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future of family practice?

Discussion in 'Family Medicine' started by tatabox80, Dec 16, 2005.

  1. tatabox80

    tatabox80 Super-Duper Member
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    I have talked to other attendings in other fields and they have mentioned that due to the increasing specializing in medicine, family practice will not exist in 15-20 years because of the broad spectrum of the specialty. What are your thoughts on this?
     
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  3. emedpa

    emedpa GlobalDoc
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    someone has to write the referals to generate pts for the specialists...unless you believe primary care will become the sole domain of midlevels( I don't think so).
     
  4. sophiejane

    sophiejane Exhausted
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    The key part of this statement is "in other fields."

    Everyone wants to believe that what they have chosen is the best and that their ship isn't sinking nearly as fast as the other guy's.

    Family practice is changing, as are all fields of medicine (someone here recently claimed that cardiothroacic surgery will also be extinct in 20 years, which I also find hard to believe), but I doubt it will ever become obsolete.

    Being a true generalist may only be possible in rural areas someday, however.
     
  5. f_w

    f_w 1K Member
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    The scope of practice in FP might change. Here are the areas I would expect to see changes:

    - The number of FPs doing OB and C-sections will decline (2nd to insurance and credentialing issues).
    - The number of FPs doing ER work will decline (2nd to growth of EM as a specialty).

    Given the changing age distribution of society, there will be an increased need for physician services in the years to come. This will not be limited to specialty services.

    The 'cradle to the grave' family practicioner might become an uncommon sight anywhere but in rural areas. Most people will provide primary care similar to a general internist, except that they don't fall over backwards if someone brings in a child to be looked at ;)
     
  6. lateness

    lateness Senior Member
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    I highly doubt that. The aafp and AMA predict the demand for FPs surpass the demand for all other specialties, because FPs are able to practice with the Greatest cost effeciency.. there will always be a need for Primary care and preventitive medicine. trust me. Could you imagine if there wasnt any. try to imagine that scenario today, that there were no FPs around this country and how many hundreds of thousands of patients who were reliant on them; where would they go? ONly to specialists? only to ERs and wait for hours? And how would the ones who needed specialty care even know that they need it if not for a primary caregiver where to first notify them of their problems? I think that that statement, usually given by doctors from other specialties is weak at best and it is impossible to predict that in the future..
     
  7. iatrosB

    iatrosB trying not to kill anyone
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    :laugh: :laugh: :laugh: enough said!
     
  8. nebrfan

    nebrfan Rx Beer
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    Couldn't they go to a NP - who is cheaper for the insurance companies - and even now can practice nearly independently?
     
  9. lateness

    lateness Senior Member
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    I suppose they could, but i dont see the majority of people doing that. Plust i dont think its much cheaper at all. ALso Everyone i know close to me, have always been seen by the doctor, maybe that just how it is in the area i live, not b/c we chose not to go to a NP it sjust they it happened. but even if there were, it wouldnt stop us from going to a primary care doc. But to imagine there being no doctor at all, as in being obsolete, is just not plausible in my opinion. Its not that much cheaper as far as i know to go to an NP and unfortunately there are still alot of peole with the attitude, that they want to go to an MD who trained in a residency. For people to say that Fam Prac will be obsolete, i guess you would have to say the same for many other specialties and fields, ER, Int Med prim care, Peds, certain OB/Gyn stuff, simple Derm and uncomplicated ENT things, and on and on, so why only say it for FM? Alot of doctors in these fields also do a lot of primary caregiving too, to supplement their practices, and so why wouldnt patients want to go to them? b/c its cheaper? i dont know how much, but i do know that the doctors i know, int med, FM, i visit their practices often, have no complaints from patients going there that I have seen,.
     
  10. skypilot

    skypilot 2K Member
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    NPs are great, they definitely serve their purpose. My sister is a NP. But do you want to go to an NP when your life is threatened by illness?...... I didn't think so.
     
