how do you start up a practice after internship?

[turquoiseblue]

How do you start up a practice if you're licensed with only a year of internship (but not board certified)? I heard that is possible, but just wondering how that works and how to do that.

Also, lets say you can get licensure in one state, can you work in other states or can you only work in the state you get licensed?

Thanks.

---

Members don't see this ad.

 

[Law2Doc]

How do you start up a practice if you're licensed with only a year of internship (but not board certified)? I heard that is possible, but just wondering how that works and how to do that.

Also, lets say you can get licensure in one state, can you work in other states or can you only work in the state you get licensed?

Thanks.

You have to be licensed in the state you plan to work in. The big hurdle to starting a business after internship is insurance. Some companies won't insure you, others charge crazy premiums. Generally if you only have an internship & license, you are better off seeing if you can line up a full schedule of "moonlighting"/"floater" type jobs using your license rather than trying to hang up a shingle. You see folks like this in some of the smaller community hospital urgent care settings. Some hospitals let you do "hospitalist" work with only a year of internship under your belt. Others may have line services that can utilize your internship procedural experience and may pay decently. I think setting up a GP practice with just internship is not only dangerous (because you frankly don't know as much as you might think after just internship -- which is the reason the average residency is 3+ years, not one), and tough to insure, but also might be a losing proposition. You aren't board certified, but somehow you are going to compete with folks with more experience, more credentials, and the like, while at the same time trying to learn to run a small business on your own. There's a reason few people go this route.

 

[Sneezing]

A GP will always be better trained than a PA or NP. Now, don't forget there are NP's out there with full autonomy in private practice. I would honestly rather see a GP. People are board certified only because insurance is "forcing" it. Board certification isn't meant to be another licensing exam. It is meant to be an optional mark, not required.

If you are a GP you will essentially have to take cash. The system will not currently let you play ball, and it will be highly unlikely you will be able to get any hospital privileges. However, doing outpatient only office work you should be able to do just fine. Make sure you post your fee schedule up. Cash upfront. People without insurance, those with high deductible health savings accounts, and those who seek you out for your bedside manner will pay.

Liability insurance is also optional. It isn't a requirement. Let your patients know up front. But if you show you can actually communicate with your patients and spend the time with them you will be busy. The argument you frequently hear for people seeing an NP over a physician, is that they spend more time with them. People don't want to feel they are in the cog of a machine.

 

[ShyRem]

Of course, this means you have to pass all levels of your boards. And still there are states you will be unable to get a license if you have multiple attempts on levels - some states state only 5 attempts max for all board levels together. some state no more than 3 attempts per level. And you have to COMPLETE an intern year - not just 10 months of an intern year.

 

[PostCall]

A GP will always be better trained than a PA or NP. Now, don't forget there are NP's out there with full autonomy in private practice. I would honestly rather see a GP. People are board certified only because insurance is "forcing" it. Board certification isn't meant to be another licensing exam. It is meant to be an optional mark, not required.

If you are a GP you will essentially have to take cash. The system will not currently let you play ball, and it will be highly unlikely you will be able to get any hospital privileges.

it's amazing that a medical degree + an internship means you are unqualified for anything...except for more training. actually, you can do 2 years of a 3 year IM or FM residency and you are still considered unqualified. but that final year somehow makes you completely and unquestionably qualified. my friends and relatives in other countries can EASILY work what they call "locum" with only an internship and make real good money. in fact some of them who don't want to/can't get into advanced training work exclusively locum their entire career and make bank. there really should be a system in place for those who have a medical degree and completed at least an internship to be able to work as a doctor in a stable manner, instead of being treated like second-class entities who are lucky to get whatever they can get. meanwhile a PA/NP with half the knowledge and training is considered qualified to do the work that a DOCTOR who has also done an internship is told they aren't.

 

[Gastrapathy]

Its not just length of time, its that you've completed a course of study with adequate performance.

OP, there are occupational medicine-type clinics that will let you do insurance/injury physicals and acute-care clinics that will employ people who are licensed but have no further training.

Or you could put an ad in the paper for medical marijuana evals.

 

[NotAProgDirector]

I believe the OP is an international grad. Most states require that IMG's have 3 years of training to have a license. Some allow 2 years. The only states that seem to allow 1 year for IMG's are Wisconsin and Wyoming, and possibly Puerto Rico. The FSMB's site summarizes it all.

 

[Arcan57]

it's amazing that a medical degree + an internship means you are unqualified for anything...except for more training. actually, you can do 2 years of a 3 year IM or FM residency and you are still considered unqualified. but that final year somehow makes you completely and unquestionably qualified. my friends and relatives in other countries can EASILY work what they call "locum" with only an internship and make real good money. in fact some of them who don't want to/can't get into advanced training work exclusively locum their entire career and make bank. there really should be a system in place for those who have a medical degree and completed at least an internship to be able to work as a doctor in a stable manner, instead of being treated like second-class entities who are lucky to get whatever they can get. meanwhile a PA/NP with half the knowledge and training is considered qualified to do the work that a DOCTOR who has also done an internship is told they aren't.

Medicine is a vast field and the truth is that medical degree+internship is not adequate training to be an independent practioner, especially if you are advertising yourself as an MD. And while it may suck for the minority of doctors that can't finish a residency, making residency training de facto helps protect the public from unqualified physicians.

