country for full scope programs just last year. I'm from the northeast and found the options for really broad training with opportunities for lots of procedural skills were a little limited there so I moved. I defined "full scope" for myself as being comfortable in many different scenarios, being able to work with all patients, and having good procedural skills. If you are willing to live outside of a dense urban area there are plenty of places where this training is available.

I chose a family medicine program where we do NOT produce physicians who do c-sections, but we do just above everything else. We first assist on c-sections, but you need a lot of volume to get comfortable with c-sections just in case things don't go smoothly. With the development of the ob/gyn laborist model, where family medicine does pre/post mgmt and obstetricians deliver, doing c-sections is probably going to continue to become less common.

One of the problems at the training level is that there are programs that do procedures but don't give you the volume you need to get privileges and feel comfortable on your own. When I applied I asked programs for average numbers to get a better sense of this.

We have residents that are graduating and getting jobs where they can do scopes because some of them have done 100+ endoscopies and 100+ colonoscopies. We also do a lot of ICU work since we have ~500 bed hospital with 24 family medicine residents and no other competition. With ICU, we have residents doing lots of central lines (>100), vent mgmt, etc. so residents can go and work just about anywhere. We place PEG tubes and on trips abroad our residents do even more, all precepted by a family medicine attending who has been trained to do all these things.

For ED work, many hospitals are now mandating that only EM board certified physicians work there. There are still plenty of opportunities available. In training you should get comfortable with placing lines, intubations, chest tubes, etc. and keep a log your procedures. If you have enough you may be able to demonstrate to a hospital why they should give you privileges. A lot of it comes down to where you are willing to live.

 

[plica]

In my state full scope Family Medicine is going strong. FM docs doing c-sections at critical access hospitals. Plenty doing inpt/outpt and OB. Almost all the rural ED's, and a good number of the more urban ED's, have Family Physicians on staff. Two graduates from our program who graduated this past June were hired into ED positions (with ED physician salary). We also regulary pick up moonlighting shifts at the critical access EDs as R2/R3s. My senior R3 and myself (an R2) have both signed contracts to do full scope inpt/outpt, OB and ED when we finish residency.

So it's out there to be had if you want it. Family Medicine rules!!

 

[PMRMD2B]

I agree with Family Medicine rules! (don't let my username confuse you..lol).

 

[VenturaResident]

In my state, there are only two known hospitals that will credential FM docs to do C-Sections, even if they completed an Ob fellowship. Additionally, I don't know of many hospitals that will credential a FM doc to do endoscopies or colonoscopies in their facilities.. which now includes hospital owned "private" practice settings.

What state are you in?

 

[PMRMD2B]

SC, where all but two counties are considered to be underserved. This fact was confirmed by the director of the state's only rural FM program and a member of the Rural health board.

 

[primadonna22274]

I'm in SC. Sickest patients anywhere (I'm sure we all say that but hands down far sicker than my comfy wine country town in western Oregon!) makes for great places to train. I can travel 10 miles in any direction from my house and hit federally underserved areas. Technically my hospital is not "underserved" but it is the county hospital for much of northeast SC and southeast NC from I-95 and I-20 all the way out to the beach.

 

[VA Hopeful Dr]

SC, where all but two counties are considered to be underserved. This fact was confirmed by the director of the state's only rural FM program and a member of the Rural health board.

And your point is....?

I know we're underserved - I did med school, residency, and 2 jobs in different regions of the state. Its a great place to be a family doctor for that reason.

 

[VenturaResident]

I think this:

In my state, there are only two known hospitals that will credential FM docs to do C-Sections, even if they completed an Ob fellowship. Additionally, I don't know of many hospitals that will credential a FM doc to do endoscopies or colonoscopies in their facilities.. which now includes hospital owned "private" practice settings.

is partially explained by this:

SC, where all but two counties are considered to be underserved. This fact was confirmed by the director of the state's only rural FM program and a member of the Rural health board.

Unsure what other states you have worked in, but I think it's fairly well known that overall Family Medicine is a different entity on the east coast and west coast. Different ideas about what FM can and should do.

As for this

(lets be honest, who do you want sticking a scope up your butt, a family doc or a GI doc)

I want someone who knows what they are doing and is competent. And there are plenty of FM docs who fit that bill. That goes for all kinds of procedures.

but I spent 10 years in upper level hospital admin in 3 states, overseeing urban and rural practices.. my division?.. yep, primary care. I am also on the board of directors for a federally qualified health center and a state rural medicine society. So, I think I have a little more idea of the real world than someone who is just learning about Starling's forces and gram negative bacteria.

