IM/Fp

[allendo]

Can you see any advantage in doing the combined residency?

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[PACtoDOC]

Can you see any advantage in doing the combined residency?

Not really. If you desire to be an IM doc, then you should probably jump in head first to that field. If you simply want to be a very exceptional FP hospitalist, then choose a residency known for producing such. JPS here in FW, Tx has a great program for this. There is no IM residency there so they basically function in this capacity when on the medicine service. Many of these guys go on to do ER and hospitalist work.

 

[lowbudget]

I'd be interested to hear what people have to say about this one.

St. Vincent's claim that they're training superdocs for rural/international work but that's what some of the unopposed county and some rural hospitals claim they do too. I suspect that IM/FP would be comfortable doing hospitalist work, and I'd imagine the IM component leaves flexibility to do critical care. But seriously, folks, is that all necessary? More training is always better than less training, but you have to ask when is enough, enough for the real world. Judging by some of the curriculum, you spend more time in each of the various IM subspecialties than FM, which is of great value because for some FM programs, you reserve your electives for that. There was talk about extending FM into 4 years, which would basically capture the spirit of the combined FM/IM, but no one has been talking about that anymore at the FM leadership level. With any combined programs, you'll always have logistical issues. One FM/IM program has you splitting clinic time over the course of your resiency between FM and IM for board's sake, which I think would be a pain in the butt given the lack of continuity. Personally, I can't imagine what an FM/IM person is doing that a FM or an IM can't do in a categorical. But, again, more training is better than less training... why not spend the rest of your life in residency? Doesn't seem practical to me... that's how I feel.

There're a couple of medline articles on this, but I can't pull the full text. If anyone can pull it and report back... These are old articles though; I wonder if there are any newer ones. It'd be interesting to see what the spirit of combined program is so that you know what you get when you sign up, and you know what you're missing when you don't.

1. Dixon JG. Barnes HV. Davies TC. Manser TG. Eng B.
A combined residency in family medicine and internal medicine at Eastern Virginia Medical School. Academic Medicine. 74(1 Suppl):S121-7, 1999 Jan.

2. Christiansen RG. Johnson LP. Boyd GE. Koepsell JE. Sutton K.
A proposal for a combined family practice--internal medicine residency.
JAMA. 255(19):2628-30, 1986 May 16.

 

[raptor5]

Study Finds Substantial Minority of Family Medicine Residents Support Extending Residency Training From Three to Four Years

 

[iatrosB]

Study Finds Substantial Minority of Family Medicine Residents Support Extending Residency Training From Three to Four Years

Interesting study. I think, however, that the study greatly underestimates the "repel of some students". If FP is bumped up to four years, many students who were previously considering a FM residency will not do it. One of FP's selling points is the quick turn around to getting out in the workforce. Will the docs be better trained, possibly. Will it lead to even more students running from FP, definately.

 

[lowbudget]

Substantial minority = 37%. Interesting. Still, 63% said no gracias. I think if you're going to do something like this, you have to look at it economically. How much additional economic return will I get if I give one more year of training? I'd do it, if I knew that I would be non-competitive if I didn't. I'm just not too sure what the value proposition is...

I asked about the 4 year FM residency when I was interviewing and all the programs I spoke to said no, not in the near future. Of course, if people are interested, you have the option of doing fellowship although for FM, it is quite limited compared to IM. I'm sure there will be some experimental programs willing to push training to 4 years, so we'll see. Unless that 4th year, either residency or fellowship, is substantially different from the 3 year program, I can't imagine earning $40k yet one more year when there's an offer calling me at 3-5x of that.

 

[FMbound]

From what I have observed to be the trend of insurers promoting the use of PAs and NPs for primary care, in order for FM to survive as a specialty, something must be done to distinguish the FM doc from the PA or NP. One method of doing this would be to extend training and provide a more in-depth education.

I would not be opposed to this since I plan to seek additional training after residency.

 

[corpsmanUP]

From what I have observed to be the trend of insurers promoting the use of PAs and NPs for primary care, in order for FM to survive as a specialty, something must be done to distinguish the FM doc from the PA or NP. One method of doing this would be to extend training and provide a more in-depth education.

