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

[hsmooth]

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I don’t know if you listen to it or have even heard of it, but there is a cool podcast called Curbsiders. If you don’t know if, it’s a podcast that is run by primary care docs that presents topics using expert interviews directed to primary care docs. It’s pretty interesting.

Anyway, my question is this: on the latest episode, an ID doc talks about how as a primary care doc, it is totally reasonable to manage HIV patients yourself if they are someone you caught on a screening or are otherwise not super complicated. HIV care interests me, but I’m not sure it interests me enough to pull me into ID. Do you know any primary care docs that manage their own HIV patients?

As an aside, he also said that when counseling newly diagnosed HIV patients, he assures them that given the choice between a diagnosis of HIV or DM2, he would pick HIV every time because it’s easier to manage and likelihood of having issues down the line is lower. How do you feel about that?

My physician colleague sees HIV patients as a primary care physician. It's probably about 10-15% of her practice. So you can see as much or as little of it as possible. The other primary care docs in our clinic just refer to her, or to infectious disease.

I'm not sure I could pick which one I'd rather have, DM or HIV... but one of the Infectious Disease docs I know wrote this in a consult for a patient I diagnosed with HIV. "Newly diagnosed HIV, despite high viral load, this will soon be very well controlled". The patient came back feeling so much better. They were reassured that they'd basically be able to carry a normal life with some meds and labs thrown in here and there.

 

[hsmooth]

I'm pretty interested in working with patients with mental health issues, and you mentioned mental health as the first thing that you see most frequently. Do you normally refer these patients to psychiatrists to work with, or continue treating them? Do you feel you normally have the time you need to give them the help that they need? Or do patient volumes make it difficult?

For anxiety and depression, I'm comfortable managing and trying up to 3 or so medications before I would refer to psychiatry. Or if someone comes to me already on some weird psych meds or more than 3 meds, I'll refer to psychiatry. I'll make time for patients that need extra hand holding or attention. So sometimes it's these mental health appointments that might set me back 10 minutes but it's usually worth it. I just make up the 10 minutes somewhere else during the day.

 

[NicMouse64]

I'm thinking of going into IM, but am also curious about FM. What % of patients come in undifferentiated? How often do you get to kinda piece together the puzzle. One of the things that always fascinated me about medicine was using science and a good P exam to come up with that diagnosis that can change a patient's life. I know the percentage is probably rather high of follow ups and HTN/DM pts, but am curious how many pts. fit into the other category.

 

[hsmooth]

I'm thinking of going into IM, but am also curious about FM. What % of patients come in undifferentiated? How often do you get to kinda piece together the puzzle. One of the things that always fascinated me about medicine was using science and a good P exam to come up with that diagnosis that can change a patient's life. I know the percentage is probably rather high of follow ups and HTN/DM pts, but am curious how many pts. fit into the other category.

Probably 30-40% of my patients in an average day come in with a new problem or something I need to work up or evaluate. Sometimes even if someone comes in with many diagnoses already made, you still have to do your evaluating and investigating to piece things together. I liken the role of a primary care / FM doc as someone who oversees everything and makes sure all the pieces of the puzzle are put together. Cardiologists look at one thing, kidney doctors look at another -- it's our job to apply everything and treat the patient as whole.

 

[stayathomemom]

While I'm familiar with what a clinic-based FM doc does, what does a hospitalist FM doc do? I like family medicine but I also love working in the hospital environment and I think I'd go crazy in a clinic.

Edited to add: Why FM appeals to me is that it is the quintessential doctor, having the skills necessary to take a person (of any age) off the street and be able to assess, diagnose, and treat. And I would like to do humanitarian work locally and possibly overseas, so FM would be perfect for that. In my dream world I'd do something in the hospital as my day job and moonlight in a clinic as much as I want.

 

[Matthew9Thirtyfive]

My physician colleague sees HIV patients as a primary care physician. It's probably about 10-15% of her practice. So you can see as much or as little of it as possible. The other primary care docs in our clinic just refer to her, or to infectious disease.

I'm not sure I could pick which one I'd rather have, DM or HIV... but one of the Infectious Disease docs I know wrote this in a consult for a patient I diagnosed with HIV. "Newly diagnosed HIV, despite high viral load, this will soon be very well controlled". The patient came back feeling so much better. They were reassured that they'd basically be able to carry a normal life with some meds and labs thrown in here and there.

