I love family medicine.....but

[FMD212]

I'm planning applying FM residency for 2012. My future plan is to work as hospitalist 3 days and 2 days outpatient for about 10 yrs then focus on outpatient the remaining of my career. is this possible? and if so how would I fair compare to IM hospitalists as far as skills. in short, which of these do you think i should do to become a great hospitalist?
1. do more inpatient with your elective months in residency
2. do a fellowship for 1 year after #1
3. don't do 1 and 2 but just complete your standar residency training

This is my first post and if this was asked before I'm sorry.

thanks.

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[deleted87716]

Of course it's possible, assuming you can find somebody to allow you to work in a hybrid model. That's how my group does it. Feel free to get in touch with me when you graduate in a few years.

Just do your residency. You don't need a fellowship.

 

[Dillatar]

From what I understand about the position, it would seem that a hospitalist is a lot like an IM doc, yet it would also seem that many of them complete family medicine residencies before entering the profession. Why is this allowed? Is a hospitalist closer to an FM in practice than a IM?

 

[deleted87716]

From what I understand about the position, it would seem that a hospitalist is a lot like an IM doc, yet it would also seem that many of them complete family medicine residencies before entering the profession. Why is this allowed? Is a hospitalist closer to an FM in practice than a IM?

What do you mean, "why is this allowed?" Hospital medicine is nothing like ambulatory medicine, but you learn both in FM as well as IM. There's nothing magical about IM that makes internists better hospitalists than FPs. IM is adult medicine, not hospital medicine. Most of our hosptalists are FPs, and the hospital they practice in has the shortest length-of-stay stats in the entire hospital system. They know what they're doing.

 

[JackADeli]

...know what they're doing.

Agreed. That is generally the key accross all specialties.

 

[lowbudget]

what do you mean, "why is this allowed?" hospital medicine is nothing like ambulatory medicine, but you learn both in fm as well as im. There's nothing magical about im that makes internists better hospitalists than fps. Im is adult medicine, not hospital medicine. Most of our hosptalists are fps, and the hospital they practice in has the shortest length-of-stay stats in the entire hospital system. They know what they're doing.

+1

 

[FMD212]

thanks guys. that's what I thought. I'm not a FM doc yet but really I don't understand how physicians in other fields(like gas, sugery, Rad..etc) feel comfortable calling themselves docs when they can't diagnose simple diseases. even IM docs can't treat kids or deliver a baby. For me I like to be in a field that doesn't limit my medical skills and I found it only FM. I can treat the kid, deliver the baby, see the elderly...etc The other day I asked my brother who is an IM-hospitalist the DD of Kiwasaki and he said sorry I don't deal with kids. I think any doc should be able to diagnose general diseasses in all people, but what can you say medicine is different these days.

The whole reason why I selected FM is that I can deliver/treat my future kid, treat my dad and mom when they become old, and generally have the confidence to answer all medical issues regardless of age and gender. The only field that can give me these is simply FM.

bottomline: I want to be the jack of all trades!!

 

[deleted6669]

long ago all interns had to do rotating internships before specializing.
some DO's still do this(and fewer md's).
kind of a shame. I also agree that anyone with md/do after their name should be able to do "basic medicine".
(some would argue that the jack of all trades would be em as they have to be able to see any acute pt and stabilize them and at least get an appropriate workup started).

 

[notinkansas]

thanks guys. that's what I thought. I'm not a FM doc yet but really I don't understand how physicians in other fields(like gas, sugery, Rad..etc) feel comfortable calling themselves docs when they can't diagnose simple diseases.

bottomline: I want to be the jack of all trades!!

Great that you want to be jack of all trades. But be careful insulting other specialties. I could just as easily say that I don't see how physicians in other fields (like FM) comfortable calling themselves docs when they can't diagnose simple problems like incarcerated vs strangulated hernia. (The story I posted earlier about this occurred in hospital where FM has strong presence and staffs ICU)

It works both ways. Each specialty has it's own area of focus. I would submit that being a jack of all trades also leaves you a master of none. What became simple to me in my surgical residency isn't necessarily simple to you after FM residency, and vice versa. I'm not sure where you think a surgical or anesthesia residency is an appropriate place to learn, say the latest best practice for managing diabetes as a outpatient, or even treating sinusitis. Just like you don't have to learn how to weigh the risks and benefits of a particular operation, what incision or approach is the best for a given patient, or which combination of drugs will provide appropriate anesthesia in a patient with severe COPD, EF of 30%, out of control DM to get them through an emergent operation alive and eventually extubatable.