  11. nebrfan

    nebrfan Rx Beer
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    Don't get me wrong - I don't think that NPs should be a replacement for FPs - I'm just playing devils advocate
     
  12. DropkickMurphy

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    How often do people really go to an FP for something immediately life threatening? I know it does happen, but all of the FP docs I know normally just have their staff dial 911 to get the patient out of their office and to a doc who can handle the emergency.
    Wouldn't an FNP be doing much the same? How different is it really? I've worked two codes in a primary care doc offices- one with 5 physicians (including one who I found out later is an assistant director of an FP residency BTW) present- and I have always had the docs stand around as though clueless while the nurses and FNP assisted us. One of the docs even went so far as to ask why we were giving lidocaine to the patient ("Uh, he's in V-Fib. Any other suggestions?" "No, no, you know what you're doing." :confused: :confused: ) So is a primary care doc really that much more beneficial than a FNP in a situation like that? Probably not. I think physicians should be specialists, and mundane things such as primary care should be relegated to the allied health professionals (I would prefer PAs over FNPs in assuming this role) who are adequately able to handle this.
     
  13. fozzy40

    fozzy40 Senior Member
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    I am just curious, does anyone responding here LIKE family medicine or planning to go into the field?
     
  14. lateness

    lateness Senior Member
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    Thats interesting, b/c i have never seen a code or emergency situation in an FP office, ata least when i worked there. But i did see a few in an internal medicine clinic/office, and all the internests called the ambulance as fast as possible, and did not know what to do. I dont know abuot where you worked, and cant judge, but from the FP doc i worked with he was awesome and was a very knowledgable doc. It also depends on the situation, and liability. Alot of clinics, do common stuff, and rarely see emergent cases, and MOST arent even equipped to handle emergencies, remember its an office/clinic, (unless in an urgent care), so obviously they wouldnt be as comfortable or expecting those situations. But the same can be said about an emergent scenario in an opthomalogy,derm, ped, etc, other clinics that dont expect to see it...
    FP docs are extreemly variable and some are incredible and some arent like in any other specialty, and i wouldnt judge any whole specialty just by a few examples. By the way when i did my ER rotation, there were a couple of clueless docs there, if it wasnt a code, they were lost, but i didnt judge the whole profession and deem it as a useless specialty to be left to only PA, and NPs. :eek:
     
  15. DropkickMurphy

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    It wasn't the couple of docs who couldn't find their butts from a whole in the ground when it comes to emergencies that gave me the negative impression of the field (after all it isn't their specialty, just like I couldn't tell you when you should give what vaccination as an FP could). It's the fact that FP and non-specialized IM is kind of the "safety net" for those who couldn't get into another residency. Granted there are those who grow up dreaming of this kind of practice, but I just feel that it is far more economical to put PA's and FNP's in their place and eliminate the "shortage" of primary care docs, since they do just as well in caring for their patients and can be trained far more quickly. This way the medical practice can be reoriented towards taking care of those patients who would really benefit from a physician- but at the same time there would need to be a lot of docs weeded out because you wouldn't want someone who wound up as FP or IM docs because they couldn't hack it as a specialist suddenly forced to become a cardiologist, EM, or other specialty that requires a great deal of knowledge.

    To answer your question Fozzy, most likely not. I can't think of many people who would be impressed by a job where you are mandated to go through a lot of education and training only to be underpaid, overworked, and basically function as a NP with a doctoral degree.
     
  16. subtlewonder

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    q
     
    #15 subtlewonder, Dec 18, 2005
    Last edited: Oct 24, 2010
  17. DropkickMurphy

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    Correction- I have faith in my colleagues- all of them: docs, nurses, nurse practitioners, RT's, PA's. I just feel that if you are going to be a physician, you should have to specialize.

    It honestly has little to do with insurance companies and everything to do with getting primary care to those who need it. It's quite obvious that FP docs are not filling the need, and something needs to be done. Perhaps I should have said "logistic" instead of "economic". There is nothing disrespectful in this. In fact it would advance medicine somewhat if we were to get rid of the safety net residency that is family practice.

    And no, I'm not a physician yet. But given that I have been around health care for 9 years in various capacities and my judgment is not clouded by blind loyalty to anyone or anything- profession or otherwise.
     
