spyyder

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Anyone have any thoughts about doing a primary care track in IM versus a FM residency. Pro/Cons? Would they have the same skill set after completion and still have the option of applying for a fellowship?
 

ForamenMagnumPI

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There are several differences between family medicine and internal medicine. Many of these are fundamental ideological things, so I would encourage you to think about how you would like to approach medicine.
Internal medicine: disease-focused, treat non-pregnant adults, often easier to pursue specialty training (oncology, GI, nephrology, etc). In my limited experience, internists tend to be very intelligent, very methodical thinkers who enjoy intellectual puzzles.
Family medicine: patient and family-focused, can treat from cradle to grave. Some family physicians practice full-spectrum FM (obstetrics, pediatrics, geriatrics) and some treat only adults, don't do OB, etc. There are some specialty options (sports med, geriatrics, palliative medicine, hospitalist, etc). In my limited experience, family doctors tend to be broad thinkers who look at the whole patient and treat diseases in the context of how the disease affects the patient's life.
I suppose you can take that for what it's worth, if anything.
 
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spyyder

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There are several differences between family medicine and internal medicine. Many of these are fundamental ideological things, so I would encourage you to think about how you would like to approach medicine.
Internal medicine: disease-focused, treat non-pregnant adults, often easier to pursue specialty training (oncology, GI, nephrology, etc). In my limited experience, internists tend to be very intelligent, very methodical thinkers who enjoy intellectual puzzles.
Family medicine: patient and family-focused, can treat from cradle to grave. Some family physicians practice full-spectrum FM (obstetrics, pediatrics, geriatrics) and some treat only adults, don't do OB, etc. There are some specialty options (sports med, geriatrics, palliative medicine, hospitalist, etc). In my limited experience, family doctors tend to be broad thinkers who look at the whole patient and treat diseases in the context of how the disease affects the patient's life.
I suppose you can take that for what it's worth, if anything.
Thanks for the reply. I am actually more curious about primary care tracks within IM that seem to focus on many aspects of a FM residency. Besides OB the curriculum seems about the same, but still give you a good balance of both inpatient and outpatient procedures. Anyone have thoughts on these tracks as perhaps an alternative to FM (i.e you still have the fellowship option, easier to find hospitalist work, get training from both areas)?
 

lowbudget

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To be honest, you really have to break it down program-by-program. All the important common stuff will present commonly and in either types of programs it'll cover it just as well. It should be noted that most people who go into IM *don't* do primary care, and even if you do the primary care track, you're still eligible to do IM fellowships. So that can be a plus/minus depending on how you look at it. And while in FM, there are fewer fellowships (and the ones that are available are still generalists specialties), most people will gravitate towards something they like or have interest in and that will usually help determine the parameters of their practice. There are hospital-heavy FM residencies all over the country that serve as the only residency in the hospital, so you can't say that IM more suits you for hospital work without looking at what's involved in the experience. When I compare my hospital experience to my IM friends who graduated with me, I'm surprised that there are some stuff (not all, but some) that I've seen and done more than they have. So you can't make these generalizations without looking at it on the micro program-by-program level.

You'll be well trained either way, and I imagine it doesn't make much of a difference at the end of the day.

The biggest mistake when people compare FM curriculum to curriculum of other specialties is that the required continuity clinic in FM doesn't get accounted. And that's truly the bulk of our training. We ramp up from 1st year to 3rd year the number of clinics we have and the more patients we have and just by sheer volume, you're going to see a lot of whatever comes in. If you just look at the block-by-block curriculum comparison between FM and IM, you won't capture the types of stuff you see in continuity clinic. And who is walking through the door? What's the community's perception and practice when it comes to PCP's? If your patients have a tendency to self-select, you may not see the types of cases you need to see in your continuity clinic. So that really makes a difference. I mean, do people in the community tend to go to primary care internists/FP for their well-woman exam or do they go to Gyn? You don't want to miss out on opportunities to explore other medical issues.

The other consideration is how much of non-IM primary care will you be experiencing. For example, will you get training/exposure to patients with ophtho, derm, uro, gyn, ortho/sports, and ENT complaints or will they simply be referred away? Will you learn skills like how to examine the eye, ENT, do biopsies, and suture? Will you get exposure down in the ED, in the major medical, minor/urgent care, and trauma? All these things will affect the types of stuff you're comfortable with when you graduate and the type of setting you can handle (rural/urban, urgent care, large multispecialty group with referral backup vs. do-it-your-own-and-keep-the-revenue)

And who are your teachers and mentors? Are they pretty homogenous in terms of their background, training, and scope of practice, or are they fairly diverse so that you can learn a lot of things all across the board?

At the end of the day, you're going to be well trained regardless. And there's going to be stuff that you won't get trained in, but will be forced to learn because that's life.

I wouldn't stress too much over what other people think. Pick something that you like to do in the way that best fits you and the rest will fall in line.
 
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spyyder

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The bottom line is: do you want to see children and do OB during residency? If so, do FM. If not do IM (an IM resident will see an occasional adolescent, but will only have to see younger kids during an ER rotation, if at all).
OB seems to be the only difference (and most FP don't do OB). Many of the primary care tracks include many of the outpatient procedures and continuity clinics. There is med/peds if you want more peds. I am just trying to weight the pro/cons of IM with the primary care track vs FM. Seems like there are far too many advantages in the IM route with 90% same training.