I would not be opposed to this since I plan to seek additional training after residency.

I have seen no evidence that insurance is pushing for PA/NP professionals to take over the PCP role. They may be starting to pay more for their services, but its not going to spell the end of family physicians. And I think it is obvious when you compare the two fields, at 7 years versus 2 years of education, that you don't need another year to proove that. Family Medicine cannot be learned in 3 years, 4 years, or 6 years. The bottom line is that at some point you just have to cut the cord and get out there and see patients on your own. Don't forget that many thousands of GP's did this right after graduation and some after internship, and their learning curve was similar but even worse! 3 years is more than enough. If its not enough for some, then perhaps they should join a big group so that they can work closely with colleagues. But it is apparent that the vast majority of programs and residents are happy with a 3 year curriculum. Once you get out, FM is just not all that glamorous or scary. I do think it would be prudent to have a 4 year FP rural program that gained you the procedures necessary to get credentialled to do C-sections, appy's, lap chole's, inguinal hernias, and perhaps a few other niche things that would really help out in the rural setting. But short of that, 4 years is a waste of time!!

 

[shemozart]

Can you see any advantage in doing the combined residency?

Hi allendo,

I'm where you were a year ago - I actually did interview at St. Vincent's in Indianapolis as the other poster referred to. A little background - I would like to do rural family medicine - ideally ER, outpatient, inpatient for my particular patient panel, and OB (undecided on C-sections). The community physicians I worked with in med school in an FP-friendly state did all of that and more with just a 3 year FP residency - and comparing them to the academic physicians I worked with at a university hospital - I was impressed. Not to be forgotten, they did have 15 to 20 years of experience under their belt, as well. So when I interviewed at St. Vincent's, the only FP/IM program accepting applications last year that I was aware of, I looked at what the program offered that would help me out in accomplishing this future practice goal - and honestly, I didn't feel the program would help me all that much with becoming a well-rounded future rural physician. No C-section options, not a lot of ER, sharing deliveries with OB/gyn residents, suburban hospital.....and the two other things that helped seal the decision. The resident who was showing me around was on a medicine subspecialty service, and I asked how busy it was "not very - maybe a couple of consults" - and he made it sound like the subspecialty services were posh - so what's the point? You can read up and see the same conditions during a good family medicine residency without needing that additional year - one just needs to be proactive. The other thing that I felt would interfere with my education was the religious aspect - the clear implication was that this program was for people intending to do mission work. When I mentioned I was interested in it for rural medicine purposes, they were clearly interested - I wouldn't doubt if it's part of their marketing of the program now. I felt somewhat out of place, although I am a white non-practicing Catholic - I was assured that you COULD prescribe birth control, it's just that the patient had to sign a consent form (?!?). I would like to be actively involved in reproductive health matters (i.e., insertion of IUDs, etc.) but this would clearly take some work to accomplish these activities (if allowed) - going to different clinics, etc. Although the IM and FP program directors seemed very cool - I really enjoyed both of them and their philosophies - their thoughts and ideas just didn't seem to match the programs' nor the resdients'.

Sorry if I rambled! I guess I was extremely interested in the thought of IM/FP, but disappointed with the program offering it. In retrospect as I begin residency now, I wish the old option of ER/FP double boarding or double residency was available - I think that would ultimately be more useful for a future rural FP. Any questions, or more specifics, please PM me! I don't want to offend anyone with my comments, so sorry if I did!!

 

[deleted6669]

"I wish the old option of ER/FP double boarding or double residency was available "

it still is....if you are a D.O. there are several 5 yr er/fp reidencies( 5 I think).

 

[Furrball2]

Other than catching babies, what would a four year FM or IM/FM program give you that a Med-Peds program wouldn't, especially if you really wanted to subspecialize?

 

[wa_medic]

Other than catching babies, what would a four year FM or IM/FM program give you that a Med-Peds program wouldn't, especially if you really wanted to subspecialize?

How about surgical experience. Many FPs still scrub-in and a few still are primary for certain procedures.