  18. ericdopt

    ericdopt Member
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    So, uhh.....are you even in medical school yet?
     
  19. DropkickMurphy

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    No, but I don't think that has much bearing on anything. Facts are facts regardless of who is presenting them. I find it rather amusing that the rebuttal you all have come up with for my points is "You're not a doc yet".
     
  20. emedpa

    emedpa GlobalDoc
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    I have worked in am hmo setting where pa's and np's work as primary care providers with minimal oversight. I think this works well if the pt panel is mostly young families or heathy elderly folks. once you start seeing lots of trainwrecks/IM type pts( as happened there) they might as well see a doc as they wil end up getting farmed out to specialists most of the time anyway. I don't see fp going away as a specialty, however I think what we will see is md fp docs working as supervisors for an increasing # of midlevels and seeing only those more difficult pts who get passed up the line. a single fp md could probably oversee/work in collaboration with 6 midlevels or so and fill out the rest of their schedule with procedural pts( treadmils, flex sigs, vasectomies, colposcopy, etc)
    I have the utnmost respect for my fp md coleagues and if the time comes that I go back to medschool I will probably pursue postgrad training at an unopposed fp residency like ventura county or contra costa county where the fp residents do everything
     
  21. skypilot

    skypilot 2K Member
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    There are emergencies and then there are life threatening illnesses. What I am asking is do you want a NP evaluating that funny mole on your back, checking you for prostate cancer, and adjusting your hypertension and diabetes medications, and making the decision on whether you should be admitted to the hospital or not? These are not necessarily emergencies but they might be life threatening and I want a doc.
     
  22. DropkickMurphy

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    All of those are learned skills- regardless of the person learning them is a physician or a physicians' assistant. The question is whether you regard the learning each goes through to be sufficient. Apparently we disagree because of your belief that it is not.
    As I said I also believe that PA's are a better choice than NP's and believe they are better trained.
     
  23. SmittySC

    SmittySC Junior Member
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    This statemant is idiotic and very uninformed. Most of the residents who decide to do FP and non-specialized IM do that type of medicine because they choose to do. Many of them have the qualifications to do any residency that that want to and have decided that primary care is what they want to do with the rest of their lives. People are not knocking your opinions because you "are not a doc yet" or because you are not even a med student yet, it is because you are shooting off at the mouth making uninformed and idiotic comments like above. Yes, you may have some experience or exposure to the medical field, but it is obvious from some of your statements that you do not have a true understanding of how it and the area of primary care really works. I normally try not to be patronizing in my posts, and Praetorian does have a right to his opinion, but dumba## comments like above burn me when they are very blatently untrue.
     
  24. DropkickMurphy

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    Is it not true that the standards for admission to FP programs are far more lax than those for say, radiology? Surgery? You can't really rely upon IM stats because of its being the gateway to specialties in many cases (thereby skewing that overall statistics).

    According to the data I was shown by a friend of mine who works for a residency program (an FP residency ironically enough), they are. It is to this I was referring to it being a safety net, because then logic would dictate if someone doesn't have the scores or ability to pursue a more selective residency that they are going to go after something with lower average board scores. If that is incorrect, I apologize, but I can only operate off the data which I have been given.
     
  25. sophiejane

    sophiejane Exhausted
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    Did I make a wrong turn?

    I thought this was a forum for people interested in pursuing a career in family medicine. Humoring posters like the above ill-informed pre-med is counterproductive and won't change his or her mind.

    The difference between the family physician and a nurse or PA is in their diagnostic skills. Most allied health folks are very up-front about what they are and are not comfortable with, and when they consult their physician colleagues it's often on the more subtle or unusual presentations. It's a times like that when you are glad that PAs and nurses usually practice with an MD or DO.
     
  26. f_w

    f_w 1K Member
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    You operate 'off data', but apparently not based on experience in a primary care setting.