We put one another down too much in medicine. I think it's wise to become more collaborative, especially in light of the current problems in health care.

 

[JackADeli]

...I don't understand how physicians in other fields(like gas, sugery, Rad..etc) feel comfortable calling themselves docs when they can't diagnose simple diseases. even IM docs can't treat kids or deliver a baby...

For starters.... because they completed a doctorate training program MD/DO. Further, who are you talking about "can't diagnose simple diseases" (rhetorical question). All USA physicians take the same licensing examination which is clinically based on a broad list of simple to complex diseases. There are plenty of community physicians throughout specialties that do treat "simple diseases". I know plenty of community FPs that do not do OB/Gyn and I know plenty of IM physicians that do some OB/Gyn... including deliveries. Some FPs will do c-sxns and some General Surgeons do c-sxns. Your statement is a little self-serving and judgemental to stand back and suggest specialists should not call and/or consider themselves doctors. It just begs the question why you believe as a medical student, going through the same general medical school as all the specialists before and after you, feel you can "define" a real doctor (rhetorical)?

...The whole reason why I selected FM is that I can deliver/treat my future kid, treat my dad and mom when they become old, and generally have the confidence to answer all medical issues regardless of age and gender...

I would not plan my entire career/future on that goal. There are numerous ethical discussions on the whole matter of treating one's own family. There are plenty of children and family members out there that have been "injured" by having a family member provide their medical care.... this includes bad diagnosis, missed diagnosis, poor treatment choices, psychiatric issues, etc..... Be cautious. I think the AMA may have certain position statements on this. I don't know if the AAFP has a position on this.... I would defer to BD.

Great that you want to be jack of all trades. But be careful insulting other specialties...

It works both ways. Each specialty has it's own area of focus...

We put one another down too much in medicine. I think it's wise to become more collaborative, especially in light of the current problems in health care.

Agreed.

 

[deleted87716]

I don't understand how physicians in other fields(like gas, sugery, Rad..etc) feel comfortable calling themselves docs when they can't diagnose simple diseases.

That's pretty insulting, as others have pointed out. I have no problem with the fact that most specialists can't do my job as well as I can any more than I have with the fact that I can't do their job as well as they can.

The whole reason why I selected FM is that I can deliver/treat my future kid, treat my dad and mom when they become old, and generally have the confidence to answer all medical issues regardless of age and gender. The only field that can give me these is simply FM...I want to be the jack of all trades!!

You want to be a generalist. That's what we all enjoy. However, I would caution you against treating friends or family except under unusual and unavoidable circumstances. It may be an ego-stroke, but it's usually a bad idea.

 

[JackADeli]

...I would caution you against treating friends or family except under unusual and unavoidable circumstances...

Does the AAFP and such have any position statements on this matter?

 

[deleted87716]

Does the AAFP and such have any position statements on this matter?

The AMA does: http://www.ama-assn.org/ama/pub/phy...l-ethics/code-medical-ethics/opinion819.shtml

The issue has also been addressed in FPM in the past: http://www.aafp.org/fpm/20000300/ask.html

 

[JackADeli]

The AMA does: http://www.ama-assn.org/ama/pub/phy...l-ethics/code-medical-ethics/opinion819.shtml

The issue has also been addressed in FPM in the past: http://www.aafp.org/fpm/20000300/ask.html

BD, thank you for those links....
I would just add... treating a family friend can actually be "easier" when you are a "specialist". Though I don't endorse or encourage such a practice. This is just an example.... If you are the general surgeon in town, your family member goes to FPs office or ER. On exam +/- imaging, they have an acute appendicitis. You could easily transfer your family member to neighboring hospitals/med ctrs. But, the appendectomy is pretty straightforward. The work-up/diagnosis has been mostly if not completely made by more objective non-family members. It could be the same for symptomatic gallstones or other less "emergent conditions". Again, I do not advocate it, but lines seem less blurred/compromised.