 

[PostCall]

Medicine is a vast field and the truth is that medical degree+internship is not adequate training to be an independent practioner, especially if you are advertising yourself as an MD. And while it may suck for the minority of doctors that can't finish a residency, making residency training de facto helps protect the public from unqualified physicians.

what you said is exactly the party line used to justify not letting anyone who hasn't completed a full residency work as a doctor. but let's talk sensible here. just as an example...i know of a PGY5 surgery resident was let go 6 months before the end of his residency. that makes him "unqualified" because technically he hasn't finished a full residency. but 6 more months and he would have been deemed totally qualified. do you honestly think those next 6 months would have made him qualified but the preceding 4.5 years makes him unqualified? not to mention in other countries (europe) as i said you can EASILY work as a locum with just an internship or internship + 1 more house officer year. in fact doctors make a career out of it..."career medical officer" or CMO as they call them. is medicine here so much more complicated or "vast" as you put it than in other industrialized western countries that you're unqualified unless you have completed your ENTIRE residency....not a month, week, or day less?

it's not an issue of being qualified as much as it's about crossing our t's, dotting our i's, and making sure all the boxes are ticked for medicolegal reasons. cuz it would almost be a slam dunk victory if the plantiff's lawyer asked the doctor on the stand "so doctor, can you tell the jury why you didn't complete your ENTIRE residency training?" or "so doctor, can you tell the jury why you're not board certified in the specialty that you practice?" it's not so much about "protecting the public" as it is about legal liability.

 

[Law2Doc]

what you said is exactly the party line used to justify not letting anyone who hasn't completed a full residency work as a doctor. but let's talk sensible here. just as an example...i know of a PGY5 surgery resident was let go 6 months before the end of his residency. that makes him "unqualified" because technically he hasn't finished a full residency. but 6 more months and he would have been deemed totally qualified. do you honestly think those next 6 months would have made him qualified but the preceding 4.5 years makes him unqualified? ...

Um, even if we buy into your argument that a PGY-4.5 should be reasonably qualified to go out and practice, that doesn't really bolster your argument that a PGY-1 would be. I think we all agree that there is a point where someone becomes qualified to function autonomously as a GP, and most of us (as well as the insurance industry) agree it is some number of years after internship. It's not a "party line" issue, it's common sense. You know a little bit after internship. Just enough to be really dangerous. But could you pull the average intern out after first year and throw them into a GP practice and expect their patients to be as well cared for as the typical post-residency doc does? Of course not. There is a reason for the multiple years of training. It's not like you learn what you need to know in first year and that the subsequent 2+ years are simply a rehash. In fact you barely make a dent in what you need to know in the first year. You learn some of the basics, and that's it. With more training you will learn more of what you need to know, but you don't have it down at the completion of the PGY-1 year, nor are you expected to. If you could be adequately trained in a shorter period of time, believe me, many folks would push for that -- this would alleviate a lot of the physician shortage issues. But poorly trained doctors don't really help things and the consensus is that that's what you get if you eliminate the latter 2+ years of residency training. I'm not sure why this concept is hard to fathom, or why you think it's a "party line" that folks aren't achieving in 1 year that which 3+ years is alotted.

 

[turquoiseblue]

I appreciate all the responses giving insight into my question. I don't doubt that a PGY1 doesn't know much as compared to a more senior PGY level who may also be board eligible or board certified, but still a PGY1 level can still potentially start up a practice regardless as a GP or urgent care at least. Personally, I'd be scared to just go out there and practice myself. I don't know if I know enough from just a PGY1 all by myself. I know i have a lot to learn. I'd wonder if one could start a partnership with a BE/BC person that could help the PGY1 until they know the ropes (maybe take a few years as if it were residency). I just wonder how others have done this and if someone more senior helped them part of the way. Maybe they already knew their stuff from being in a previous residency in their own country??

 

[PostCall]

Um, even if we buy into your argument that a PGY-4.5 should be reasonably qualified to go out and practice, that doesn't really bolster your argument that a PGY-1 would be. I think we all agree that there is a point where someone becomes qualified to function autonomously as a GP, and most of us (as well as the insurance industry) agree it is some number of years after internship. It's not a "party line" issue, it's common sense. You know a little bit after internship. Just enough to be really dangerous. But could you pull the average intern out after first year and throw them into a GP practice and expect their patients to be as well cared for as the typical post-residency doc does? Of course not. There is a reason for the multiple years of training. It's not like you learn what you need to know in first year and that the subsequent 2+ years are simply a rehash. In fact you barely make a dent in what you need to know in the first year. You learn some of the basics, and that's it. With more training you will learn more of what you need to know, but you don't have it down at the completion of the PGY-1 year, nor are you expected to. If you could be adequately trained in a shorter period of time, believe me, many folks would push for that -- this would alleviate a lot of the physician shortage issues. But poorly trained doctors don't really help things and the consensus is that that's what you get if you eliminate the latter 2+ years of residency training. I'm not sure why this concept is hard to fathom, or why you think it's a "party line" that folks aren't achieving in 1 year that which 3+ years is alotted.

except as i mentioned for the fact that in other western nations you can work as a doctor after an internship or internship+1 house officer year, and they don't make it so difficult to do so or make you out to be "unqualified". the main difference is here we're way more lawsuit happy so everybody has to be properly "credentialed" and everytime you so much as talk to a patient you have to "document it", etc. i hope you don't actually believe all that is for the "protection of the public" as much as it is for liability. if it was indeed about the "protection of the public" then they'd never have a resident independently covering patients in the middle of the night like we know happens all the time while the attending is tucked away sound asleep at his house...cuz you know they're not "qualified" until they've finished the last day of their residency.

 

[turquoiseblue]

except as i mentioned for the fact that in other western nations you can work as a doctor after an internship or internship+1 house officer year, and they don't make it so difficult to do so or make you out to be "unqualified". the main difference is here we're way more lawsuit happy so everybody has to be properly "credentialed" and everytime you so much as talk to a patient you have to "document it", etc. i hope you don't actually believe all that is for the "protection of the public" as much as it is for liability. if it was indeed about the "protection of the public" then they'd never have a resident independently covering patients in the middle of the night like we know happens all the time while the attending is tucked away sound asleep at his house...cuz you know they're not "qualified" until they've finished the last day of their residency.

