I'm a Family Medicine attending in my 2nd year of practice. Ask me anything

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hsmooth said:
You're welcome! I was going to type up a long reply to your question before the edit, are you still interested in my thoughts on that?
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I am if you don't mind! 🙂
 
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hsmooth said:
Send me a pm with your question!
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I wound up just putting it back. It is as follows.

I work as a patient care technician and sometimes float to inpatient pediatrics. Parents can definitely be overly demanding/condescending/difficult to deal with diplomatically. Is navigating pediatric patients' parents something that gets easier out in practice/with experience? Are some people just better with dealing with parents, like some people are just better with kids, and this is a difficult skill to develop?
 
RespectTheChemistry19 said:
I wound up just putting it back. It is as follows.

I work as a patient care technician and sometimes float to inpatient pediatrics. Parents can definitely be overly demanding/condescending/difficult to deal with diplomatically. Is navigating pediatric patients' parents something that gets easier out in practice/with experience? Are some people just better with dealing with parents, like some people are just better with kids, and this is a difficult skill to develop?
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Sorry it's taken me so long to reply, have had a few things pop up! For everyone else, you can keep posting your questions here too.

I'll simplify your question a bit into how I personally deal with 'difficult patient encounters'. We did take a few classes during residency about this and you end up practicing the techniques you learn.

I've found that a lot of conflict stems from miscommunication, or patients' expectations that don't match reality.

Here are some things I do to try to ease a potentially difficult patient encounter, in no particular order
  1. Introduce myself to all people in the exam room
  2. Sit at the same level as the patients, on a chair. Standing gives the impression that you're in a hurry and don't value their time or share their concern. Try to maintain as much eye contact as possible even though we use laptops for our EMRs.
  3. "I understand you're here for X, but is there anything else (Y) that you're hoping to take care of today?". This will allow us to mutually set an agenda for the visit. If pt has 3 other things on their mind, I can quickly do a triage in my mind and tell them if we can realistically address them this visit, or if we should schedule a follow up visit so that "each problem gets enough time and attention that it deserves".
  4. Give them about 2-4 uninteruppted minutes to tell me about their chief complaint. Some research has shown that a pt can tell you most of the details and information you need within 2 minutes and they can still feel like they've been given adequate time to speak of their concerns.
  5. Summary statements to show you're listening and also to make sure you're understanding what your patient is telling you. "You mentioned that Johnny's been not himself lately, can you explain to me in what ways?"
  6. Patients respond better to empathy rather than sympathy. Empathy statement: "I can see why you're so upset, Johnny is in pain and both you and him probably arent sleeping much". Sympathy statement: " I'm sorry Johnny is feeling this way"
  7. Setting clear boundaries if your patients requests or expectations simply cannot be met, while discussing alternative plans. "I'm not convinced Johnny has ADHD so unfortunately I cannot prescribe him adderall at this time. He would probably respond better to X and Y. However if you are interested in a second opinion I can help arrange a referral for you to meet with Dr. Smith who is an excellent child psychiatrist that can help us with diagnosis and treatment plan"
  8. Finally, sometimes people are still going to get frustrated no matter what you do, and there's nothing else to do besides move on to the next and try to not let it get to you personally.
 
Thank you so much for all your help in letting us know more about health care! As a physician, what would you say is the most difficult thing or obstacle in the way of getting patients the treatment they need?
 
As a physician, what would you say is the most difficult thing or obstacle in the way of getting patients the treatment they need?
You're welcome!

A few things stick out in my mind.
1) The games health insurance companies play.
and
2) Our North American lifestyle.

For instance:
A pre diabetes patient with metabolic syndrome and morbid obesity could really stand to learn about diet and nutrition, yet good luck getting them to speak with a nutritionist because insurance will only cover the costs of a visit if they have full blown diabetes.

A patient with back pain would really benefit from working with a physical therapist to avoid a costly and limited-benefit surgery, yet insurance will only pay for 5 visits and they won't cover "extras" such as ultrasound therapy, dry needling therapy, etc.