    While there are undoubtedly people in primary care IM and FP who couldn't make it into anything else, I encounter enough M1 and M3 students rotating through our department who have primary care as their career goal. These are smart people who plan on becoming a doctor to care for the whole patient. They will never be able do do some of the procedures that I do on a routine basis, but their function is a different one and equally important in the healthcare system. If you think that a PA can replace all the functions of a trained internist or FP, you just demonstrate your lack of experience in this area of medicine.
     
  27. DropkickMurphy

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    Yes, I have little experience in primary care (beyond a few hundred hours of observation time) but having worked as an RT and echocardiographer as well as in EMS for several years, I think that anyone who chooses to pursue FP is selling themselves short. I should say that I am glad there are people who are willing to fill those primary care spots because I could never do it. I'd rather take my MD, go to law school and become a malpractice attorney and feed off the mistakes of primary care docs than to ever become one myself.

    I'm not misguided or ill-informed. I just don't agree with you all. That has become quite clear and I see no point in carrying this further unless someone has something else intelligent to add to the conversation beyond toeing the party line.
     
  28. f_w

    f_w 1K Member
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    All areas far removed from primary care.

    How is that ?

    There are enough PCPs who make decent money and have the lifestyle they desire.

    Do us all a favour and go directly to law school. You fit in better over there.(actually, the combination of big ego with little factual knowledge is far better suited for a MBA program. with all your 'healthcare experience' :laugh: :laugh: you could find a job consulting for hospitals in no time)
     
  29. DropkickMurphy

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    I openly said that I didn't work primary care- although a lot of my business as an echocardiographer came from FP docs and I dealt with those physicians all the time. It is partly their attitude towards their chosen area that cemented my desire to avoid primary care.

    How do you figure I won't make a good doctor? Because I don't think that there is something glorious about being a family doc? We are each called to something different, and my calling happens to be a specialty. Just as you might look down your nose at me for not wanting your chosen profession and disagreeing with you on how best to deliver primary care (wouldn't you rather dealing with complex medical patients all day rather than preventative care? That is what I am advocating), I don't think very highly of you for brushing me off because of my stances. I'm as dedicated to taking care of people as you, I just choose to go about it in a different manner- that is by pursuing specialty practice.

    The only reason I would not pursue primary care is that I would rapidly become bored by it and I want more time with my family than it can offer. When bored and dissatisfied I (just like most people) find it hard to continue day after day, week after week, to give my best. I would not choose to do that to my patients.
     
  30. DropkickMurphy

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    Oh, and by the way, if you actually knew me, you'd realize I have very little in the way of ego- especially in comparison to many of my fellow premeds. I don't appreciate the condescending assumptions you are making about me (just as you don't appreciate the conclusions I draw about FP). Good night. :laugh:
     
  31. raptor5

    raptor5 Fooled by Randomness
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    Stop feeding the troll!
     
  32. DropkickMurphy

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    How am I a troll? I'm not purposely trying to cause trouble, just stating my opinions.
     
  33. ramblin_med

    ramblin_med Junior Member
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    This turned into a ridiculous thread. I could hijack a thread saying specialists are all greedy, lazy, and selfish people who care less about their patients than money and free time. I could also say that they would rather play with the newest toy or argue about etiologies than actually talk to a patient. All of those things would be a gross overgeneralization, though.

    BTW, if you plan on becoming a specialist, you will need to suck up to the "rejects" who went into primary care. Your referrals have to come from somewhere.

    I would leave the "I would rather support a lawsuit against them than have their job" comments out of my applications to med school or residency if I were you. It is also probably not something to bring up when trying to get referrals.

    Anyway, have a nice day, but don't come back.
     
  34. sophiejane

    sophiejane Exhausted
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    Great...please come back in 8-12 years or whenever you are done becoming a laprascopic cardiothoracic surgeon for short statured individuals or whatever your chosen super duper specialty is, and tell us how much time you've got for your family. That should be an interesting (and short) discussion.

    I'll take a 9-5 clinic in a small group of lowly primary care losers (with call one weekend a month) any day....

    And as for boring...I can't imagine how seeing the same diseases day after day in a specialist's office would be more exciting than the wide range of illnesses that primary care docs manage on a daily basis. But to each his own.
     