I agree that the US residency is way more rigorous than even overseas, and usually the 1st year is the worst in terms of busy-ness...in IM or maybe even FP in 2nd or 3rd year you just watch over your residents cover the floors like 'madpeople', you help em just a bit, come in late, go home early before the 1st years, and the rest is a breeze--or at least that is what I saw in my program.

I also agree that in other countries residency requirements are much more lax and doctors are trusted more, don't see red flags as much....or at least so it appears. On the other hand, docs in other countries are paid less.

With too much litigation though, the whole system becomes a bunch of porcupines pricking each other all day getting nothing done and causing massive bleeding to all parties (so to speak), so there should be a limit to the finger pointing (aka red flags, blame games, paranoia, etc).

 

[Arcan57]

except as i mentioned for the fact that in other western nations you can work as a doctor after an internship or internship+1 house officer year, and they don't make it so difficult to do so or make you out to be "unqualified". the main difference is here we're way more lawsuit happy so everybody has to be properly "credentialed" and everytime you so much as talk to a patient you have to "document it", etc. i hope you don't actually believe all that is for the "protection of the public" as much as it is for liability. if it was indeed about the "protection of the public" then they'd never have a resident independently covering patients in the middle of the night like we know happens all the time while the attending is tucked away sound asleep at his house...cuz you know they're not "qualified" until they've finished the last day of their residency.

From your prior post, if a PGY-5 surgeon is dismissed prior to graduation, then that means they were not fit to practice surgery independently. While you can argue that they shouldn't have been allowed to progress that far, clearly the consensus was that the resident would have been dangerous as an independently practicing surgeon.

Being an attending and the level of responsibility that comes with it is a very different experience from being a resident. Many of the moderators and senior members of the board have remarked on the transition from resident to attending. I've never once seen a post saying they felt overqualified or wish they had less experience starting out as an attending.

You have argued for both a return of the GP as well as wishing for an apprentice system. The current system exists because both of those systems failed to consistently produce qualified doctors. Regarding apprenticeship, if you think residency is malignant, imagine your work conditions without perks like the 80-hr work week restriction, 1 day per week off, and no limit on shift length. Then toss in a mentor that bears no medicolegal responsibility for what you do.

 

[Winged Scapula]

From your prior post, if a PGY-5 surgeon is dismissed prior to graduation, then that means they were not fit to practice surgery independently. While you can argue that they shouldn't have been allowed to progress that far, clearly the consensus was that the resident would have been dangerous as an independently practicing surgeon.

That may not be the case. Most surgical residencies would terminate someone much much earlier if they felt that the resident was dangerous. While I do not know the situation with PostCall's friend, a PGY-5 here was let go with less than 6 months of residency because of non-surgical/knowledge/skill related issues. I'm sure most of you heard about the photo taken in the OR with a cell phone. Obviously he had some judgement issues but his program had little choice once it was public knowledge. This is not a case of being dangerous to independently practice.

Being an attending and the level of responsibility that comes with it is a very different experience from being a resident. Many of the moderators and senior members of the board have remarked on the transition from resident to attending. I've never once seen a post saying they felt overqualified or wish they had less experience starting out as an attending.

Absolutely agree. At times I wish training had been longer, but I tell myself there was no way I'd be able to see everything I've come across in my few short years of practice during residency. I never felt like I was overtrained...I know quite a few surgical residents in the forums here feel "ready" for practice but I'm sure once they actually get out "there", they will change their tune.

I appreciate all the responses giving insight into my question. I don't doubt that a PGY1 doesn't know much as compared to a more senior PGY level who may also be board eligible or board certified, but still a PGY1 level can still potentially start up a practice regardless as a GP or urgent care at least. Personally, I'd be scared to just go out there and practice myself. I don't know if I know enough from just a PGY1 all by myself. I know i have a lot to learn. I'd wonder if one could start a partnership with a BE/BC person that could help the PGY1 until they know the ropes (maybe take a few years as if it were residency). I just wonder how others have done this and if someone more senior helped them part of the way. Maybe they already knew their stuff from being in a previous residency in their own country??

I personally would not feel comfortable doing that (ie, taking someone on as a partner without having completed training) at least not as a partner. Once you become business partners, each becomes responsible for the other. My partner and I had to purchase a separate malpractice rider to cover ourselves in case the practice was sued on the basis of what the other did. Being partners with someone without full training opens one up to liability. Even as an employee, I'd still be responsible for you, but the liability is less. Perhaps this is an avenue for you, but in a lower litiginous field.

 

[PostCall]

From your prior post, if a PGY-5 surgeon is dismissed prior to graduation, then that means they were not fit to practice surgery independently. While you can argue that they shouldn't have been allowed to progress that far, clearly the consensus was that the resident would have been dangerous as an independently practicing surgeon.

you can state so surely, without knowing the circumstances, the reason he was dismissed conveniently at the 6 month mark before finishing residency was because as you put it "he was not fit to practice surgery independently"? people get railroaded all the time in this profession. all it takes is for one attending to take a disliking to a powerless resident, even for reasons other than competency, and that resident is finished if the attending wants him to be. but they can always write it off with a convenient cover story of it being about "competency", or "protecting the public", or the ultimate irrefutable magic bullet: "unprofessional conduct". come on man, stop talking like we're still green premeds who think doctors are nothing less than completely moral and hospital politics has nothing to do with who is allowed to finish residency and who isn't.