Our North American lifestyle has many people working long hours, on changing shifts, with little to minimal time or resources to 'take care of ourselves'. A lot of people can't afford to take 2 hours or a half day off during the middle of the work week to go see their counselor or work with their physical therapist, let alone exercise for 30-45 minutes after they get home from working 14 hours straight.

We get in our car and drive everywhere, and stop at the local convenience store to grab an unhealthy breakfast or dinner on the way to or from work. Because that's probably cheaper and quicker than doing meal planning, going to the market and picking up some fresh organic produce, cooking, and then the dishes / cleanup.

LoveBeingHuman:) said:
Thank you so much for all your help in letting us know more about health care! As a physician, what would you say is the most difficult thing or obstacle in the way of getting patients the treatment they need?
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hsmooth said:
What is your pre tax annual income?
I finished residency 2 years ago and signed on to my job with an 18 month salary guarantee of $220k pretax. I live in a low cost of living area in the midwest, in a slightly smaller town of about 80,000. This salary was about $35k more than if I stayed in the city where I did residency which was a medium to larger city of population 600,000 / 2 million in the greater city region. After my 18 month salary guarantee, my income is mostly based on production / RVUs and to some small degree patient satisfaction scores and quality metrics.

Taking about 8 weeks of vacation this year I figure to earn about $245k. Next year, if I take only 4-6 weeks of vacation I hope to make $300k. I definitely feel this is fair compensation. As a med student, I never really thought I could make this much as a family med doc.

I know some family med docs in my group that make >$300k.

Any things you are thinking about in the future to increase your compensation?
Have multiple streams of income, maybe not necessarily medicine related. Maximize my investments. Decrease extraneous purchases. Rental property? Online blogger? Develop some product?

Practice good medicine, be personable and likeable by your patients, show them you care, and you'll have as busy of a practice as you want. I might try to convince the manager to hire a scribe for me.
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"Only 4-6 weeks of vacation" omg I always am shocked to see people who actually have a life.
As one attending to another--do you feel the money is worth it for being non-specialized and having to deal with whatever comes through the door? Was always curious since I'm exactly the opposite within my career.
 
OrthoTraumaMD said:
"Only 4-6 weeks of vacation" omg I always am shocked to see people who actually have a life.
As one attending to another--do you feel the money is worth it for being non-specialized and having to deal with whatever comes through the door? Was always curious since I'm exactly the opposite within my career.
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Sometimes I do stress myself out with some of the crazy things that walk through the door. Or the infamous "follow up with your PCP" and you literally have no clue what to do next with this patient that probably will never be healthy. It feels like I'm constantly learning about things and reading things that maybe I only saw once before, years ago.

Work life is way better when you have great specialists to "fall back on" when things get hairy or complicated. To tell you the truth when I was a premed and going through med school I never thought they'd pay PCPs this much, so I feel really lucky to be so nicely compensated for a 8-5 'office job'.

You surgeons work too hard though 😉
 
hsmooth said:
Sometimes I do stress myself out with some of the crazy things that walk through the door. Or the infamous "follow up with your PCP" and you literally have no clue what to do next with this patient that probably will never be healthy. It feels like I'm constantly learning about things and reading things that maybe I only saw once before, years ago.

Work life is way better when you have great specialists to "fall back on" when things get hairy or complicated. To tell you the truth when I was a premed and going through med school I never thought they'd pay PCPs this much, so I feel really lucky to be so nicely compensated for a 8-5 'office job'.

You surgeons work too hard though 😉
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Glutton for punishment, haha.
 
I am interested in eventually practicing family medicine in a small midwest town (more like 5,000-20,000). Should I expect pressure/push to include inpatient and/or OB/Gyn in my practice due to the often limited resources at smaller hospitals/healthcare settings? I ask this question assuming you looked at even smaller practice settings in the Midwest. I know you mentioned having 6-8 weeks vacation yearly. Is this something you negotiated for given your interests outside of medicine or is this pretty standard?
 