  35. skypilot

    skypilot 2K Member
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    As far as boredom goes. I think it might be more boring looking at the same illness everyday as a specialist. At least FP gives you some variety in terms of patient population and illnesses treated.
     
  36. erichaj

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    The most up to date data suggests that primary care physicians get sued less than most specialist.

    Unless you are a physician you really are not in a place to comment on most of this.

    It sounds nice, become an attorney and M.D. and sue doctors. Except I don't think you really know what it takes to do this. In fact you have a technical degree right ? Your hundred hours of observation experience is great. I have over a thousand hours of watching baseball on T.V. but that does not make me a pro baseball player.

    It's easy to judge when you are standing on the outside looking in.

    I don't write this to be mean to you. but I feel you need to get your facts right.
     
  37. erichaj

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    The bottom line is that everybody is different and each specialty has it's advantages and disadvantages.

    Doctors have a nasty habit of beating up on each other. It's the ego. I'm better than him etc. etc.

    Get real, you went to medical school to help people and make a good living.

    We deserve respect for taking the challenge of medical school. Few do this.
    That does not mean that you should be worshiped. Grow up.

    We all have a job to do, specialty, primary care. I have very little respect for the doctor who puts down another because of his specialty.

    There is a place for everyone in medicine. Not everyone wants to cut open someones chest and put a new heart in there.
     
  38. DropkickMurphy

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    Nicely put. :thumbup: Point taken. Nothing further will be said in regards to this on my part.
     
  39. Poety

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    Hi Prae,

    I just wanted to let you know, that in order to be say a cardiologist, gastro, nephro, heme onc - or whatever other specialty you must first complete a 3 year residency in internal med. I realize you are saying that these are very competitive fields - but you'll also find that many people can attain this goal, even with below average scores or MLE's just by excelling in their residency. IM residency is NOT competitive and there are a LOT of IM residency's with fellowships that they funnel to their own.

    When you get into med school, you'll find that those people with those extraordinary stats are not the norm - I thought I was literally bottom of the barrel until I saw my dean's letter - in which case I found I was dead smack with the rest of my class, and even better than some - and this was with mostly P's, a couple of HP's and a couple of H's - people are so wrapped up in the board scores and the stats - you'd be amazed that a lot of people have actually mediocre board scores, and have become surgeons, rads, onco's and derm - its not impossible. Primary care is not reserved for those that have below avge stats - its reserved for those that choose to have a lot of variety and prefer patient management to anything else. FP's not only have to know medicine, they have to know where their patients are going, who they are seeing for what, what the results are, and literally coordinate their patients healthcare - its a incorrect for you to think these docs are not necessary, especially with the growing population of geriatrics that need them to manage their needs.

    Now you might say an NP or PA can do this - but I seriously think that its more beneficial to have an actual physician managing multiple medical problems as opposed to a mid level.

    What I've found is that there seems to be a lot of spirit breaking on these forums - and its just not necessary. Pick your specialty according to what you love. Don't resent your colleagues, support them - because I guarantee, at one point in time you will need one of "their kind" at some point in your life.

    Good luck with medical school - and don't blow off OB! ;)
     
  40. fozzy40

    fozzy40 Senior Member
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    Well said:)
     
  41. erichaj

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    Studies have shown that high or low board scores do not perdict how someone will do as a physician. In fact there are people in Mensa ( I think that is how it is spelled) with IQ of 170 + that are not doctors or lawyers or anything like this.

    Book smarts is very good but it also takes an overall ability. This does not mean that a person with a score of 260 on USMLE will not do well, but it does not mean that they will do well either.


    It does not take a genius to become a dermatologist. It takes training and experience. It does not take a genius to become at surgeon, It takes someone good with hands and 3d mental mind set. Or someone who is good at remembering steps to procedures.

    These come with experience.

    True genius is like Albert Einstein who had so much creativity that he came up with a theory that no one else could come up with.
     