Being an attending and the level of responsibility that comes with it is a very different experience from being a resident. Many of the moderators and senior members of the board have remarked on the transition from resident to attending. I've never once seen a post saying they felt overqualified or wish they had less experience starting out as an attending.

but again, we let those apparently "unqualified" residents act as defacto attendings unsupervised at night when the qualified attending is home asleep. if they're still unqualified what are they doing acting independently late at night while the attending is miles away tucked in bed? if you're going to bring up the "protecting of the public" bit then shouldn't it be the attending there at 3 a.m. taking care of those patients or at least directly supervising the unqualified resident's decisions instead of the unqualified resident doing so independently on his own?

 

[Sneezing]

If people are so against the concept of a GP pursuing their legal right to practice medicine, why aren't you just as vohemently up in arms against NPs, DNPs, prescribing psychologists, and even PAs? It just doesn't compute.

Somehow going through the gauntlet of medical school and an intern year isn't as good as someone who had lower credentials going through a lower quality, and far shorter program to practice medicine? Really?

A GP will have a healthy respect for the vast field of medicine and recognize more readily when they are over their heads.

 

[Arcan57]

I did see a PGY-5 surgery resident dismissed for reasons of clinical competency, so I probably do everestimate how frequently that happens. "Unprofessional conduct" can cause you to lose your license (and thus livelihood) as an attending, so I'm not sure why you think residents should be immune.

Postcall, you feel the attending should be the one making medical decisions at 3am. You've stated that in multiple posts. So you don't feel confident enough in your physical exam and clinical skills to make decisions without an attending at the bedside (versus calling them at home when you need help). But you would feel comfortable being their sole provider if the patient was paying you? That's not internally consistent.

Sneezing, I object to undertrained MDs in private practice for two reasons. 1) They have the same degree that I do (something midlevels cannot claim) but have thousands of fewer hours of training. Clinically incompetent MDs tarnish our reputation. Failure to police ourselves tends to result in punitive or draconian regulations from government organizations.

2) I don't think that a GP would be more likely then a NP or PA-C to recognize that they're in over their heads. The vast majority of midlevels are very careful (sometimes frustratingly so) about staying within their area of comfort. Many PGY-2s overestimate their knowledge base, and are far more certain of the diagnosis/treatment plan than is warranted.

 

[PostCall]

So you don't feel confident enough in your physical exam and clinical skills to make decisions without an attending at the bedside (versus calling them at home when you need help). But you would feel comfortable being their sole provider if the patient was paying you? That's not internally consistent.

that's not what i was saying. more that it's kind of hypocritical to say someone who hasn't finished a full residency is "unqualified" but we nevertheless let them practice independently at times when it is inconvenient for the qualified attending to do so (middle of the night). not to mention these so called "unqualified" physicians (according to our definition) practice independently in other first world countries and i haven't heard things falling apart over there because of it.

 

[Arcan57]

You've missed my point about 3am patient care. YOU ARE NOT PRACTICING INDEPENDENTLY AS A RESIDENT. Help is a phone call away, either to your senior or to your attending. And even if you never call, not having that option changes things fundamentally.

Regarding attending inconvenience, teaching residents is incovenient from a time/money standpoint. As an attending, it is almost always easier for me to see a patient then it is to staff a patient the resident has seen. Even the convenience of having them write orders/document is offset by having to fix/clarify said orders or review the documentation for inaccuracies. The hospitalists where I work make far more money and handle inpatient censi much larger then the ward attendings where I trained.

Regarding other countries, becoming a GP is not uncommon secondary to lack of specialty residency spots. The US grad has a better chance of landing a spot in their desired specialty straight out of school. I have no idea what type of job situation is the norm for newly minted GPs in other countries, or how much supervision/mentoring occurs during those early years. America has made a choice regarding its medical system, and what it expects from an MD. The trade off has been that in return for 3-5 years of supervised clinical training, we're allowed almost unfettered freedom in how we practice as attendings. Now there are forces at work against that freedom, but we're still the most unregulated 1st world health care system. And that level of freedom requires additional training.

 

[turquoiseblue]

postcall,

Im sure your pgy 4.5 surgery friend would at least be able to be a GP (not a surgeon) regardless if anyone on here or anywhere else thought he was incompetent IF he is able to get licensed in any one state. But i hear the pay is not good and you have problems, although it is possible to do this. Additionally he is well qualified to practice as a full fledged doctor in many other country with his experience, and his past experience would be looked at in a postitive, not negative, light. Using this experience is allowed in other countries, but not here in the US. he can hopefully get a PGY4 and finish up so he can be a surgeon if that is what he wanted. Different countries, different rules and attitudes. I want change too but i dont see it happening with all these negative attitudes around among collegues. but then again you can always start a petition and talk to congress about it, etc.

 

[ShyRem]

If you want to use different rules, go to those countries. There is a reason why folks from all over the world come to the US for training.

 

[Pilot Doc]

The military sends interns out to practice independently every day. They see healthly people for aches and sniffles. If you wanted to set up that sort of practice, I'd say that's within the scope of someone with a year of training. There are a number of practical hurdles, but you could make a living at it.

 

[captaincrunch]

I personally wouldn't want to see a doctor who was dismissed from their residency and failed to complete it elsewhere. It's not that six additional months confer some kind of special medicine. Most IM and Surgery residents in their last months of training are probably ready to move on and practice (and they're probably doing electives at this point anyway). However, a resident who was terminated is a different story, and that suggests that the person is not ready to practice on their own.

 

[turquoiseblue]

some of you should read the book "complications, a surgeons's notes on an imperfect science" by atul gawande...the guy graduated from Harvard and was a resident in Boston.....talks about his mistakes and it is hilarious in some parts talking how he couldn't get a central line in for so long, etc....and yet reminds us all of how fallable and imperfectly human doctors are....i dont know how some of you may react to his mistakes you may think he's a complete idiot, but he still made it regardless. so don't act like you never made mistakes in residency! you know you did! everyone did--its how you learn and how you become a better doctor!