Have you ever been sued as a FM physician? I understand it's your second year of attending, but do you believe you will get sued in the future?
 
Coltuna said:
I am interested in eventually practicing family medicine in a small midwest town (more like 5,000-20,000). Should I expect pressure/push to include inpatient and/or OB/Gyn in my practice due to the often limited resources at smaller hospitals/healthcare settings? I ask this question assuming you looked at even smaller practice settings in the Midwest. I know you mentioned having 6-8 weeks vacation yearly. Is this something you negotiated for given your interests outside of medicine or is this pretty standard?
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Awesome! It'd probably be location and job dependent on whether they want you to do inpatient or OB. I was looking at a job in a town of 2,000 and it was entirely outpatient FM. There may have been an option to do some prenatal OB care up until first trimester or so, but I wasn't interested in it. In my opinion, you can be selective in FM jobs in smaller midwest towns. Find the perfect fit for what you want to do. Most of those jobs have a bit more challenge attracting physicians for various reasons, so often they're quite flexible.

Most jobs within a medical group usually have 'standard' amount of time off built into their contracts, and usually aren't as negotiable. You can negotiate your hours and which days off, to an extent, but usually not 'more' vacation time. You'd also probably have more room to negotiate other things such as salary, sign on bonus, etc, rather than vacation time. This has just been my own experience, however.
 
DoctHouse said:
Have you ever been sued as a FM physician? I understand it's your second year of attending, but do you believe you will get sued in the future?
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Nope, I have never been sued yet. Statistically speaking, I'll probably see a lawsuit or something like that at least once in my career. It's nice to have malpractice insurance paid for by the medical group, and it's also nice to have a good risk management team. Studies have shown if you have a good rapport with your patients, take time in communicating things, and generally not be a jerk, your odds of getting sued are lower.
 
hsmooth said:
I have a lull in my clinic day, so I'll bump up my thread and answer any other questions you may have!
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Man, I just wanted to say thanks so much for doing this thread and actively answering questions... I've learned so much from reading this thread and I just wanted to share my appreciation.
 
cj_cregg said:
Thanks again so much for answering questions! It's so helpful.

I'm an M2, super interested in family medicine at this point. I'm going to be starting my clerkships in July and family medicine is up first. Any tips on how not to look like an idiot assuming I'll need LORs from some of the FM faculty at some point?
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Awesome! Good to see people interested in primary care.

Here are some tips in no particular order:
- be professional and personable. As an attending, If I'm going to write a good LOR for you it makes it a lot easier to do if I actually like you and know some things about you.
- be on time, try not to look bored. Basically don't be a jerk or d*ck.
- let your attending know at some point that you have an interest in FM. Get to know your attending. Don't be afraid to ask them how they ended up in FM, what they like about it, etc. Be genuinely interested in the specialty
- don't ever turn down a learning opportunity.
- ask for feedback half way through the rotation and at the end of the rotation
- be nice to all staff members, nurses, MAs, PSRs, etc at the clinic site.
- don't be arrogant

If your preceptor doesn't know it's your first clerkship, at some point let them know. Honestly, I don't really expect an M3 on their first rotation to know much so I adjust my expectations accordingly.
 
The places that offered great loan repayment options, are you able to redirect that money? i.e- they offer a 5 year contract for 200k loan repayment but you only have 100k. Are you able to negotiate that remaining 100k into salary/benefits or do you just have to leave it on the table when they find out you have less in loans?
 
YoungDoc25 said:
The places that offered great loan repayment options, are you able to redirect that money? i.e- they offer a 5 year contract for 200k loan repayment but you only have 100k. Are you able to negotiate that remaining 100k into salary/benefits or do you just have to leave it on the table when they find out you have less in loans?
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You can certainly try to negotiate into other benefits. Like a larger non-loan repayment signing bonus, higher guaranteed salary, higher RVU reimbursement rate, etc. It never hurts to ask for things. Worse thing they can say is no.
 
