Full Spectrum FM

[ThreatLevel_12:00AM]

Hi there, I am an M3 trying to figure out what to do with my life. I have followed this forum for a while and I have seen tons of great advice, some related to the question at hand, but I can't find any threads directly considering the subject.

The crux really is how possible full-spectrum (FS) FM is in the current climate (leaving aside COVID), and how tenable that practice will be in the future. Here is what I understand at this point:

• Practices like this are disappearing. Large HC corporations drive small practices out of favorable markets and also want specialist care because it makes more money, squeezing out generalists who want to do it all. Furthermore, at some point in the next 40-50 years (my career) we will most likely be transitioning to some sort of government-funded care, which has the potential to rekindle or snuff out FS care, a large unknown at this point.
• You have to go rural, or academic. Also geographic. From what I understand, the western US is more amenable to this type of practice. But how rural is rural? Are we talking town of 1500 in Kansas or 30,000 in colorado? I just don't know, and jobs like this aren't really advertised so this info is hard to find.
• Often, the biggest barrier to FS FM is that it becomes a logistical nightmare. Call coverage, malpractice, hospital admin, and appropriate volume to optimize remuneration make it untenable. I have no answers here...
• The lifestyle is not great. Inpatient, outpatient, ED, OB, etc. leaves little time in the day for other things. I am OK with this, I have been preparing all through med school for a surgical sub with a terrible lifestyle, I understand it is part of the job.

I guess my consternation stems from the fact I know I wouldn't be happy practicing FM like I see it done in the city I live in now. Refer everything, get beat up by specialists, basic algorithmic medicine. I would rather do 4-5 different specialties than that. I am attracted to FM because I am driven by being challenged. Ideally, FM would be better than any specialty at stretching my limits, intellectually, technologically, procedurally, etc. I have heard people say every specialty is boring once you achieve competence, but I feel that FM is (in a perfect world) so broad, the goal line is always moving. I know there are programs that still train this way, but I really have no idea about what comes after, whether my career will straddle the death throes of the old-time doc or if that syle of medicine has breathed its last.

I appreciate any thoughts you kind people have. I understand that my ideas are most definitely ill-formed and naive, so feel free to disabuse me of my misguided notions. Thanks!

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[AMEHigh]

So I’ll just say that more full spectrum isn’t just available in rural areas. There are under-resourced areas in cities that more full spectrum is still practiced. Yes those are often at more places like FQHCs and other community health type places.

I have colleagues that are certified to provide comprehensive HIV care, colleagues doing ob, working in ED (less acute side), urgent care, prenatal care, gender affirming care, reproductive health care including things like vasectomies and abortion care, etc etc and this is all in non-rural areas.

I actually hated my FM rotation during 3rd year. It wasn’t an academic space and He def seemed to refer a lot of patients out. Sure some doctors practice like that but not all.

So overall I think if you think you’ll enjoy FM then you should go for it. You can shape your career how you want it once you figure out more what you want out of your career and life.

 

[AMEHigh]

Are there FQHC people doing full spectrum, ie outpatient + inpatient (or deliveries, although that's not my interest these days)? That would be my dream practice environment but I just haven't seen anybody doing it, at least at the handful of FQHCs I know people at. Maybe a regional thing as well.

I’ve seen this model in academics. There are family med programs that are run out of FQHCs, so I’ve seen it done that way to do both inpatient and outpatient working in an fqhc, getting paid by them, but also having faculty responsibilities. There are definitely FQHCs that are not academic where you can do outpatient and OB.

I do think the model of admitting your own patients is definitely not much of a thing in large cities from what I’ve seen.

 

[Keona]

Family medicine you can do broad training and figure out what you like the most and enjoy practicing. I’m rural family medicine with the large cities a 1.5 hour drive. I refer things I can’t handle. We don’t do hospital medicine anymore at my practice but they did up to 7 years ago. We do admit our own patients to the nursing home. The problem with admitting to the hospital is rounding and also having time for clinic in the same day. I love practicing rural and I’m on path to being a partner in a physician owned practice. My patients are so grateful for me coming into the community. We have lots of conversations about my hobby farm and kids.

 

[ThreatLevel_12:00AM]

So I’ll just say that more full spectrum isn’t just available in rural areas. There are under-resourced areas in cities that more full spectrum is still practiced. Yes those are often at more places like FQHCs and other community health type places.

I have colleagues that are certified to provide comprehensive HIV care, colleagues doing ob, working in ED (less acute side), urgent care, prenatal care, gender affirming care, reproductive health care including things like vasectomies and abortion care, etc etc and this is all in non-rural areas.