 

[PostCall]

You've missed my point about 3am patient care. YOU ARE NOT PRACTICING INDEPENDENTLY AS A RESIDENT. Help is a phone call away, either to your senior or to your attending. And even if you never call, not having that option changes things fundamentally.

wouldn't a resident calling a more senior resident be one unqualified doctor calling another unqualified doctor? given that neither one of them has finished residency to make them qualified. the only proper course of action would be to run every single decision made by these unqaulified doctors through and approved by an attending before they are carried out...otherwise you are letting unqualified doctors practice independently.

you can't have it both ways where you claim they are unqualified to practice independently...but then turn around and let them do it anyway because they have the option to phone a friend. besides didn't you say how these unqualified residents overestimate their knowledge base? so how can you be certain that they're going to call you anyway?

 

[captaincrunch]

some of you should read the book "complications, a surgeons's notes on an imperfect science" by atul gawande...the guy graduated from Harvard and was a resident in Boston.....talks about his mistakes and it is hilarious in some parts talking how he couldn't get a central line in for so long, etc....and yet reminds us all of how fallable and imperfectly human doctors are....i dont know how some of you may react to his mistakes you may think he's a complete idiot, but he still made it regardless. so don't act like you never made mistakes in residency! you know you did! everyone did--its how you learn and how you become a better doctor!

I don't think you can equate failing out of a residency to Atul Gawande's admission of making mistakes a a resident (and you're right: Complications is an excellent book). You're also right that every resident makes mistakes, and that's part of the learning process. Others have correctly pointed out that sometimes supervision is inadequate (though a senior resident is a licensed physician) and that ultimate responsibility lies with the attending, not the intern.

However, these are not excuses that can be used to absolve every resident who is fired from a residency program. Unless we're arguing that every single doctor is excellent and should be allowed to practice no-questions-asked, then there has to be some limit to who we allow to practice in our field. I know far too many incompetent doctors who are fully board certified to start allowing those who aren't to start practicing.

Edit: To answer your original question, though, I think your options would be limited. You could try working on your own, but I think this would be both dangerous and unlikely to be profitable as insurance companies will not want to contract with you. Malpractice insurance would be hard to come by. Similarly, hospital based jobs would be difficult. Most credentialing committees probably wouldn't accept you and I can tell you that my own hospitalist group (I know my profile says I'm a resident still), as rejected people for a lot less. I've never heard of a "line service," but I don't think you would get credentialed for that either. Working abroad is also likely out, as most countries vet prospective doctors and European countries require you to complete their own training. If you didn't do well in residency, I don't think doing in German is going to make it easier. I think you might be underestimating the damage that not completing a resident can have on your career. As someone pointed out, disability exams do not require board certification, and in fact are common jobs for residents to take. This might be your only realistic option. Other than that, you're looking at non-clinical careers. But remember, finance jobs, expert witness jobs, consulting, etc require a good educational pedigree. These might not be easy jobs to come by either.

 

[tncekm]

If people are so against the concept of a GP pursuing their legal right to practice medicine, why aren't you just as vohemently up in arms against NPs, DNPs, prescribing psychologists, and even PAs? It just doesn't compute.

I'm sorry, but can you please refrain from pointing out the elephant in the room? It disturbs people.

I'm gonna toss this response to your question out there, but also acknowledge that I have zero experience from which to base this other than my knowledge of "human nature": (1) all doctors must be thoroughly hazed for the sake of tradition (2) all nurses must be thoroughly appeased for fear of their numbers

Edit: I'm not arguing to let MD's practice after an intern year, I'm simply doing my part to highlight the obvious inconsistency.

 

[Law2Doc]

wouldn't a resident calling a more senior resident be one unqualified doctor calling another unqualified doctor? given that neither one of them has finished residency to make them qualified. the only proper course of action would be to run every single decision made by these unqaulified doctors through and approved by an attending before they are carried out...otherwise you are letting unqualified doctors practice independently.

you can't have it both ways where you claim they are unqualified to practice independently...but then turn around and let them do it anyway because they have the option to phone a friend. besides didn't you say how these unqualified residents overestimate their knowledge base? so how can you be certain that they're going to call you anyway?

Um no. You call your senior because he has more experience. If the senior is stumped, they can get on the phone and call the attending. The point of the prior poster is that neither is functioning "independently". A support system is in place. This is how training works in any field -- you learn how to do it first by being shown, and thereafter with a safety net, they let you try your hand at it first, while you are on call. If you get into trouble you call someone with more experience. If the senior gets into trouble, he too is still training with a safety net, and calls the attending. This system allows the newbies to learn by trying, and also lets the attending sleep until he's really needed. It avoids total hand-holding, but at the same time realizes that these folks in the hospital at night are not 100% functioning GPs able to tackle every problem on their own. It's a pretty ingenious training system actually. Any country that scoffs at this and says -- you did a year of training you are ready to function without a net, is one that does not protect its patients very well, and likely this is because they don't have the litigiousness of the US which hold practitioners feet to the fire if they do something stupid right out of training. I think the consensus in this country is that you train your doctors over a number of years so you don't end up having them damaging patients and being sued into oblivion. In other countries the lawsuits aren't such a threat, and so the training doesn't have to be as thorough. That doesn't make the other countries system better. Might be better for you personally if you have a vested interest in finding a job out of residency, but not better for the US society. Things are set up for reasons, and this one happens to have been set up for a pretty legit reason.

 

[Law2Doc]

I'm sorry, but can you please refrain from pointing out the elephant in the room? It disturbs people.