Great! Thanks for the info! Yeah, his reasoning was that it's easy to keep it under control with just one pill a day, you don't have to check things every day, and once it's under control, you don't have to worry about transmission through sex (I actually didn't know that, so that was interesting to learn) so even that is no longer an issue. Pretty remarkable considering how recently HIV became a thing.

 

[hsmooth]

While I'm familiar with what a clinic-based FM doc does, what does a hospitalist FM doc do? I like family medicine but I also love working in the hospital environment and I think I'd go crazy in a clinic.

Edited to add: Why FM appeals to me is that it is the quintessential doctor, having the skills necessary to take a person (of any age) off the street and be able to assess, diagnose, and treat. And I would like to do humanitarian work locally and possibly overseas, so FM would be perfect for that. In my dream world I'd do something in the hospital as my day job and moonlight in a clinic as much as I want.

Sorry for the late reply!

Here's what a hospitalist would usually do:
- schedules differ, but typically work 7 days straight, then have 7 days off work
- There are different 'shifts' such as day shift or night shift. We're starting to see 'nocturnalists' or hospitalist doctors that strictly work night time. Typically pay would be a bit better for those shifts
- during the day, hospitalist would take care of the patients that are admitted under their care. Could be anything from pneumonia to heart attack to stroke to kidney failure, etc.
- co ordinate and arrange the appropriate blood tests, imaging tests, or treatment. Order medications, monitor progress of the patient's health.
- call for consultations of specialists if they are required.
- communicate with patient's family
- perform 'family meetings' if the situation arises. usually if someone is not doing well and they need to discuss topics such as end of life care.
-work with social workers to find the appropriate housing or nursing home to discharge patients to
- Take new admissions from patients from the ER or from the clinic. Evaluate the patient that's getting admitted, and order subsequent testing and treatment needed.
- go to any emergency code situations, perform procedures such as placing central lines, managing resuscitation if people go into cardiac arrest, etc.
- at the end of the shift, 'sign out' the events of the day to the doctor that's coming in to replace him / her

 

[Shammyguy3]

Sorry for the late reply!

Here's what a hospitalist would usually do:
- schedules differ, but typically work 7 days straight, then have 7 days off work
- There are different 'shifts' such as day shift or night shift. We're starting to see 'nocturnalists' or hospitalist doctors that strictly work night time. Typically pay would be a bit better for those shifts
- during the day, hospitalist would take care of the patients that are admitted under their care. Could be anything from pneumonia to heart attack to stroke to kidney failure, etc.
- co ordinate and arrange the appropriate blood tests, imaging tests, or treatment. Order medications, monitor progress of the patient's health.
- call for consultations of specialists if they are required.
- communicate with patient's family
- perform 'family meetings' if the situation arises. usually if someone is not doing well and they need to discuss topics such as end of life care.
-work with social workers to find the appropriate housing or nursing home to discharge patients to
- Take new admissions from patients from the ER or from the clinic. Evaluate the patient that's getting admitted, and order subsequent testing and treatment needed.
- go to any emergency code situations, perform procedures such as placing central lines, managing resuscitation if people go into cardiac arrest, etc.
- at the end of the shift, 'sign out' the events of the day to the doctor that's coming in to replace him / her

Was there a particular reason(s) that you chose to be in the clinic as opposed to being strictly a hospitalist or a FM in both clinic/hospital?

 

[stayathomemom]

Sorry for the late reply!

Here's what a hospitalist would usually do:
- schedules differ, but typically work 7 days straight, then have 7 days off work
- There are different 'shifts' such as day shift or night shift. We're starting to see 'nocturnalists' or hospitalist doctors that strictly work night time. Typically pay would be a bit better for those shifts
- during the day, hospitalist would take care of the patients that are admitted under their care. Could be anything from pneumonia to heart attack to stroke to kidney failure, etc.
- co ordinate and arrange the appropriate blood tests, imaging tests, or treatment. Order medications, monitor progress of the patient's health.
- call for consultations of specialists if they are required.
- communicate with patient's family
- perform 'family meetings' if the situation arises. usually if someone is not doing well and they need to discuss topics such as end of life care.
-work with social workers to find the appropriate housing or nursing home to discharge patients to
- Take new admissions from patients from the ER or from the clinic. Evaluate the patient that's getting admitted, and order subsequent testing and treatment needed.
- go to any emergency code situations, perform procedures such as placing central lines, managing resuscitation if people go into cardiac arrest, etc.
- at the end of the shift, 'sign out' the events of the day to the doctor that's coming in to replace him / her

Thank you for your reply!
So is it pretty much the same as IM except that FM can also treat children?
What kinds of fellowships can a FM doc do?