I actually hated my FM rotation during 3rd year. It wasn’t an academic space and He def seemed to refer a lot of patients out. Sure some doctors practice like that but not all.

So overall I think if you think you’ll enjoy FM then you should go for it. You can shape your career how you want it once you figure out more what you want out of your career and life.

Thanks for taking the time to type out a reply! It is comforting to hear that someone else didn't like their FM rotation who ended up liking it. I'm going to a rural practice for a rotation later this year and keeping my fingers crossed...

I want to do international/global health as well, and so while it is possible in the surg sub I thought I always wanted I can't help but notice how much more versatile FM trained docs are in that scene.

I had an FM doc tell me one time not to do it because, as he said, "it is so f**king boring". In spite of my initial intention to be like the generalists of old, I still worry about regretting not pursuing something higher octane.

 

[ThreatLevel_12:00AM]

Family medicine you can do broad training and figure out what you like the most and enjoy practicing. I’m rural family medicine with the large cities a 1.5 hour drive. I refer things I can’t handle. We don’t do hospital medicine anymore at my practice but they did up to 7 years ago. We do admit our own patients to the nursing home. The problem with admitting to the hospital is rounding and also having time for clinic in the same day. I love practicing rural and I’m on path to being a partner in a physician owned practice. My patients are so grateful for me coming into the community. We have lots of conversations about my hobby farm and kids.

Thanks! What are you able to incorporate into your practice as far as procedures, peds, OB, etc?

And tell me more about that hobby farm One of my dreams has always been to homestead lite and get back to working with horses like I did growing up.

 

[smq123]

Hi there, I am an M3 trying to figure out what to do with my life. I have followed this forum for a while and I have seen tons of great advice, some related to the question at hand, but I can't find any threads directly considering the subject.

The crux really is how possible full-spectrum (FS) FM is in the current climate (leaving aside COVID), and how tenable that practice will be in the future. Here is what I understand at this point:

• Practices like this are disappearing. Large HC corporations drive small practices out of favorable markets and also want specialist care because it makes more money, squeezing out generalists who want to do it all. Furthermore, at some point in the next 40-50 years (my career) we will most likely be transitioning to some sort of government-funded care, which has the potential to rekindle or snuff out FS care, a large unknown at this point.
• You have to go rural, or academic. Also geographic. From what I understand, the western US is more amenable to this type of practice. But how rural is rural? Are we talking town of 1500 in Kansas or 30,000 in colorado? I just don't know, and jobs like this aren't really advertised so this info is hard to find.
• Often, the biggest barrier to FS FM is that it becomes a logistical nightmare. Call coverage, malpractice, hospital admin, and appropriate volume to optimize remuneration make it untenable. I have no answers here...
• The lifestyle is not great. Inpatient, outpatient, ED, OB, etc. leaves little time in the day for other things. I am OK with this, I have been preparing all through med school for a surgical sub with a terrible lifestyle, I understand it is part of the job.

I guess my consternation stems from the fact I know I wouldn't be happy practicing FM like I see it done in the city I live in now. Refer everything, get beat up by specialists, basic algorithmic medicine. I would rather do 4-5 different specialties than that. I am attracted to FM because I am driven by being challenged. Ideally, FM would be better than any specialty at stretching my limits, intellectually, technologically, procedurally, etc. I have heard people say every specialty is boring once you achieve competence, but I feel that FM is (in a perfect world) so broad, the goal line is always moving. I know there are programs that still train this way, but I really have no idea about what comes after, whether my career will straddle the death throes of the old-time doc or if that syle of medicine has breathed its last.

I appreciate any thoughts you kind people have. I understand that my ideas are most definitely ill-formed and naive, so feel free to disabuse me of my misguided notions. Thanks!

A couple of thoughts....

- I am not convinced that "full spectrum" (or at least "extended spectrum") family medicine will ever go away completely. With insurance companies still liking the "shared risk" model, there seems to be at least some push towards trying to keep everything in your clinic, as much as possible.

- I do only outpatient FM, and I have never been beaten up by specialists. If anything, I get Christmas cards and bottles of wine from specialists in the area - which can sometimes be quite uncomfortable to accept because some of the doctors sending gifts are awful and I purposely avoid referring any patients to them.

- Even in just outpatient FM, it still gets challenging and there will be many patients who will force you to abandon algorithms and "cookbook medicine." There is an inherent, and sometimes endless, challenge in having patients come to you with absolutely no work up and (often) vague symptoms that could be anything.