 

[maxheadroom]

"I do think it would be prudent to have a 4 year FP rural program that gained you the procedures necessary to get credentialled to do C-sections, appy's, lap chole's, inguinal hernias, and perhaps a few other niche things that would really help out in the rural setting."

Yes, I know that it's fairly common for a FP to do C-sections. I also know of some FPs who scrub cases (all as an assist in my knowledge). A simple appendix is no big deal, but what if it isn't simple? Lap choles and hernias are just bad ideas -- they should be cared for by a surgeon. If a hernia is incarcerated, it definitely requires a surgeon to for the procedure. If it's elective, you're going to piss off your surgical colleagues. And honestly, an inguinal hernia can be a pretty complicated case. Lap choles, while often fairly simple, can have problems, too. Once you see a common bile duct injury, you'll respect the procedure that much more.

Short note: leave surgery to surgeons. There are very few communities to have no access to adequate surgical care, especially in the age of ambulances and helicopters.

This isn't to slam FPs. A good PCP is one of the best things in the world. They make appropriate referals and communicate their patients' problems.

 

[lowbudget]

Re: C-sections
You should read the AAFP position statement on that (http://www.aafp.org/x25030.xml). In short, it should depend on community need and experience, not what specialty you belong to. That said though, it is easier for OB to get C-section numbers because that's what they do, during residency and beyond. In FP, you worry about other things and the training into learning C-section and complication management means taking away from learning other things. And once you learn it, you gotta keep up with it too. The other interesting issue is whether or not you were trained to do a Hyst.

 

[lowbudget]

Re: Difference between IM/FP and Med/Peds
Clearly, you can make broad generalizations because you have to meet RRC requirements and be ready to sit for your Board(s). But here's a comparison of 2 programs in Indiana, just for sh#ts and giggles.

St. Vincent's IM/FP (http://www.stvincent.org/education/meded/resprog/imfm/curriculum.htm)
Adult Inpt Med 3+1.5+1+1 = (6.5)
Adult ICU 2+1+1+1 = (5)
Ped 2+1.5+0+0 = (3.5)
NICU 1+0+0+0 = (1)
OB/Gyn 2+1.5+1 = (4.5)
Med Sub (incl Geri) 1+1+2+4 = (8)
Neuro 1+0+0+0 = (1)
GS 0+2+0+0 = (2)
Surg Sub (incl SM) 0+1+3+0 = (4)
Psych 0+1+0+0 =(1)
ER 0+1+0+0 =(1)
Elective 0+0+1+5 = (6)

Indiana Univ Med/Peds (http://www.iupui.edu/~deptpeds/medpeds/scheduleMP.html)
Adult Inpt Med 2+3+1+1 = (7)
Adult ICU 0+1+0+0 = (1)
Ped Inpt 1+0+2+0 = (3)
NICU/PICU 1+1+1+0 = (3)
Med Sub (incl Geri) 1+1+2+2 = (6)
Med Elective/Sub 0+2+0+4 = (6)
Med Ambu 1+0+1+0 = (2)
Neuro 0+1+0+0 = (1)
Ped Sub (incl Adol) 3+1+3+2 = (9)
Ped Elective/Sub 1+0+2+1 = (4)
Ped Ambu 1+0+0+0 = (1)
M/P ER 1+2+0+2 = (5)

So it looks like IM/FP has more of Ob/Gyn, Psych, Surg & Subs, Adult ICU.

And Med/Peds has more NICU/PICU, ER, Peds Sub, and Electives.

What's weird about the electives for Indiana's Med/Peds is that they cram electives with subspecialty experience (?) which is really interesting. I wonder what residents think about that.

Also, I can't imagine you doing that much OR surgery during a 1-2 month rotation. I'm sure you get procedures, but you won't be at the level of a 5th year surgical resident. Chances are on surgery rotations, you'll be working at the level of a 1st/2nd year surgical resident (even if you're a 3rd year resident) which means lots of clinic, floors, consults, and minor procedures (maybe 1 or 2 common major surgeries). All of which are appropriate for non-surgeons.

Man, looking at these two curriculums make me shiver. I thought it was hard enough doing one Board, much less try to get enough experience and time to sit for 2. No wonder many dual Board-ers end up dropping one.