 

[hsmooth]

Was there a particular reason(s) that you chose to be in the clinic as opposed to being strictly a hospitalist or a FM in both clinic/hospital?

To be honest, the hospital setting stressed me out too much. Too many beeping noises and people trying to die on you. Just not my cup of tea.

 

[hsmooth]

Thank you for your reply!
So is it pretty much the same as IM except that FM can also treat children?
What kinds of fellowships can a FM doc do?

Yes, pretty much! And some OB too if you'd like. Off the top of my head some fellowships out of FM are: Sports med, geriatrics, community medicine, Obstetrics, obesity medicine, sleep, palliative / hospice, adolescent, maybe pain?

 

[hsmooth]

One avenue where I feel being in primary care (whether internal medicine or family medicine) can be advantageous is all the diverse opportunities you have to make a paycheck. You don't 'just' have to work in a clinic. You have medical director roles, advisory roles, chart reviews, utilization management, telemedicine jobs you can do. If you're an ultra specialist, it could limit what you do.

I have been doing telemedicine now and enjoy making $200+ / hour working from home in my pyjamas. If any of you are interested in this, I can talk about it more.

 

[Matthew9Thirtyfive]

One avenue where I feel being in primary care (whether internal medicine or family medicine) can be advantageous is all the diverse opportunities you have to make a paycheck. You don't 'just' have to work in a clinic. You have medical director roles, advisory roles, chart reviews, utilization management, telemedicine jobs you can do. If you're an ultra specialist, it could limit what you do.

I have been doing telemedicine now and enjoy making $200+ / hour working from home in my pyjamas. If any of you are interested in this, I can talk about it more.

I am. Curious how that works and the type of stuff you deal with.

 

[SLC]

One avenue where I feel being in primary care (whether internal medicine or family medicine) can be advantageous is all the diverse opportunities you have to make a paycheck. You don't 'just' have to work in a clinic. You have medical director roles, advisory roles, chart reviews, utilization management, telemedicine jobs you can do. If you're an ultra specialist, it could limit what you do.

I have been doing telemedicine now and enjoy making $200+ / hour working from home in my pyjamas. If any of you are interested in this, I can talk about it more.

I’m interested in hearing about telemedicine. I’m a newly minted FM attending doing a rural job out west. I do 4 clinic days a week, average 2 weekends a month of (usually) light hospitalist call, and am considering pulling a few ER shifts. I don’t do OB as a matter of personal preference. It sounds like a lot, but at least 2 weekends I could be answering calls or doing videoconferencing.

What can you tell me?

 

[hsmooth]

I am. Curious how that works and the type of stuff you deal with.

I’m interested in hearing about telemedicine. I’m a newly minted FM attending doing a rural job out west. I do 4 clinic days a week, average 2 weekends a month of (usually) light hospitalist call, and am considering pulling a few ER shifts. I don’t do OB as a matter of personal preference. It sounds like a lot, but at least 2 weekends I could be answering calls or doing videoconferencing.

What can you tell me?

There are different telemedicine companies. Some are general medicine, some are specialty like erectile dysfunction, hair loss, STD treatment, etc. I work for a general one. Some are telephone and video, or telephone only / video only. I do telephone only.

Pay range can be between $20-$30 per consult. The one I work for is $23 per call. Once you get used to the platform, you can really crank out the consults. I can do a typical consult in 4-9 minutes, including finishing the SOAP note. A typical day I may do 8 phone consults spread out through the typical 8-5pm hours, then maybe 4 from the time I'm done eating dinner until bed time. Depending on how often you do this, you could add $60,000 - $90,000 extra income per year just doing phone consults.

Busiest times are the weekends.