- I get what you're saying about how it seems boring that many suburban/urban FM physicians "refer everything out." However, please keep in mind that they may not do so because they're forced to or because local practice patterns require it. Rather, it is possible that they choose to do so because, honestly, it's easier and they get to go home at 5:30. Unfortunately, the more exciting medicine is, it often means that the worse the hours are. Eventually, it becomes a question of which matters more to you - the intellectual challenge or the burning desire to be home by 6 and in bed by 10.

Thanks for taking the time to type out a reply! It is comforting to hear that someone else didn't like their FM rotation who ended up liking it. I'm going to a rural practice for a rotation later this year and keeping my fingers crossed...

I want to do international/global health as well, and so while it is possible in the surg sub I thought I always wanted I can't help but notice how much more versatile FM trained docs are in that scene.

I had an FM doc tell me one time not to do it because, as he said, "it is so f**king boring". In spite of my initial intention to be like the generalists of old, I still worry about regretting not pursuing something higher octane.

Unfortunately, medicine, like anything else, can be "so f**king boring" if you do it long enough. I don't think that FM is any different from any other specialty in that regard. Your 500th cataract, your 500th CHF admission, your 500th stage II breast cancer patient, your 500th hernia....after a while, it's not fresh and exciting any more.

Your post is making me think of a conversation that I had with a former coworker. I have worked in an FQHC for several years. I have always said that one of the things that I love about working in an FQHC is that it is unpredictable. The patients are never ever boring. There are a lot of social work issues, as you can imagine in a clinic whose mission is to help the underserved, but it is pretty much never boring. Because many of these patients lack resources, you are often called to treat or do things outside of your comfort zone.

An NP that I worked with had worked in that FQHC for over a decade. She, too, loved the intellectual challenge of dealing with these unpredictable and often challenging patients....until she didn't. She was coming home late, drained, and mentally exhausted. It was fine when she was single and childless, but not so much fun when she had a 3yo who wanted to know why "mommy never wants to play."

So she quit and went to work for a subspecialist. She has admitted to me that it's incredibly boring. All the patients have insurance and are financially comfortable. The medicine is textbook and rote. One note is very much like the other. And yet...she's out the door by 5:10, she's home by 5:25, and she gets to spend the rest of the evening playing games with her family or helping her kids with homework. And that's a trade off that she's very willing to make.

 

[Medic_90x]

Hi there, I am an M3 trying to figure out what to do with my life. I have followed this forum for a while and I have seen tons of great advice, some related to the question at hand, but I can't find any threads directly considering the subject.

The crux really is how possible full-spectrum (FS) FM is in the current climate (leaving aside COVID), and how tenable that practice will be in the future. Here is what I understand at this point:

• Practices like this are disappearing. Large HC corporations drive small practices out of favorable markets and also want specialist care because it makes more money, squeezing out generalists who want to do it all. Furthermore, at some point in the next 40-50 years (my career) we will most likely be transitioning to some sort of government-funded care, which has the potential to rekindle or snuff out FS care, a large unknown at this point.
• You have to go rural, or academic. Also geographic. From what I understand, the western US is more amenable to this type of practice. But how rural is rural? Are we talking town of 1500 in Kansas or 30,000 in colorado? I just don't know, and jobs like this aren't really advertised so this info is hard to find.
• Often, the biggest barrier to FS FM is that it becomes a logistical nightmare. Call coverage, malpractice, hospital admin, and appropriate volume to optimize remuneration make it untenable. I have no answers here...
• The lifestyle is not great. Inpatient, outpatient, ED, OB, etc. leaves little time in the day for other things. I am OK with this, I have been preparing all through med school for a surgical sub with a terrible lifestyle, I understand it is part of the job.

I guess my consternation stems from the fact I know I wouldn't be happy practicing FM like I see it done in the city I live in now. Refer everything, get beat up by specialists, basic algorithmic medicine. I would rather do 4-5 different specialties than that. I am attracted to FM because I am driven by being challenged. Ideally, FM would be better than any specialty at stretching my limits, intellectually, technologically, procedurally, etc. I have heard people say every specialty is boring once you achieve competence, but I feel that FM is (in a perfect world) so broad, the goal line is always moving. I know there are programs that still train this way, but I really have no idea about what comes after, whether my career will straddle the death throes of the old-time doc or if that syle of medicine has breathed its last.

I appreciate any thoughts you kind people have. I understand that my ideas are most definitely ill-formed and naive, so feel free to disabuse me of my misguided notions. Thanks!