  42. Poety

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    you got that right - and wasn't he kicked outta school :)
     
  43. Newdoc2002

    Newdoc2002 Senior Member
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    Yeah, I was weeded out in med school. I chose FM because I couldn't get into anything else. It was my safety net. I mean, my life experience, VP of my class, student government executive officer, top half of my class, board scores well above the 3/4 percentile, great dean's letter and letters of recommendation including one from the top cardiologist on faculty weren't enough to get me into any of the "good" specialties.

    I guess tomorrow I won't see any of the seven in-patients admitted to my service with florid CHF, possible bowel infarction, lower GI bleed, COPD exacerbation, etc. Prae's experience means I'm just too stupid to take of these people. Later, I'll go to clinic and what will I do with the uncontrolled diabetic or the seven year old with new onset asthma or the 87 y/o with hypercalcemia? And god forbid I attempt the two colonoscopies I've got scheduled for next week.

    Pray tell Prae? Oh, I'm sure that I'll stand around while my patient codes too.
    All those codes I ran in residency at two AM were never good enough experience. Only critical care specs and cardiologist can do that.

    PS - When is a doctor not immediately going to immediately activate EMS in their office during a code? When was the last time you took ACLS?
     
  44. hartmanan

    hartmanan New Member

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    If I talk to most specialist about the Ottowa ankle rules for fx, or the ATP-III guidlines for CAD eval for med tx, or the Framingham study for risk stratification for MI/CVA they have no idea of what I'm talking about. As a FP I must know all of this to address a patient appropriately. NP and PA aren't taught this either. They have no idea what the difference between a Jone's fracture and a simple midshaft metatarsal fx. One needs ortho, the other needs time. When a PA or NP sees this patient they just send them off. I manage them. The only specialty that maximizes health outcomes and minimizes costs is Family Practice. Unfortunatly our medical system is disfunctional so that it is discouraging people out of primary care. The fact that you have no clinical experience and probably have no idea what the above means (like the 2 PA's and 1 NP I supervise) shows you no understanding abou the training rigor of primary care ( 7 years of medical training) for say a PA (1 year of class and 1 year of clinicals).
     
  45. rs2006

    rs2006 student
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    Hi all,

    Merry Christmas and happy holidays everyone. As a fourth year medical student just wanted to add that the BEST physicians and nicest people I ever worked with during my clerkships were family docs-- they did not have the arrogant, money hungry, ego driven, greedy attitude that most other docs-- they were just great human beings who truly cared for their patient-- something we all need more of in this world of money hungry, arrogant physicians that are all so prevalent in all the forums on this site!!

     
  46. DropkickMurphy

    DropkickMurphy Membership Revoked
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    "Discouraging" might not be correct. I don't imagine many people who really want to be FP docs are going to be warded off by the current state of medicine.

    Actually I am familiar with the Framingham study and the Ottawa rules (although not as familiar as I would like to be) . And "no clinical experience" isn't correct. I'm not an MD, but I am far from inexperienced.

    I stand behind many of my assessments but at the same time I will admit that I was wrong in the comment about FP being a safety net (someone PM'ed me with match statistics for FP and I was shocked by the numbers).
     
  47. Poety

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    I just have to ask if anyone else has experienced this situation: what is UP with the attitude from NP's? Why do they think they know so much and try to challenge everything someone studying medicine says? Its so annoying!!!! I just wanted to know if those of you who work intimately with the NP's have experienced this or if its just the couple I've encountered that have this chip on their shoulder? :mad: :scared:
     
  48. prominence

    prominence Senior Member
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    have u ever considered listening to the NPs' input? Some have 20+ yrs experience, and their insight can be helpful.

    also, most staff don't care to listen to someone in a short white coat. things will change when u get that MD title after ur name, and as such, more respect will come to u.
     
  49. Poety

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    Prom, ofcourse I have, and I was a nurse for 8+ years myself - this is something I've seen for more than 13 years and has gotten worse since a med student - also, as a nurse, I know what the NP's say about the residents as well - this isn't just the short white coat.
     
  50. Blue Dog

    Blue Dog Fides et ratio.
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    Well put. :)
     

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