The types of calls I get weight heavily towards URI, bronchitis, sinusitis, allergies, UTI, yeast infections, ear aches, kids with fevers, rashes. Pretty simple stuff

About 50% I'm prescribing some sort of prescription medication
10% of the time I'm telling patients go to urgent care or see PCP the next day
10% of the time it's triaging the acuity of their complaint and telling them when they should see their PCP and what tests they may expect to receive
30% of the time I'm recommending OTC or home treatment for their acute issue.

No one asks for controlled substances - actually, you're not allowed to prescribe it through the telemedicine company rules. There's some strict rules too, like no diagnosis otitis media over the phone, etc. So they have some rules to protect the provider too. Malpractice covered by the telemedicine company usually.

Majority of patients are gracious and thankful they can get medical advice without the hassle of going in to the doctors office.

1 / 180 patients I've consulted this month was pissed at me.

1099 income, so will be deducting expenses such as phone bills, internet, etc to help with taxes.

Pretty sweet side gig so far.

 

[Matthew9Thirtyfive]

There are different telemedicine companies. Some are general medicine, some are specialty like erectile dysfunction, hair loss, STD treatment, etc. I work for a general one. Some are telephone and video, or telephone only / video only. I do telephone only.

Pay range can be between $20-$30 per consult. The one I work for is $23 per call. Once you get used to the platform, you can really crank out the consults. I can do a typical consult in 4-9 minutes, including finishing the SOAP note. A typical day I may do 8 phone consults spread out through the typical 8-5pm hours, then maybe 4 from the time I'm done eating dinner until bed time. Depending on how often you do this, you could add $60,000 - $90,000 extra income per year just doing phone consults.

Busiest times are the weekends.

The types of calls I get weight heavily towards URI, bronchitis, sinusitis, allergies, UTI, yeast infections, ear aches, kids with fevers, rashes. Pretty simple stuff

About 50% I'm prescribing some sort of prescription medication
10% of the time I'm telling patients go to urgent care or see PCP the next day
10% of the time it's triaging the acuity of their complaint and telling them when they should see their PCP and what tests they may expect to receive
30% of the time I'm recommending OTC or home treatment for their acute issue.

No one asks for controlled substances - actually, you're not allowed to prescribe it through the telemedicine company rules. There's some strict rules too, like no diagnosis otitis media over the phone, etc. So they have some rules to protect the provider too. Malpractice covered by the telemedicine company usually.

Majority of patients are gracious and thankful they can get medical advice without the hassle of going in to the doctors office.

1 / 180 patients I've consulted this month was pissed at me.

1099 income, so will be deducting expenses such as phone bills, internet, etc to help with taxes.

Pretty sweet side gig so far.

Wow that sounds crazy. Are you ever worried about not being able to do a physical exam? Or do you just have a low threshold for referral/rxing?

 

[hsmooth]

Wow that sounds crazy. Are you ever worried about not being able to do a physical exam? Or do you just have a low threshold for referral/rxing?

Exactly - anything that sounds like it needs someone to examine something, I recommend they see their doctor.

 

[Matthew9Thirtyfive]

Exactly - anything that sounds like it needs someone to examine something, I recommend they see their doctor.

Do you think you rx more abx for things you might have a higher rx threshold in person? Like if someone calls with what seems like a simple acute bronchitis, do you give them a z pack anyway just to cover your ass, or do you counsel them on symptomatic relief and tell them to follow up if...?

 

[hsmooth]

Do you think you rx more abx for things you might have a higher rx threshold in person? Like if someone calls with what seems like a simple acute bronchitis, do you give them a z pack anyway just to cover your ass, or do you counsel them on symptomatic relief and tell them to follow up if...?

I'd like to think my practices are pretty similar comparing between telemedicine or in person.

 

[Reader88]

Sorry if this has been answered before, but do you feel like you manage more complex patients than your NP and PA co-workers? I'm scribing in family med and really enjoy it, and the doc I work for seems like a phenomenal physician, but I'm having a hard time seeing how her job is different than theirs.

 

[Eagleye2]

Hey thanks for doing this. When i was shadowing doctors i noticed alot of them complained about the electronic medical records. Do you feel like EMR taking more time to complete is truely due to the EMR or do you think its more of a result of the older generation of doctors not being as tech savvy as the newer generation?