Whether or not you refer, is up to you. You can choose to workup and manage whatever you like (within reason).

 

[Keona]

Thanks! What are you able to incorporate into your practice as far as procedures, peds, OB, etc?

And tell me more about that hobby farm One of my dreams has always been to homestead lite and get back to working with horses like I did growing up.

So I did not want to practice ob so I don’t and I’m part of a rural health clinic which has super annoying rules regarding billing of devices so can’t do some procedures such as nexplanons. Since we don’t do ob we don’t have a lot of kids but our practice sees kids 2 and up. My patient panel is fairly elderly because I ended up with 2.5 patient panels basically dropped on me after I started. (Was hired to replace one and another one retired and another one died). So I do more geriatrics than any thing else and honesty I’m loving it. My 80 and 90 yo are awesome but I also have a mixture of younger patients I don’t see as frequently. I do injections and skin biopsies. I put splints on, I suture things. Different people in my practice like different things so sometimes I’ll refer to another who does more derm than me but is in our practice. We are very lucky to have specialists like cardiology and nephrology that’s come to our town a few times a month. If needed I refer patients to them. Now hobby farm is the biggest reason my husband talked me into this. He despised living in a large city and had been miserable there during medical school and residency. He deals with all the animals and I get to just look at them and throw them food sometimes. I’ve got goats, pigs, ducks, turkeys, Guinneas and chickens. My husband insists they’re all for eating. So far we’ve eaten two very mean roosters. I think we’ve got a whole lot of pets lol. One of my friends is doing completely full spectrum family med and seems to be loving it. I’ve got others who are doing just urgent care. Family med really lets you pick what you like the most and get to do it. (I end up with pregnant patients, etc at times still as well, we only have two obs in town and they don’t always have enough time to see the acute non ob issues. That doesn’t happen very often but If they’re our patients id much rather them see a family med md than internal med Or random urgent care. I’m very happy with what I’m doing. today I left a little after 5 and am entirely caught up on everything. One of my patients and I had a nice conversation about his refinishing of furniture.

 

[AMEHigh]

Thanks for taking the time to type out a reply! It is comforting to hear that someone else didn't like their FM rotation who ended up liking it. I'm going to a rural practice for a rotation later this year and keeping my fingers crossed...

I want to do international/global health as well, and so while it is possible in the surg sub I thought I always wanted I can't help but notice how much more versatile FM trained docs are in that scene.

I had an FM doc tell me one time not to do it because, as he said, "it is so f**king boring". In spite of my initial intention to be like the generalists of old, I still worry about regretting not pursuing something higher octane.

I guess any job can get boring?
I’d say the beauty of family med is the ability to be versatile and do a variety of things. I don’t think people should change jobs every 2 years but if you do get bored there is the option to find something else.

The ability to change things up really hit me when I was talking to my good friend. Her spouse recently finished a pretty specialized "cool" fellowship. But that meant there were pretty much only 4 jobs they could pick from in the country. I was like no thanks I’m glad I didn’t end up with a speciality like that.

 

[VA Hopeful Dr]

I guess any job can get boring?
I’d say the beauty of family med is the ability to be versatile and do a variety of things. I don’t think people should change jobs every 2 years but if you do get bored there is the option to find something else.

The ability to change things up really hit me when I was talking to my good friend. Her spouse recently finished a pretty specialized "cool" fellowship. But that meant there were pretty much only 4 jobs they could pick from in the country. I was like no thanks I’m glad I didn’t end up with a speciality like that.

This is a big thing for me as well. Since finishing residency we've moved 3 times. Each time I had my pick of multiple job offers. And these were small-medium sized Southern towns.

 

[topraman]

I trained recently at a classic full-spectrum program. A few thoughts:

1) It's not about what you end up doing, it's better training regardless. Strong, broad acute care training is a great foundation for anything. It's a mindset. It's a can-do attitude, it demystifies medicine, and you understand, that done smartly and certainly with extra effort, you can find your way in anything. That's important in medicine life long, it lets you reinvent yourself, and you never get intimidated or bored.
2) Skills wise, if you did anesthesia regularly (we had the chance), procedural sedation is easy. If you did crash C-sections and controlled major bleeding (we did), you won't bat an eye at any office based lump and bump. If your plastics guy had you repair tendon lacs in the ER (we did), you won't mind managing bad hand lacs.
3) The role modeling is different when your FM attendings do everything and your specialty consultants believe you can also do much of what they do.
4) Don't underestimate the value of this confidence and the active learning it promotes. If you can take the higher stakes, you won't stand passively by for lower level dysfunction. You won't whine about the office problems, you'll fix them.
5) Full-spectrum training isn't just procedural. We had generalists who did subspecialty clinics, from neuro rheum, urology, cardio and many more. And the system didn't make money of internal referrals. So your specialty needs patients were most often managed by you with help through curbsides and inbaskets as needed. You wrote for the methotrexate, adjusted the heartfailure, titrated the VPA, or ordered the rituximab infusion.
6) The actual practice still exists and is strong. I know the West Coast. Most of my class does some mix of full-spectrum whether inpatient-outpatient, outpatient-surgical L&D, homeless care-ER, and that too in or right around major metropolitan areas. It takes effort and creativity and networks though. It might mean 2 or 3 jobs rather than one. And there are headaches to accompany it (privileging paperwork, scheduling). In rural areas much easier and within the same place. The point is where there is a will there's a way.
7) We lost out on things for sure. All coding/billing. Not much telehealth. Probably behind in the latest clinic productivity or management tricks. But to me residency training is about sequencing. Go for what you can only get in that time. The rest is not unimportant, but it can come later.

 

[MedicineZ0Z]

I trained recently at a classic full-spectrum program. A few thoughts:

1) It's not about what you end up doing, it's better training regardless. Strong, broad acute care training is a great foundation for anything. It's a mindset. It's a can-do attitude, it demystifies medicine, and you understand, that done smartly and certainly with extra effort, you can find your way in anything. That's important in medicine life long, it lets you reinvent yourself, and you never get intimidated or bored.
2) Skills wise, if you did anesthesia regularly (we had the chance), procedural sedation is easy. If you did crash C-sections and controlled major bleeding (we did), you won't bat an eye at any office based lump and bump. If your plastics guy had you repair tendon lacs in the ER (we did), you won't mind managing bad hand lacs.
3) The role modeling is different when your FM attendings do everything and your specialty consultants believe you can also do much of what they do.
4) Don't underestimate the value of this confidence and the active learning it promotes. If you can take the higher stakes, you won't stand passively by for lower level dysfunction. You won't whine about the office problems, you'll fix them.
5) Full-spectrum training isn't just procedural. We had generalists who did subspecialty clinics, from neuro rheum, urology, cardio and many more. And the system didn't make money of internal referrals. So your specialty needs patients were most often managed by you with help through curbsides and inbaskets as needed. You wrote for the methotrexate, adjusted the heartfailure, titrated the VPA, or ordered the rituximab infusion.
6) The actual practice still exists and is strong. I know the West Coast. Most of my class does some mix of full-spectrum whether inpatient-outpatient, outpatient-surgical L&D, homeless care-ER, and that too in or right around major metropolitan areas. It takes effort and creativity and networks though. It might mean 2 or 3 jobs rather than one. And there are headaches to accompany it (privileging paperwork, scheduling). In rural areas much easier and within the same place. The point is where there is a will there's a way.
7) We lost out on things for sure. All coding/billing. Not much telehealth. Probably behind in the latest clinic productivity or management tricks. But to me residency training is about sequencing. Go for what you can only get in that time. The rest is not unimportant, but it can come later.

Strongly agree.

There's just no way that "outpatient focused" programs are anywhere near the caliber of training physicians that true full spectrum programs are. Even for pure outpatient bread n butter practice.
If your inpatient training is weak, your clinic probably isn't managing complex patients. These tend to be places where referral is prioritized and only bread and butter is managed in the clinic. Good inpatient training is also a sign of the department being respected in the institution.

 

[ThreatLevel_12:00AM]

A couple of thoughts....

- I am not convinced that "full spectrum" (or at least "extended spectrum") family medicine will ever go away completely. With insurance companies still liking the "shared risk" model, there seems to be at least some push towards trying to keep everything in your clinic, as much as possible.

- I do only outpatient FM, and I have never been beaten up by specialists. If anything, I get Christmas cards and bottles of wine from specialists in the area - which can sometimes be quite uncomfortable to accept because some of the doctors sending gifts are awful and I purposely avoid referring any patients to them.

- Even in just outpatient FM, it still gets challenging and there will be many patients who will force you to abandon algorithms and "cookbook medicine." There is an inherent, and sometimes endless, challenge in having patients come to you with absolutely no work up and (often) vague symptoms that could be anything.