I'm gonna toss this response to your question out there, but also acknowledge that I have zero experience from which to base this other than my knowledge of "human nature": (1) all doctors must be thoroughly hazed for the sake of tradition (2) all nurses must be thoroughly appeased for fear of their numbers

Edit: I'm not arguing to let MD's practice after an intern year, I'm simply doing my part to highlight the obvious inconsistency.

I think it's a "two wrongs don't make a right" argument, actually. Those on here who think the current residency system is appropriate also think that NPs shouldn't be "practicing medicine" without having jumped through similar hoops. You don't fix that by cutting down residency and throwing unprepared doctors into the mix. You fix that by political action.

Lawyers had similar issues with paralegals, realtors, and accountants all wanting to do various legal functions over the years. Lawyers went to court, went to congress, made a stink about unlicensed individuals practicing law without a law license, and cut all these groups off at the knees. Medicine seems to be sitting in a corner, not doing anything. It seems much easier to define what constitutes practicing medicine than law and yet we don't seem to have a problem with non-physicians practicing medicine without a medical license. I don't know why this profession is wimping out, but it has.

But the answer is not to flood the market with unqualified doctors to compete with NPs. The answer is to combat the rights of NPs to hold themselves out as doctors and to dispense medical care without a medical license. Two wrongs doesn't make a right. It's not an elephant in the room for this particular argument. It's a different issue altogether, one that medicine should address before it's too late. (And it might be as many folks in the public are happy with their NP "doctor" and don't realize they are not getting a physician's trainings worth of knowledge from this individual). In a time of healthcare shortage allowing folks to jump in and provide service to the underserved is expected, but if nobody is minding the gates, too much territory is going to be lost, irretrievably.

 

[Winged Scapula]

Most IM and Surgery residents in their last months of training are probably ready to move on and practice (and they're probably doing electives at this point anyway).

FYI: I cannot speak for IM residents, but the American Board of Surgery does not allow electives during the last two years of residency for general surgery residency.

 

[Arcan57]

wouldn't a resident calling a more senior resident be one unqualified doctor calling another unqualified doctor? given that neither one of them has finished residency to make them qualified. the only proper course of action would be to run every single decision made by these unqaulified doctors through and approved by an attending before they are carried out...otherwise you are letting unqualified doctors practice independently.

you can't have it both ways where you claim they are unqualified to practice independently...but then turn around and let them do it anyway because they have the option to phone a friend. besides didn't you say how these unqualified residents overestimate their knowledge base? so how can you be certain that they're going to call you anyway?

Lawdoc has already done an excellent job of addressing this post. If you're out in private practice and don't know what to do, usually you'll consult/refer to a specialist. The time frame for getting an answer back is going to be in hours (rarely) and more likely days-weeks depending on the workload of the specialist. In residency, the time frame for hearing back from your attending should be in minutes. And all of the events that happened on night float will be reviewed by an attending in the am. If you claim to not understand that these positions are fundamentally different, I'm going to have to assume you are just trolling and would request that you return to under your bridge.

 

[Arcan57]

FYI: I cannot speak for IM residents, but the American Board of Surgery does not allow electives during the last two years of residency for general surgery residency.

That's interesting. Do you know off-hand the reason why? Also, when in surgical residency do you apply for a fellowship? Thanks.

 

[Winged Scapula]

That's interesting. Do you know off-hand the reason why?

I cannot speak for the board but I suspect it has to do with the requirements to be Chief resident for 12 months and to complete the board requirements of advanced, progressive supervised training in the core elements of general surgery. Generally residents on electives are not serving as Chief residents, nor are they allowed progressive training. You can petition the board for certain electives that may be approved as long as they are one of the core elements (ie, one of my senior residents got approved to do Surg Onc in Ireland, but that's a Core Element...I recall it being a real PITA to get approval; for some reason he couldn't do it until 4th year) but this can be difficult because of the requirement that all of your training during the final two clinical years is at the same program; "away" electives don't generally fulfill that requirement.

Also, when in surgical residency do you apply for a fellowship? Thanks.

Depends on the fellowship. Some are during the 4th clinical year, and some during the fall of the 5th clinical year.

 

[tncekm]

I think it's a "two wrongs don't make a right" argument, actually.

You're right on all counts, IMHO. Except, for the elephant in the room comment. The elephant in the room was the obvious inconsistency in being vehemently opposed to letting PGY1's practice, yet be more than willing to let NP's have almost full autonomy nationwide... unless I'm using the term in appropriately for some reason. Meh, w/e... like you said, we need to act. But, I'm very concerned because it doesn't seem that physicians or med students have the heart to go through with it. They think we need to play the infinite appeaser, and just be happy with "saving lives". Of course, it's wonderful we get to make such a positive impact on people's lives, but my personal opinion is that it's both dangerous to not address issues of physician "turf" and "compensation", but also naive to think that it's not going to matter to practitioners and/or patients in the future.

 

[Law2Doc]

You're right on all counts, IMHO. Except, for the elephant in the room comment. The elephant in the room was the obvious inconsistency in being vehemently opposed to letting PGY1's practice, yet be more than willing to let NP's have almost full autonomy nationwide... ,.

I'm saying that's not an elephant in the room, it's an elephant in a different room. The people who are opposed to letting PGY1s practice because they lack experience are also opposed to letting NPs have full autonomy. It's not like we're okay with one but not the other, ie hypocrites. These are two separate arguments and I think most of us aren't inconsistent on these. The profession needs to act on the latter. They don't solve this by backing down on the former.

 

[tncekm]

It's not like we're okay with one but not the other, ie hypocrites.