It is so nice of you to post this thread for all of us. A question I have is what is the ratio of children to adults you see?
 
Is there any benefit to getting a sports med fellowship from FM (meaning wouldn't people with sports injuries just go to an ortho doc w/sports med instead)?
Also, at what point in residency or post-residency did you become confident enough to see whatever comes through the door. I imagine that it must be quite difficult to remember such a vast amount of material since you could literally see anything, so do you have to do a lot of reading? Thank you!
 
hsmooth said:
One reason is simple supply and demand economics. Classic "less desirable" or "rural" areas have a harder time recruiting physicians to work there than your typical LAs, NYCs, San Diegos, etc. So they are forced to offer better compensation plans and sign on bonuses. There's enough demand for people to want to live in San Diego for example that they'd take whatever is offered. That's why you'll see some FM jobs along the east or west coast that offer much less, like $160-$180k.
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1) Might not be relevant and potentially silly to ask, but is 40K a noticeable difference in living style? I mean at 160K you're already well above the national avg for an average family household income.

2) How much of your work consists of OMM and would you suggest taking an extra year to learn more about the practices of OMM?
 
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GrignardsReagent said:
Any interesting cases lately?

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Tragic case, fairly young person in their 50's with Marfan Syndrome. Had a dissecting aortic aneurysm we picked up on CT. Got patient down to a medical center that could actually work on it, during the operation it dissected up to the level of the heart. Really sad.
 
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Any advice on what to do about the debt? I'm going to a private school with a high cost of living and I am really interested in primary care.

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CHICK-FIL-A>POPEYES>KFC said:
Is there any benefit to getting a sports med fellowship from FM (meaning wouldn't people with sports injuries just go to an ortho doc w/sports med instead)?
Also, at what point in residency or post-residency did you become confident enough to see whatever comes through the door. I imagine that it must be quite difficult to remember such a vast amount of material since you could literally see anything, so do you have to do a lot of reading? Thank you!
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1) Do a Sports med / fellowship if you want to do exclusive sports med, get into academics, or get in to an orthopedics group to do non-surgical ortho.
If you just want to be comfortable doing major joint injections, casting, splinting, that kind of thing for a regular practice, you can learn that in any good FM residency.

2) You're always going to continuously be learning things. Uptodate and AAFP are still my best friends several times a week. You start getting comfortable with bread and butter FM cases probably around 2nd year of residency. 3rd year residency you feel like you could go out and practice yourself and can't wait to finish. Your first year out in practice you feel like an Intern again and are like, "WHAT AM I DOING??!".
 
Ehwic said:
1) Might not be relevant and potentially silly to ask, but is 40K a noticeable difference in living style? I mean at 160K you're already well above the national avg for an average family household income.

2) How much of your work consists of OMM and would you suggest taking an extra year to learn more about the practices of OMM?
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1) Depends. If you have a lot of loans to pay back, 40K can make a difference for sure. Just remember that once you start jumping tax brackets you get less per dollar earned. So maximize your tax-friendly retirement plans. Now that I'm making six figures I can say that I can afford nicer vacations and material goods but I wouldn't say I'm exponentially happier than when I was a 3rd year resident making $50,000 a year. YMMV.

2) If you feel like you want to go into academics and teach OMM or do research in the area, then go for it. If you just want to incorporate it into your practice, don't take an extra year off to do an OMM fellowship. You can learn enough in your normal DO school curriculum, and just do CME when you're in practice. Don't lose out on a full year's salary as a practicing physician.

I probably do OMM a handful of times per month
 
GrignardsReagent said:
Any advice on what to do about the debt? I'm going to a private school with a high cost of living and I am really interested in primary care.