- I get what you're saying about how it seems boring that many suburban/urban FM physicians "refer everything out." However, please keep in mind that they may not do so because they're forced to or because local practice patterns require it. Rather, it is possible that they choose to do so because, honestly, it's easier and they get to go home at 5:30. Unfortunately, the more exciting medicine is, it often means that the worse the hours are. Eventually, it becomes a question of which matters more to you - the intellectual challenge or the burning desire to be home by 6 and in bed by 10.



Unfortunately, medicine, like anything else, can be "so f**king boring" if you do it long enough. I don't think that FM is any different from any other specialty in that regard. Your 500th cataract, your 500th CHF admission, your 500th stage II breast cancer patient, your 500th hernia....after a while, it's not fresh and exciting any more.

Your post is making me think of a conversation that I had with a former coworker. I have worked in an FQHC for several years. I have always said that one of the things that I love about working in an FQHC is that it is unpredictable. The patients are never ever boring. There are a lot of social work issues, as you can imagine in a clinic whose mission is to help the underserved, but it is pretty much never boring. Because many of these patients lack resources, you are often called to treat or do things outside of your comfort zone.

An NP that I worked with had worked in that FQHC for over a decade. She, too, loved the intellectual challenge of dealing with these unpredictable and often challenging patients....until she didn't. She was coming home late, drained, and mentally exhausted. It was fine when she was single and childless, but not so much fun when she had a 3yo who wanted to know why "mommy never wants to play."

So she quit and went to work for a subspecialist. She has admitted to me that it's incredibly boring. All the patients have insurance and are financially comfortable. The medicine is textbook and rote. One note is very much like the other. And yet...she's out the door by 5:10, she's home by 5:25, and she gets to spend the rest of the evening playing games with her family or helping her kids with homework. And that's a trade off that she's very willing to make.

Hey, thanks for taking the time!

I think that you bring up great points. The goalposts for what makes a career 'satisfying' will shift over a career and I'm sure I won't be any different in that regard. And while you are probably correct that what I want out of my career will change, based on what I have seen I wasn't sure whether FS was even a possibility except in the most remote spots. Hopefully, that doesn't change and FM doctors will continue to have the option to choose either path.

 

[ThreatLevel_12:00AM]

So I did not want to practice ob so I don’t and I’m part of a rural health clinic which has super annoying rules regarding billing of devices so can’t do some procedures such as nexplanons. Since we don’t do ob we don’t have a lot of kids but our practice sees kids 2 and up. My patient panel is fairly elderly because I ended up with 2.5 patient panels basically dropped on me after I started. (Was hired to replace one and another one retired and another one died). So I do more geriatrics than any thing else and honesty I’m loving it. My 80 and 90 yo are awesome but I also have a mixture of younger patients I don’t see as frequently. I do injections and skin biopsies. I put splints on, I suture things. Different people in my practice like different things so sometimes I’ll refer to another who does more derm than me but is in our practice. We are very lucky to have specialists like cardiology and nephrology that’s come to our town a few times a month. If needed I refer patients to them. Now hobby farm is the biggest reason my husband talked me into this. He despised living in a large city and had been miserable there during medical school and residency. He deals with all the animals and I get to just look at them and throw them food sometimes. I’ve got goats, pigs, ducks, turkeys, Guinneas and chickens. My husband insists they’re all for eating. So far we’ve eaten two very mean roosters. I think we’ve got a whole lot of pets lol. One of my friends is doing completely full spectrum family med and seems to be loving it. I’ve got others who are doing just urgent care. Family med really lets you pick what you like the most and get to do it. (I end up with pregnant patients, etc at times still as well, we only have two obs in town and they don’t always have enough time to see the acute non ob issues. That doesn’t happen very often but If they’re our patients id much rather them see a family med md than internal med Or random urgent care. I’m very happy with what I’m doing. today I left a little after 5 and am entirely caught up on everything. One of my patients and I had a nice conversation about his refinishing of furniture.

Sounds like a lot of fun! It is nice to catch glimpses like these of the other side, realistic visions of the future are hard to come by at this stage of my life.