I think many people are being hypocritical. Many physicians want NP's to have near-full autonomy so they can make cash off of them without ever having to be present. I.e. they let their personal greed affect patient care and profession as a whole. So, it's physicians who are giving NP's essentially full autonomy and then telling PGY-1's to keep away b/c they're "dangerous". If physicians made a big stink about NP autonomy, it'd sure as hell get addressed. But, they don't... You've got the "yayz, my NP makes me moneyz" crowd, and the "oh noez, whoez is me" crowd. Big problem.

 

[turquoiseblue]

Does the new healthcare law prevent doctors from accepting cash only? if so, Then the gp option would no longer b possible. If everyones insured how can anyone need cash only physicians?

 

[Law2Doc]

I think many people are being hypocritical. Many physicians want NP's to have near-full autonomy so they can make cash off of them without ever having to be present. I.e. they let their personal greed affect patient care and profession as a whole. So, it's physicians who are giving NP's essentially full autonomy and then telling PGY-1's to keep away b/c they're "dangerous". If physicians made a big stink about NP autonomy, it'd sure as hell get addressed. But, they don't... You've got the "yayz, my NP makes me moneyz" crowd, and the "oh noez, whoez is me" crowd. Big problem.

You are not understanding the NP "autonomy" issue. Autonomy is not about job function, it's about supervision requirements. Having NPs work under physicians, like a PA is fine with most professionals. This holds true whether the doctor is there or whether the doctor is a phone call away. What NPs are doing now, however, is going out on their own, and even creating a "doctor of NP" degree, and opening up shops where there is no doctor involved, and they practice medicine, wearing white coats, and calling themselves Dr X. I think that's where most people in medicine feel the autonomy shouldn't exist. But to have an NP working under a doctor much like a paralegal works under a lawyer? No real danger zone. It's still some doctor's license on the line and he can give them as much of a free hand as he feels comfortable, it's still HIM practicing medicine. Not so if an NP sets up shop on his own. Huge difference. The latter has autonomy, the former maybe "feels like" they have autonomy.

 

[tncekm]

Okay, fair enough. It's an elephant in a different room. But, it's still an elephant haha

You are not understanding the NP "autonomy" issue. Autonomy is not about job function, it's about supervision requirements. Having NPs work under physicians, like a PA is fine with most professionals. This holds true whether the doctor is there or whether the doctor is a phone call away. What NPs are doing now, however, is going out on their own, and even creating a "doctor of NP" degree, and opening up shops where there is no doctor involved, and they practice medicine, wearing white coats, and calling themselves Dr X. I think that's where most people in medicine feel the autonomy shouldn't exist. But to have an NP working under a doctor much like a paralegal works under a lawyer? No real danger zone. It's still some doctor's license on the line and he can give them as much of a free hand as he feels comfortable, it's still HIM practicing medicine. Not so if an NP sets up shop on his own. Huge difference. The latter has autonomy, the former maybe "feels like" they have autonomy.

 

[PostCall]

Um no. You call your senior because he has more experience. If the senior is stumped, they can get on the phone and call the attending. The point of the prior poster is that neither is functioning "independently". A support system is in place. This is how training works in any field -- you learn how to do it first by being shown, and thereafter with a safety net, they let you try your hand at it first, while you are on call. If you get into trouble you call someone with more experience. If the senior gets into trouble, he too is still training with a safety net, and calls the attending. This system allows the newbies to learn by trying, and also lets the attending sleep until he's really needed. It avoids total hand-holding, but at the same time realizes that these folks in the hospital at night are not 100% functioning GPs able to tackle every problem on their own. It's a pretty ingenious training system actually. Any country that scoffs at this and says -- you did a year of training you are ready to function without a net, is one that does not protect its patients very well, and likely this is because they don't have the litigiousness of the US which hold practitioners feet to the fire if they do something stupid right out of training. I think the consensus in this country is that you train your doctors over a number of years so you don't end up having them damaging patients and being sued into oblivion. In other countries the lawsuits aren't such a threat, and so the training doesn't have to be as thorough. That doesn't make the other countries system better. Might be better for you personally if you have a vested interest in finding a job out of residency, but not better for the US society. Things are set up for reasons, and this one happens to have been set up for a pretty legit reason.

the point is every time a junior or senior resident (who are both apparently "unqualified" because neither one has finished residency) makes a decision without getting it approved by an attending...then they are practicing independently. as i said you guys want it both ways...for them to practice independently when it's convenient but then trying to pass it off as they aren't really practicing independently because they have the option to call a friend. when anybody who has spent even a night on call knows that residents make and carry out decisions all the time without ever calling an attending.

 

[PostCall]

The military sends interns out to practice independently every day. They see healthly people for aches and sniffles. If you wanted to set up that sort of practice, I'd say that's within the scope of someone with a year of training. There are a number of practical hurdles, but you could make a living at it.

game. set. match.

 

[Rabbit Hole]

I think it's a "two wrongs don't make a right" argument, actually. Those on here who think the current residency system is appropriate also think that NPs shouldn't be "practicing medicine" without having jumped through similar hoops. You don't fix that by cutting down residency and throwing unprepared doctors into the mix. You fix that by political action.

Lawyers had similar issues with paralegals, realtors, and accountants all wanting to do various legal functions over the years. Lawyers went to court, went to congress, made a stink about unlicensed individuals practicing law without a law license, and cut all these groups off at the knees. Medicine seems to be sitting in a corner, not doing anything. It seems much easier to define what constitutes practicing medicine than law and yet we don't seem to have a problem with non-physicians practicing medicine without a medical license. I don't know why this profession is wimping out, but it has.