On the otherhand, in a primary care setting, you have to do the primary exam and diagnosis. Are you going to do the Pap-smrs, pelvic exams, rectal exams, breast exams, prenatal, obstetric, etc.... care for your mom, wife, daughter/s, etc.... How about testicular and rectal exams on the male side of your families? Will you do them or "deferr" the exam, possibly missing a diagnosis. Those points/questions (and others) are what the AMA and others are concerned about in treating friends and families.

 

[deleted87716]

treating a family friend can actually be "easier" when you are a "specialist". Though I don't endorse or encourage such a practice. This is just an example.... If you are the general surgeon in town, your family member goes to FPs office or ER. On exam +/- imaging, they have an acute appendicitis. You could easily transfer your family member to neighboring hospitals/med ctrs. But, the appendectomy is pretty straightforward.

There is no difference.

In your example, if you are the only doc in town, it would be reasonable for you to treat a friend or family member. You would, of course, keep a chart on them and otherwise treat them exactly as you would any other patient. The fact that you might be a tad less objective about a loved one remains a potential risk, both for you and the patient. Also, a bad outcome could make for awkward dinner table conversation.

 

[JackADeli]

...You would, of course, keep a chart on them and otherwise treat them exactly as you would any other patient. The fact that you might be a tad less objective about a loved one remains a potential risk, both for you and the patient. Also, a bad outcome could make for awkward dinner table conversation.

Absolutely agree should be avoided at all levels. Definately provide standard of care. Definately remains a risk.

But, I do believe there are some differences... as opposed to "no difference" even if not sufficient to promote the practice. I do believe there are some ~alleviating/mitigating factors when the patient/family member arrives to you through multiple non-family evaluations/referrals. Again, I would much rather send my family member with a symptomatic gallbladder to a neighboring town say 50+ miles away. It's not an emergency. The procedure need not be performed with any urgency. The patient could have their GB removed in six months, plan it around a holliday, etc....

Either way, I think the practice of family/friend provider should be avoided. My point was simply to illustrate there are some differences... not to say you should do it as a subspecialists vs PCP. I think by recognizing the differences/mitigating components to the risk and still recognizing the risk remains even in the face of these mitigating factors is important. Thus, the practice should be avoided.

 

[FMD212]

I'm deeply sorry if I insulted anyone, I had no intention of insulting anyone, perhaps it was poor choice of words. My point was that there should be at least 1 year of general medicine training regardless of what the doctor wants to specialize in. In regards to treating my family, I know that's not the best ethical way and even too safe, and that when dealing with family members that one may not be objective in their skills and rather become somewhat subjective due to emotions. anyways, I have respect for all doctors and all humans regardless of class, race, religion, skills...etc. Thanks for pointing out my faults.

 

[JackADeli]

I'm deeply sorry if I insulted anyone, I had no intention of insulting anyone, perhaps it was poor choice of words...

No worries.... we live and we learn.

...My point was that there should be at least 1 year of general medicine training regardless of what the doctor wants to specialize in....

All doctors do.... it's called medical school. You learn extensively accross the board. Hence, after some period of post-graduate training (depending on the state you train in), all USA licensed physicians take the same standardized USMLE licensing examination. The final steps of the USMLE does not change or focus on one specialty or another.... Everyone has an opinion about what residency should or should not include... The amount of knowledge in medicine continues to grow. I don't think a year of FP or IM or pediatrics or etc... will acomplish any great revolution beyond lengthening training and/or distracting from the training of the given specialty. My board exams in General surgery included plenty on diabetes, heart disease, when not to operate, and medicine from pedes to adults, from urology to neurosurgery.... etc.

 

[cali-ob]

It works both ways. Each specialty has it's own area of focus.......We put one another down too much in medicine. I think it's wise to become more collaborative, especially in light of the current problems in health care.