You really don't have any idea who else you are in conversation with here, what their backgrounds may be in administration, or in other areas that shed light on this question. Even in hospital admin, you see one piece of the puzzle. As a medical student, you aren't exposed to, say, the range of daily job recruitment notices that residents get. You don't have the practical experience that attending physicians have. You haven't seen your classmates go out and get all kinds of jobs. Prior job experiences can be useful, but you haven't seen all of it, just your corner of it. Making sweeping statements about physician practice as a student (even one with hospital admin work prior) makes you come off looking kind of silly, particularly when it's mixed with the kind of unnecessary snarkiness in the quote above.[/QUOTE]

 

[styphon]

Maybe we are at odds on what you consider to be "full scope". There are very few family physicians who regularly practice full OB with C-section, vasectomies, and scoping procedures, etc. In fact, anyone who has been in residency will tell you that you can't be proficient in all these areas. Even rural programs who focus more on this comprehensive approach will tell you that their doctors can't do it all.

I think I may be misunderstanding you, but with significant numbers most hospitals (even urban hospitals) will give privileges to a FM who has c-section training. Often the "Womens health" fellowship in FM gives you ~250 c/sections as primary surgeon, which is more than enough to get you practice privileges. I also know of specific FM practioners who do +200 c-scopes a year who are reimburst by insurances.

I do vaginal deliveries, injections, joint reductions, OB/GYN procedures (IUD, endometrial biopsy, colposcopy), inpt procedures (central lines, paracentesis) and have not had trouble being reimburst or trouble getting privileges AND I am in state that heavily favors specialists!

I know of a FM doctor who delivers 150-200 babies a year in a REGIONAL childrens hospital - does VBACS (with a higher success rate than local OBs) - he is private and depends solely on reimburstment!

**NOW** you may actually be saying that it is rare for ONE specific FM person to do C/sections, vascetomies, scopes - which I would agree with. How would you get that amount of training? I worked hard to get the numbers I needed not only to be "certified" but also comfortable in the above procedures - and would think its impossible to do in 3 years in all these different areas.

 

[PMRMD2B]

I think this:



is partially explained by this:


Unsure what other states you have worked in, but I think it's fairly well known that overall Family Medicine is a different entity on the east coast and west coast. Different ideas about what FM can and should do.

As for this

I want someone who knows what they are doing and is competent. And there are plenty of FM docs who fit that bill. That goes for all kinds of procedures.


You really don't have any idea who else you are in conversation with here, what their backgrounds may be in administration, or in other areas that shed light on this question. Even in hospital admin, you see one piece of the puzzle. As a medical student, you aren't exposed to, say, the range of daily job recruitment notices that residents get. You don't have the practical experience that attending physicians have. You haven't seen your classmates go out and get all kinds of jobs. Prior job experiences can be useful, but you haven't seen all of it, just your corner of it. Making sweeping statements about physician practice as a student (even one with hospital admin work prior) makes you come off looking kind of silly, particularly when it's mixed with the kind of unnecessary snarkiness in the quote above.

[/QUOTE]


To the beginning of your post, you are correct. I was answering a specific question that someone asked, however I did not quote their question with my response.
As to the end of your post, I agree. I was acting ugly when I posted that, but again I was posting specifically in response to a 2nd year medical student's comments... and I do understand that there are others with various experience on here. Without boring you to death, I've worked in healthcare for 17 years (7 as a mid level provider before medical school, 10 years in administration).

The first few years of admin work, my forte was primary care clinics, mostly family medicine. I was the director of physician practices and was responsible for new start up practices, which included for a large part..recruiting physicians. My last 3 years was in a residency program (one of the reasons I chose to go to medical school), where as part of my responsibilities was to aid residents in career counseling and connecting them with opportunities that fit their goals. My wife is an attorney, and while at this program we also advised residents on contract negotiations, risk management, taught fundamental business concepts. Additionally, I owned and operated a healthcare consulting group throughout SC, GA, FL, and KY that consulted for hospitals, private practices, physical therapy facilities, and pain management clinics. I am also on the board of directors for a federally qualified health center.

So I have been part of many parts of a puzzle. Sorry if I didn't post my CV before posting and making a "snarky" comment to that student. I am not arrogant, I am simply giving MY opinion and experiences, which are usually more broad than most students and residents. This only comes from my years of being involved in healthcare.

**For Styphon: I was trying to make the statement that it is rare, few and far between, when it comes to FM docs who do a very broad scope of practice, especially with proficiency.

***For primadonna22274: The Pee Dee area is worse than other areas, so I am sure you see a lot of sick people, but I think Georgia is worse.