 

[ThreatLevel_12:00AM]

I trained recently at a classic full-spectrum program. A few thoughts:

1) It's not about what you end up doing, it's better training regardless. Strong, broad acute care training is a great foundation for anything. It's a mindset. It's a can-do attitude, it demystifies medicine, and you understand, that done smartly and certainly with extra effort, you can find your way in anything. That's important in medicine life long, it lets you reinvent yourself, and you never get intimidated or bored.
2) Skills wise, if you did anesthesia regularly (we had the chance), procedural sedation is easy. If you did crash C-sections and controlled major bleeding (we did), you won't bat an eye at any office based lump and bump. If your plastics guy had you repair tendon lacs in the ER (we did), you won't mind managing bad hand lacs.
3) The role modeling is different when your FM attendings do everything and your specialty consultants believe you can also do much of what they do.
4) Don't underestimate the value of this confidence and the active learning it promotes. If you can take the higher stakes, you won't stand passively by for lower level dysfunction. You won't whine about the office problems, you'll fix them.
5) Full-spectrum training isn't just procedural. We had generalists who did subspecialty clinics, from neuro rheum, urology, cardio and many more. And the system didn't make money of internal referrals. So your specialty needs patients were most often managed by you with help through curbsides and inbaskets as needed. You wrote for the methotrexate, adjusted the heartfailure, titrated the VPA, or ordered the rituximab infusion.
6) The actual practice still exists and is strong. I know the West Coast. Most of my class does some mix of full-spectrum whether inpatient-outpatient, outpatient-surgical L&D, homeless care-ER, and that too in or right around major metropolitan areas. It takes effort and creativity and networks though. It might mean 2 or 3 jobs rather than one. And there are headaches to accompany it (privileging paperwork, scheduling). In rural areas much easier and within the same place. The point is where there is a will there's a way.
7) We lost out on things for sure. All coding/billing. Not much telehealth. Probably behind in the latest clinic productivity or management tricks. But to me residency training is about sequencing. Go for what you can only get in that time. The rest is not unimportant, but it can come later.

Thank you for writing this up. I have heard of a few programs that train like this, but unless you know someone it isn't very common (for me at least) to come across people on the other side of training living except every now and again.

One point you bring up is a lesson I learned in college that can be difficult for me to remember. I did chemical engineering, and people (including myself) when they are starting out see the degree as their ticket, but underestimate how much the individual's talents, drive, and mindset determines what kind of job they end up with, not the degree itself. Thanks for the advice!

 

[simpler2]

I believe @smq123 , @topraman and @Keona provide excellent insight that gets beyond what the OP thinks they want to know. I would only add that I consider it a fools errand to try to force your practice environment to provide for you the vision you have in your clinical practice. However you end up earning your income, it will be earned because someone or some group considers you to be providing a service of value. I've found frequently the most satisfied providers start by asking how they can provide a service of value and then building a career on the foundation of answers they discover over time.

That being said...don't go rads if you want to shoot yourself after sitting in a reading room for more than 30 min =).

 

[ThreatLevel_12:00AM]

I believe @smq123 , @topraman and @Keona provide excellent insight that gets beyond what the OP thinks they want to know. I would only add that I consider it a fools errand to try to force your practice environment to provide for you the vision you have in your clinical practice. However you end up earning your income, it will be earned because someone or some group considers you to be providing a service of value. I've found frequently the most satisfied providers start by asking how they can provide a service of value and then building a career on the foundation of answers they discover over time.

That being said...don't go rads if you want to shoot yourself after sitting in a reading room for more than 30 min =).

Would you mind elaborating on your first sentence? I'm not sure what you mean by their insights going beyond what I think I want to know. Or maybe you mean that their insights go beyond what you think I think I want to know? (just kidding)

 

[simpler2]

Would you mind elaborating on your first sentence? I'm not sure what you mean by their insights going beyond what I think I want to know. Or maybe you mean that their insights go beyond what you think I think I want to know? (just kidding)

I was more commenting on the predicament that you are in, which we all faced in training. With significant uncertainty in your future, you are at a cross roads where you must make a decision that will greatly affect your future self without being able to fully know what will most benefit this hypothetical person. I saw the three posters I mentioned as having provided very well articulated responses about their work experiences and views towards practice/professional goals in general. These responses didn't necessarily speak directly to your original post but they spoke to me as someone almost a decade into practice as being some of the most genuine, concrete, and straight forward responses in this thread.

 

[ThreatLevel_12:00AM]

I was more commenting on the predicament that you are in, which we all faced in training. With significant uncertainty in your future, you are at a cross roads where you must make a decision that will greatly affect your future self without being able to fully know what will most benefit this hypothetical person. I saw the three posters I mentioned as having provided very well articulated responses about their work experiences and views towards practice/professional goals in general. These responses didn't necessarily speak directly to your original post but they spoke to me as someone almost a decade into practice as being some of the most genuine, concrete, and straight forward responses in this thread.