Sent from my SM-N910T3 using SDN mobile
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Go read the WhiteCoatInvestor's website, and buy his e-book. Live like a resident for a few years after you start working full time. Don't buy a house just because you can, don't buy a BMW or sports car just because you can. Maximize your retirement funds, pay down the highest loans first / refinance to a lower rate. If you can stomach living in a rural area for 3-4 years after residency, you can probably find a job that will pay back up to $250,000 of your loans.
 
Ah thanks for the quick reply. Did you begin with an interest in OMM or was it something that grew on you?

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1. What percentage of your time do you spend treating mental health/psychosocial issues at your practice?

2. Why are general surgery rotations incorporated into family medicine residency? Family medicine seems pretty far removed from surgery compared to other specialties.

Thanks!
 
coffeemycupoftea said:
1. What percentage of your time do you spend treating mental health/psychosocial issues at your practice?

2. Why are general surgery rotations incorporated into family medicine residency? Family medicine seems pretty far removed from surgery compared to other specialties.

Thanks!
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If I see 18 patients in a day, probably at least 5-7 of them have some sort of mental health aspect (anxiety, depression). Throw in a few ADDs as well on top of that.

I suppose the most I learned from general surgery rotations are how to do suturing, learning who is sick / not sick in terms of surgical cases (routine referral vs urgent referral), and general workup.

I don't think the 4am rounding really added anything to my education other than staying humble and appreciating how good life is in an outpatient non surgical setting.
 
cj_cregg said:
This might be a dumb question, but how do you do that?
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- Pick a state you can imagine yourself living in. You're more likely to find higher compensated positions in the midwest or great plains type states. Probably less so in the coastal states.
- google some health systems in the area you may be interested in practicing.
- email the recruiter directly and tell them you have some interest in practicing there.
- recruiter will then probably call you to talk over the phone and figure out what kind of practice you're looking for
- they'll probably mention compensation and salary averages at some point, then you can ask if they offer loan repayment programs.
 
hsmooth said:
- Pick a state you can imagine yourself living in. You're more likely to find higher compensated positions in the midwest or great plains type states. Probably less so in the coastal states.
- google some health systems in the area you may be interested in practicing.
- email the recruiter directly and tell them you have some interest in practicing there.
- recruiter will then probably call you to talk over the phone and figure out what kind of practice you're looking for
- they'll probably mention compensation and salary averages at some point, then you can ask if they offer loan repayment programs.
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I'm a fresh medical graduate, just matched into Family Medicine. I was just browsing forums, and thinking of my pre-med days when I though my average MCATs would hinder my path to pursuing my dreams,hence thought I'd post some motivation for pre-meds...luckily I saw this post by you, and I honestly want to express how much I respect and admire you for taking out your time as an attending to help people in a pre-med forum! Thank you! My biggest fear as I start residency is that I would become a jaded physician. Do you have any advice/input on how you stay so involved and avoid becoming "overworked?"
 
cj_cregg said:
I live in the Midwest and would like to stay here, grew up in a rural area and am fine with living in one, so this seems like a good fit for me. How do the loan repayment programs typically work? Do you lose salary/benefits if you take a loan repayment program? Is this common even in the smaller health systems that are typical of rural areas?

Also, what are your thoughts on the advantages/disadvantages of working for a health system vs a smaller group practice or having your own practice as an FM doc?

Thanks again for your time and advice! Much appreciated.
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You're welcome!

Usually, the medical group will make you stay in the area and work for them for 'x' amount of years. Anything from 3-7 years. The more loan money they give you the longer they'd ask you to stay. There's sometimes a clause where if you break your contract and leave earlier, you just have to pay back the prorated amount of loan money they gave you initially. (i.e you leave halfway through your commitment, you pay back half the loan amount).

Personally I wouldn't take any rural job where you have less benefits than a comparable job in the cities. Most rural jobs will have better salary guarantee though. I've seen that benefits (like retirement plans, health insurance, etc) are pretty similar across the board between medical groups. You still have to compare it though.