 

[primadonna22274]

Interesting background you have there...but I love the Pee Dee

 

[EdibleEgg]

I'm a 3rd medical student, and I'm interested in what a rural family medicine physician might feel comfortable managing or doing that his urban counterpart may not. What procedures do they often know that other family physicians might not? For example, would they do more laceration repair or fracture management? Are there really that many rural family physicians that have a practice and do scopes, vasectomies, or C-sections? And enough of them to keep up the skill? What does "full scope" really mean anyway? Is it simply being competent in an array of procedures, or is it being comfortable managing more complicated OB/peds/ER/inpatient cases, or is it more complicated than that?

I don't know that anyone really practices "full scope" family medicine. There are a few people I know well that come close, but it would be difficult to literally do everything that falls under the scope of a family physician. The flexibility of the well trained generalist is one of the appealing things about family medicine. I spend a good deal of time in the ED and I do more than 500 scopes a year. Those were the things that interested me. One of the other docs in my town really enjoyed cardiology; he does nuclear stress tests and ECHO's in his office. There are no FP's here doing deliveries, but if some one came to town to with 250 c sections, there wouldn't be an issue. The OB's here would love to have another name in the call group. In the next town over, one of the FP's does lots of wound care and frequently goes to the OR for debridements and amputations. Basiclally, it is what you make it. It's not easy or for the thin skinned, but I still look forward to going to work nearly a decade in.


PMRMD2B,

Maybe I'm projecting, because the head of physician practices here is a real sleaze ball. He has a 70's porn stache, wears short sleeve shirts with ties, and is one of the reasons I will never be employed . His wife is an attorney, but she could do a lot better. I don't know, but either way, you do come off as arrogant and you are definitely misinformed.

I keep deleting my comments, I don't want to cross a line. I'll leave it at this, opportunites abound and proficiency is high.

 

[NurWollen]

I don't know that anyone really practices "full scope" family medicine. There are a few people I know well that come close, but it would be difficult to literally do everything that falls under the scope of a family physician. The flexibility of the well trained generalist is one of the appealing things about family medicine. I spend a good deal of time in the ED and I do more than 500 scopes a year. Those were the things that interested me. One of the other docs in my town really enjoyed cardiology; he does nuclear stress tests and ECHO's in his office. There are no FP's here doing deliveries, but if some one came to town to with 250 c sections, there wouldn't be an issue. The OB's here would love to have another name in the call group. In the next town over, one of the FP's does lots of wound care and frequently goes to the OR for debridements and amputations. Basiclally, it is what you make it. It's not easy or for the thin skinned, but I still look forward to going to work nearly a decade in.


PMRMD2B,

Maybe I'm projecting, because the head of physician practices here is a real sleaze ball. He has a 70's porn stache, wears short sleeve shirts with ties, and is one of the reasons I will never be employed . His wife is an attorney, but she could do a lot better. I don't know, but either way, you do come off as arrogant and you are definitely misinformed.

I keep deleting my comments, I don't want to cross a line. I'll leave it at this, opportunites abound and proficiency is high.

Thanks for this post.

 

[missy2918]

I'm an intern in Family Medicine and I looked all around the country for full scope programs just last year. I'm from the northeast and found the options for really broad training with opportunities for lots of procedural skills were a little limited there so I moved. I defined "full scope" for myself as being comfortable in many different scenarios, being able to work with all patients, and having good procedural skills. If you are willing to live outside of a dense urban area there are plenty of places where this training is available.

I chose a family medicine program where we do NOT produce physicians who do c-sections, but we do just above everything else. We first assist on c-sections, but you need a lot of volume to get comfortable with c-sections just in case things don't go smoothly. With the development of the ob/gyn laborist model, where family medicine does pre/post mgmt and obstetricians deliver, doing c-sections is probably going to continue to become less common.

One of the problems at the training level is that there are programs that do procedures but don't give you the volume you need to get privileges and feel comfortable on your own. When I applied I asked programs for average numbers to get a better sense of this.

We have residents that are graduating and getting jobs where they can do scopes because some of them have done 100+ endoscopies and 100+ colonoscopies. We also do a lot of ICU work since we have ~500 bed hospital with 24 family medicine residents and no other competition. With ICU, we have residents doing lots of central lines (>100), vent mgmt, etc. so residents can go and work just about anywhere. We place PEG tubes and on trips abroad our residents do even more, all precepted by a family medicine attending who has been trained to do all these things.

For ED work, many hospitals are now mandating that only EM board certified physicians work there. There are still plenty of opportunities available. In training you should get comfortable with placing lines, intubations, chest tubes, etc. and keep a log your procedures. If you have enough you may be able to demonstrate to a hospital why they should give you privileges. A lot of it comes down to where you are willing to live.