 

[hsmooth]

Hey thanks for doing this. When i was shadowing doctors i noticed alot of them complained about the electronic medical records. Do you feel like EMR taking more time to complete is truely due to the EMR or do you think its more of a result of the older generation of doctors not being as tech savvy as the newer generation?

There's honestly some really horrible EMRs out there that just aren't user friendly, and I get it. The EMRs that are more user friendly can make charting less of a chore. Taking the time to learn shortcuts or learn how to use dictation software will pay off a thousand times over. For example, I can see 20 patients in a day and get all my charting done by 5pm, while my colleagues that don't dictate or use shortcuts and free type everything may have 5 charts to do at home or stay an extra 45 minutes later than I do.

 

[hsmooth]

Sorry if this has been answered before, but do you feel like you manage more complex patients than your NP and PA co-workers? I'm scribing in family med and really enjoy it, and the doc I work for seems like a phenomenal physician, but I'm having a hard time seeing how her job is different than theirs.

It all depends on the practice. At my current clinic, NPs and PAs are expected to see the same patients as the docs. There's a lot of bouncing off ideas off each other though for complicated patients.

 

[drumass]

Have a few miscellaneous questions!

1) Can you take more vacation if you wanted? Say you wanted to be full time, but have 12 weeks off a year instead of 6 could you do that? Maybe picking up more weekend/evening shifts to stay "full time" Will a typical job be flexible like this?

2) What would your advice be to someone who will only graduate with 60K in debt.

 

[Reader88]

It all depends on the practice. At my current clinic, NPs and PAs are expected to see the same patients as the docs. There's a lot of bouncing off ideas off each other though for complicated patients.

Thanks for the reply! Does that make you worry for your job security? I'm interested in primary care but if clinics can pay NPs and PAs significantly less to do the same job, why wouldn't they?

 

[hsmooth]

Have a few miscellaneous questions!

1) Can you take more vacation if you wanted? Say you wanted to be full time, but have 12 weeks off a year instead of 6 could you do that? Maybe picking up more weekend/evening shifts to stay "full time" Will a typical job be flexible like this?

2) What would your advice be to someone who will only graduate with 60K in debt.

1. Depends on where you work. For a group practice, "budgeting" time is around August where you can tell them if you want to change your work hours or make requests for extended or longer time off for the next calendar year.

2. Graduating with only 60k in debt is awesome. Some people graduate with 500k. Make a budget and stick to it. Live like a resident for another 5 years. Pay off your loans rapidly. Maximize your 401/403k accounts. Contribute the maximum to an IRA and HSA if available.

 

[westsidestoryz]

I just finished reading "Distracted" by Matthew Hahn.

After reading how terrible and convoluted our current healthcare system is, how do you go about bringing the best care for patients with so many restrictions, regulations, and penalties from both the government and pharmaceutical companies? (There are some horror stories in that book...)

It seems like PCPs are struggling 24/7 with regulators on how to get paid and gets dictated on how to treat patients from people who have no clinical experiences and sit behind a desk. (I know this and seen it firsthand as I am currently working for a prior auth medical group)

Thank you for your answer!

 

[Deecee2DO]

I know a FM doctor who primarily runs an infectious disease clinic, and says had she known that's where she would end up, she would have just specialized in infectious disease and made more money. Do you ever feel that way, ending up in IM (essentially)? I know hindsight is 20/20.

Interesting, since you really don't make that much more money in ID, no procedures and less variety with more training and still around the same salary when in FM you can literally just do everything an ID doc can. And now I just saw that this was already brought up in past posts lol

 

[hsmooth]

I apologize if this has been asked previously...

Did any of the FM fellowships appeal to you? Did any colleagues of yours decide to apply?

Sports medicine briefly, but decided just to start working instead of doing the fellowship. One of my resident classmates did a sports fellowship and is not practicing sports med / non surgical ortho.

 

[hsmooth]

Interesting, since you really don't make that much more money in ID, no procedures and less variety with more training and still around the same salary when in FM you can literally just do everything an ID doc can. And now I just saw that this was already brought up in past posts lol

yep!! haha

 

[I'mJustCurious]

1. What was the hardest thing about medical school and how did you handle it?
2. What is the hardest thing about practicing now and how are you handling it?