Well said. It does seem folly to choose a hypothetical career based on constraints I don't yet understand. My hope is that the initial conditions I choose will leave enough degrees of freedom to allow for some flexibility in the future. Their responses are in fact different than what I might have expected making the thread, and quality, as is your's. Thanks for posting.

 

[topgun2990]

So I did not want to practice ob so I don’t and I’m part of a rural health clinic which has super annoying rules regarding billing of devices so can’t do some procedures such as nexplanons. Since we don’t do ob we don’t have a lot of kids but our practice sees kids 2 and up. My patient panel is fairly elderly because I ended up with 2.5 patient panels basically dropped on me after I started. (Was hired to replace one and another one retired and another one died). So I do more geriatrics than any thing else and honesty I’m loving it. My 80 and 90 yo are awesome but I also have a mixture of younger patients I don’t see as frequently. I do injections and skin biopsies. I put splints on, I suture things. Different people in my practice like different things so sometimes I’ll refer to another who does more derm than me but is in our practice. We are very lucky to have specialists like cardiology and nephrology that’s come to our town a few times a month. If needed I refer patients to them. Now hobby farm is the biggest reason my husband talked me into this. He despised living in a large city and had been miserable there during medical school and residency. He deals with all the animals and I get to just look at them and throw them food sometimes. I’ve got goats, pigs, ducks, turkeys, Guinneas and chickens. My husband insists they’re all for eating. So far we’ve eaten two very mean roosters. I think we’ve got a whole lot of pets lol. One of my friends is doing completely full spectrum family med and seems to be loving it. I’ve got others who are doing just urgent care. Family med really lets you pick what you like the most and get to do it. (I end up with pregnant patients, etc at times still as well, we only have two obs in town and they don’t always have enough time to see the acute non ob issues. That doesn’t happen very often but If they’re our patients id much rather them see a family med md than internal med Or random urgent care. I’m very happy with what I’m doing. today I left a little after 5 and am entirely caught up on everything. One of my patients and I had a nice conversation about his refinishing of furniture.

That sounds awesome! I'm totally new to this forum but I'm an MS3 looking into rural FM or FM sports med because I left my surgical rotation wishing I was home with my family more and dreading an 80-100 hr/week residency. But, I still want to work with my hands, fix things, and have meaningful patient interactions. Mind if I ask in what state you practice? How big is the town you practice in? (Trying to get a feel for how small a city has to be in order to do a little bit of everything.) Feel free to DM.

 

[topgun2990]

I trained recently at a classic full-spectrum program. A few thoughts:

1) It's not about what you end up doing, it's better training regardless. Strong, broad acute care training is a great foundation for anything. It's a mindset. It's a can-do attitude, it demystifies medicine, and you understand, that done smartly and certainly with extra effort, you can find your way in anything. That's important in medicine life long, it lets you reinvent yourself, and you never get intimidated or bored.
2) Skills wise, if you did anesthesia regularly (we had the chance), procedural sedation is easy. If you did crash C-sections and controlled major bleeding (we did), you won't bat an eye at any office based lump and bump. If your plastics guy had you repair tendon lacs in the ER (we did), you won't mind managing bad hand lacs.
3) The role modeling is different when your FM attendings do everything and your specialty consultants believe you can also do much of what they do.
4) Don't underestimate the value of this confidence and the active learning it promotes. If you can take the higher stakes, you won't stand passively by for lower level dysfunction. You won't whine about the office problems, you'll fix them.
5) Full-spectrum training isn't just procedural. We had generalists who did subspecialty clinics, from neuro rheum, urology, cardio and many more. And the system didn't make money of internal referrals. So your specialty needs patients were most often managed by you with help through curbsides and inbaskets as needed. You wrote for the methotrexate, adjusted the heartfailure, titrated the VPA, or ordered the rituximab infusion.
6) The actual practice still exists and is strong. I know the West Coast. Most of my class does some mix of full-spectrum whether inpatient-outpatient, outpatient-surgical L&D, homeless care-ER, and that too in or right around major metropolitan areas. It takes effort and creativity and networks though. It might mean 2 or 3 jobs rather than one. And there are headaches to accompany it (privileging paperwork, scheduling). In rural areas much easier and within the same place. The point is where there is a will there's a way.
7) We lost out on things for sure. All coding/billing. Not much telehealth. Probably behind in the latest clinic productivity or management tricks. But to me residency training is about sequencing. Go for what you can only get in that time. The rest is not unimportant, but it can come later.

Sounds like you received awesome training in residency! Mind if I ask what program? Feel free to DM.