A lot of physicians are apathetic or just plain clueless. I'm realizing this more and more everyday. Most know a lot about one thing but know nothing about everything else. Medical students have a one track mind once they get on the medical train it's game over. It's the nature of this profession.. saturated with medical knowledge but lacking in so many other areas like business, law, cooking, politics, etc.

If we were more proactive maybe we would be in a better position to call the shots.. but now, it's like we're at the mercy of the situation that we put ourselves into (by doing nothing, i.e. inactivity). I mean, I hear a lot of complaining, but nothing really gets done because we're too busy complaining. Whereas other groups are organized and pushing policy encroaching on our scope of practice and they know they can do it because they're aware of our lack of prowess in anything outside the medical field.

 

[Sneezing]

NP's, DNP's, prescribing psychologists and a little bit so PA's are the elephant in the room. NP's are expanding the states they have autonomous practice in. Prescribing psychologists just got their third state.

The practice of medicine is being lost. The key argument to all of these groups is based on "underserved" and "not enough physicians." So we have to make a choice.

Do we want a two tiered system of us phsysicians and them?

Or do we want a two tiered system consisting of entirely physicians where there is an army of GPs (drowning out lesser training) and then specialists (including FP and IM)? In this system we all recognize each others training, we all know how to communicate with each other, we all have mutual respect for the hurdles we've endured. In this system it would still be possible for upward movement as a GP into specialties. Or it would be feasible to practice for a few years to pay down loans before they balloon out of control. In this system you know a doctor IS a doctor.

The elephant in the room is the issue. We are arranging deck chairs on this sinking titanic slandering the qualifications of a GP.

 

[Law2Doc]

game. set. match.

Except that numerous things happen in the military that are exceptions to the rules. Or rather they have their own rules, that very clearly don't apply to civilian life. So actually different game, with different rules..

 

[Law2Doc]

NP's, DNP's, prescribing psychologists and a little bit so PA's are the elephant in the room. NP's are expanding the states they have autonomous practice in. Prescribing psychologists just got their third state.

The practice of medicine is being lost. The key argument to all of these groups is based on "underserved" and "not enough physicians." So we have to make a choice.

Do we want a two tiered system of us phsysicians and them?

Or do we want a two tiered system consisting of entirely physicians where there is an army of GPs (drowning out lesser training) and then specialists (including FP and IM)? In this system we all recognize each others training, we all know how to communicate with each other, we all have mutual respect for the hurdles we've endured. In this system it would still be possible for upward movement as a GP into specialties. Or it would be feasible to practice for a few years to pay down loans before they balloon out of control. In this system you know a doctor IS a doctor.

The elephant in the room is the issue. We are arranging deck chairs on this sinking titanic slandering the qualifications of a GP.

Um no, the "solution" to this issue isn't sending out an army of lesser qualified GPs. That's like trying to fix the Titanic by drilling lots of holes in the bottom to let the water out. The way you fix this, is the same way folks in the legal profession fixed it. If your ship is in danger of sinking you start firing torpedos at all the potential attackers. You run to court and sink them. Show judges and congressmen why the practice of medicine should be left to folks with adequate training and education. Sue people for unauthorized practice of medicine. There have to be tons of dead babies and other outrageous mishaps you can parade out to show the travesty of having unqualified folks rendering medical services. What you cannot do (and which the profession seems bent on doing) is assume that the administration and politicians and the insurance lobby, etc are going to come to the right conclusion on their own. They aren't. In their push for healthcare for underserved, they are basically willing to destroy the medical profession to give every person someone in a white coat to take care of them, regardless of qualifications. If doctors don't stand up and say "no, that NP at the minute clinic in your local CVS isn't providing equivalent care as a physician", the public is more than happy to blindly let the politicians push them in this direction. Someone has to show that there are risks to providing medical care without adequate training. If instead you say, the answer is to pump out our own untrained people, then you aren't solving the problem, you are compounding it. I really am astounded that you see this as a viable solution. Arm the torpedos and full speed ahead if you want to fix this. Don't go down and start drilling holes instead.

 

[Law2Doc]

the point is every time a junior or senior resident (who are both apparently "unqualified" because neither one has finished residency) makes a decision without getting it approved by an attending...then they are practicing independently. as i said you guys want it both ways...for them to practice independently when it's convenient but then trying to pass it off as they aren't really practicing independently because they have the option to call a friend. when anybody who has spent even a night on call knows that residents make and carry out decisions all the time without ever calling an attending.

But they are never really making a decision without the attending being a phone call away. And they have to report to the attending the next day on whatever decision they did make and why. And this changes the decision making process more than you seem to realize. So no it's not really independent, any more than riding a bike with training wheels is independent. You might not actually need those training wheels to help you most of the time, but the fact that they are there makes a difference.

 

[Arcan57]

game. set. match.

IF ONLY people with no pathology (ie aches and sniffles) presented, then I don't care who see them. Have you seen the list of conditions that the Walgreens urgent care treats? The vast majority of mothers would be competent to see people for those conditions. It's the 51 yo with chest pain that saw an GP at an urgent care, is sent home, and dies the same day from a saddle PE that needed a well-qualified doctor.

Even if you could guarantee that nobody beyond your skills showed up, do you think a doctor that sees non-sick patients all day is going to "make bank"? Ask an office-based pediatrician (who does see some sick kids) what kind of volume they have to see to make a decent living.

 

[Arcan57]

But they are never really making a decision without the attending being a phone call away. And they have to report to the attending the next day on whatever decision they did make and why. And this changes the decision making process more than you seem to realize. So no it's not really independent, any more than riding a bike with training wheels is independent. You might not actually need those training wheels to help you most of the time, but the fact that they are there makes a difference.

I don't think he's capable of thinking critically about this point. Maybe if he makes it through residency he'll realize the difference.

 

[PostCall]

.