 

[RNthenDoc]

... one of the Infectious Disease docs I know wrote this in a consult for a patient I diagnosed with HIV. "Newly diagnosed HIV, despite high viral load, this will soon be very well controlled". The patient came back feeling so much better. They were reassured that they'd basically be able to carry a normal life with some meds and labs thrown in here and there.

So ******* cool.

My compatriots in med school don't remember the AIDs crisis (Or 9/11 for that matter), so they don't understand my excitement when we learn about the advancements made in this disease.

 

[OsteoTorontoNick]

haha! The 'osteopathic school' in Canada / Quebec are not medical doctors. But if you go to a DO school in the states, you practice in Canada as a "medical doctor". There's an osteopathic association in Canada so there are definitely 'osteopathic medical physicians' practicing in Canada.

How about training at an Osteopathic School in France (4 years post undergrad, placement in hospitals etc)? Would there be an equivalency test for a designation that fits somewhere in between a DO and a Canadian Osteopathic School?

 

[588442]

This is a very helpful thread, thank you for working so hard on this. Did you do audition rotations in family med? I haven’t heard of many students doing those, however, I did think it would give me a leg up if I did well. What do you think?

 

[premeddestiny]

Thanks for your invaluable answers. I have a few questions for you:

1) For patients who you suspect to be drug-seeking, what would be the best approach?

2) Are there research opportunities for FM physicians?

3) What's the disease(s) you find most rewarding to manage?

 

[hsmooth]

This is a very helpful thread, thank you for working so hard on this. Did you do audition rotations in family med? I haven’t heard of many students doing those, however, I did think it would give me a leg up if I did well. What do you think?

I think I did one audition rotation. It wasn't my first choice but I know they ranked me high. If you rock the rotation it can only help you. But at the same time it also gives them a long look at you too 🙂

 

[Shammyguy3]

Did you do any research while in med school? Do you believe it is required for FM residencies?

 

[hsmooth]

Did you do any research while in med school? Do you believe it is required for FM residencies?

Nope, and for the most part, not required.

 

[Zpak19]

Hey hsmooth. I just stumbled upon this thread and have really enjoyed reading it. I wanted to ask you about PA vs DO. Having a wife who is a PA and seeing her scope of practice, would you still do medical school if you could re-do everything? I have been struggling with making a decision for my career path and I can see myself practicing happily in either role (particularly family medicine). Would you say the extra 5 years in training was worth it retrospectively? Thanks

 

[Cranjis McBasketball]

Hey hsmooth. I just stumbled upon this thread and have really enjoyed reading it. I wanted to ask you about PA vs DO. Having a wife who is a PA and seeing her scope of practice, would you still do medical school if you could re-do everything? I have been struggling with making a decision for my career path and I can see myself practicing happily in either role (particularly family medicine). Would you say the extra 5 years in training was worth it retrospectively? Thanks

Not an attending or hsmooth but ill add my input. I was the same and went back and forth on PA vs med school. Then I shadowed an older PA and he just told me straight up to go to med school. He said PA was amazing the first 5 even 10 years out because he made more money than all his friends and loved his job. After that he felt like he had a ceiling in terms of job growth. When I shadowed him he had been practicing for about 30 years and told me how hard it is to have worked in a specialty for 20 something years and know the ins and outs and have a fresh 20 something old finish residency and instantly be over him, making twice what he did.
So thats my small input from what made me pursue the full med school (current 2nd year)

 

[efle]

Not an attending or hsmooth but ill add my input. I was the same and went back and forth on PA vs med school. Then I shadowed an older PA and he just told me straight up to go to med school. He said PA was amazing the first 5 even 10 years out because he made more money than all his friends and loved his job. After that he felt like he had a ceiling in terms of job growth. When I shadowed him he had been practicing for about 30 years and told me how hard it is to have worked in a specialty for 20 something years and know the ins and outs and have a fresh 20 something old finish residency and instantly be over him, making twice what he did.
So thats my small input from what made me pursue the full med school (current 2nd year)

The local primary care my family uses is several midlevels with one supervising MD. When I saw the midlevel to get my titers checked for starting med school, they said the same thing, that they've wished for a long time they went for the MD.