I don't have experience with smaller medical groups in rural areas. The places I've looked in to were part of large medical groups that just had satellite clinics in the rural areas. So you get the benefits of being part of a larger 'stable' medical system but just practice in a small clinic that's owned by them.

I don't mind practicing for a health system. It eliminates all the 'business' stressors like hiring people, paying for overhead, etc. Basically clock in, clock out. If your clinic tanks or goes under, they would probably just transfer you to a different clinic site in the region. The downside is that you lose a bit of autonomy in exactly how you want to do things. You would have to follow certain protocols and things like that.
 
studyaholic said:
I'm a fresh medical graduate, just matched into Family Medicine. I was just browsing forums, and thinking of my pre-med days when I though my average MCATs would hinder my path to pursuing my dreams,hence thought I'd post some motivation for pre-meds...luckily I saw this post by you, and I honestly want to express how much I respect and admire you for taking out your time as an attending to help people in a pre-med forum! Thank you! My biggest fear as I start residency is that I would become a jaded physician. Do you have any advice/input on how you stay so involved and avoid becoming "overworked?"
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You're welcome! I'm glad this thread has been a bit helpful.

At some point in your career, *hopefully* you learn that money isn't everything. In fact I will be turning down a job opportunity that will pay me 10% more salary and a six-figure signing bonus, so that I can take my dream job with less hours and some more time to work in policy and administration. With my extra free time I plan also to do some things outside of work, hopefully volunteer within the community. You have to figure out what your passion in life and in medicine is and work towards it. Finances and paying back your student loans are important, but shouldn't be the be-all-end-all. No matter what kind of job you take as a physician, whether you make $160k a year or $500k, if you're smart with your planning, you're going to be able to retire just fine.
 
Hello again Dr.hsmooth, to match FM, is there anything I should be doing during my summers that might help my chances? I'm getting emails about research and trips already from my school and I'm not sure what's the best use of my time would be. Thanks again for your time!
 
popopopop said:
Hello again Dr.hsmooth, to match FM, is there anything I should be doing during my summers that might help my chances? I'm getting emails about research and trips already from my school and I'm not sure what's the best use of my time would be. Thanks again for your time!
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Hi! If you're doing this while already in medical school -- If you actually think you'd enjoy doing those types of things, then do it. If it's of no personal interest to you, just take time off and do something you enjoy.
Matching FM, I'd say it's more important to pass your boards and get the best score you possibly can, and also a lot of it is how well you interview too (personality, interesting to talk to, humble, etc). It's not imperative to do research in med school.
 
You. are. the. man.

Seriously though, thanks a lot for this - it has totally changed my perception of FM. My burning questions, which I'm sure you'd rather PM me the answers to some, are:

which school did you attend?
which residency did you attend?
how many contiguous ranks did you list for FM?
how many other specialties did you rank?
how many interviews did you get invited to / go on?
what kind of med student were you (I know you stated you were never great at exams, but performance in class / general grades)?
what (general range is fine) were your actual COMLEX scores?
what was the single hardest part of the preclinical years for you?
how did you overcome this hardest part?
how did you know what kind of procedures you were interested in before you even started the clinical years (referencing your advice to ask attendings to perform procedures you are interested in learning during derm / ortho / whatever rotations)?
where do you actually practice now (I have tried to piece the clues together and want to say smalltown, Indiana or somewhere like it)?
how many other docs work in your practice (I saw the 1 doc - 2 midlevels - handful others, but wondering if this is literal or ratio)?
what is your post-tax income?
what would you say was the most important preclinical class that helped you during residency?

Again, thanks for taking the time to do this. I have always wanted to do primary care, but the general SDN "doom and gloom" has been pushing me to consider something like pm&r more, so your story is certainly reassuring.
 
Oh yes, I also wanted to say that I once had a conversation (on SDN, no less) with a Canadian doc who said to me "I must admit, though, that in Canada we don't have your profession. So I can only speak about physicians and not osteopaths". 😕😕😕😕😕😕😕
 
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