I am wondering why anyone would still pursue FM if you aren't going to do OB or peds (which is the case most of the time).
 

lowbudget

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OB seems to be the only difference (and most FP don't do OB). Many of the primary care tracks include many of the outpatient procedures and continuity clinics. There is med/peds if you want more peds. I am just trying to weight the pro/cons of IM with the primary care track vs FM. Seems like there are far too many advantages in the IM route with 90% same training.

I am wondering why anyone would still pursue FM if you aren't going to do OB or peds (which is the case most of the time).
I'm curious as to what outpatient procedures are being taught at IM-PC track programs. Can you elaborate?

How often are IM-PC residents in continuity clinic?
For FM, in general, it's:
Intern: 1-2 half days per week (at 4-6 patients per half)
2nd year: 2-3 halves (at 6-10 pts)
3rd year: 3-5 halves (at 8-12 pts)

What are the 90% similarities and what are the advantages from your perspective? Just curious.

For some people, that 10% difference is a big difference. My thing is if you know you're doing primary care, why wouldn't you do FM?
 
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spyyder

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I'm curious as to what outpatient procedures are being taught at IM-PC track programs. Can you elaborate?

How often are IM-PC residents in continuity clinic?
For FM, in general, it's:
Intern: 1-2 half days per week (at 4-6 patients per half)
2nd year: 2-3 halves (at 6-10 pts)
3rd year: 3-5 halves (at 8-12 pts)

What are the 90% similarities and what are the advantages from your perspective? Just curious.

For some people, that 10% difference is a big difference. My thing is if you know you're doing primary care, why wouldn't you do FM?
Going based on some of the websites

http://www2.medicine.wisc.edu/home/housestaff/hsprimarycare
http://www.stonybrookmedicalcenter.org/medicine/residency/primarycare_track.cfm
http://im.dom.uab.edu/primary.htm

Most are teaching scopes, derm, injections, ortho, womens health etc...
What I mean is that the curriculum is 90% similar in that they are 'virtually' interchangeable. Perhaps a FM doc will be more thoroughly trained in primary care (larger breath), but my confusion is that if most of what is taught through the primary care track is the same, why limit yourself by pursuing a FM residency. Perhaps later on you decide there was one specific areas you found to be more interesting and you can then do a fellowship. Hospitalist position are also primarily given to IM trained docs. Why reduce your options out of the door. Sure there is ped/ob training missing, but the numbers suggest that few are including this population in their practice. I like primary care, but also want to keep my options open. I am just curious why this isn't considered a better route.
 

lowbudget

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Going based on some of the websites

http://www2.medicine.wisc.edu/home/housestaff/hsprimarycare
http://www.stonybrookmedicalcenter.org/medicine/residency/primarycare_track.cfm
http://im.dom.uab.edu/primary.htm

Most are teaching scopes, derm, injections, ortho, womens health etc...
What I mean is that the curriculum is 90% similar in that they are 'virtually' interchangeable. Perhaps a FM doc will be more thoroughly trained in primary care (larger breath), but my confusion is that if most of what is taught through the primary care track is the same, why limit yourself by pursuing a FM residency. Perhaps later on you decide there was one specific areas you found to be more interesting and you can then do a fellowship. Hospitalist position are also primarily given to IM trained docs. Why reduce your options out of the door. Sure there is ped/ob training missing, but the numbers suggest that few are including this population in their practice. I like primary care, but also want to keep my options open. I am just curious why this isn't considered a better route.
Cool thanks. Yea, I think the websites you provided are really interesting. Derm procedures are everywhere and aren't hard to set up. Women's health is easy too, although I'm not sure from the website you showed us if people are doing colposcopies (which we get in FM). And I'm not talking about rotating or what not. I'm talking about the resident's own clinic is set up to do these procedures. Some programs will even do LEEPs and cones. Ortho is hit and miss. Most primary care clinics will have a few, especially chronic stuff. Occasionally you might get an acute, but the place to get lots of ortho injuries would be in urgent care, which a lot of IM docs don't feel comfortable staffing. I don't know the IM faculty at those programs listed, so it's something you might ask, whether the resident's staff an urgent care (or at least have an opportunity to do so). One of the program you listed has a sports med clinic. I believe that same program has a fellowship, so I would ask how the work is divided between residents, fellows, and faculty.

Interesting you mentioned scopes, because I was curious whether IM-PC was teaching its residents to do GI scopes... looks like they're doing flex sigs, which are falling by the wayside. Standard of care, to be frank, is colonoscopy, and I'm curious how willing GI is willing to teach primary care how to do screening colonoscopies. I know on the FM front it's not easy. But, I haven't seen anything that suggests that IM-PC are having easier time getting colonoscopies as well. Interesting...

One also interesting thing that was missing on the websites is exercise stress testing. Again, you would think that they would teach it to IM-PC, but I'm not convinced that their own residents are doing those procedures on their own patients either. Again, interesting.

You should pick whatever best suits your interest, like I said, but I haven't seen anything thus far that convincingly makes IM-PC that much more superior to FM residency when it comes to primary care work. I think the procedure offerings are par, if not worse; unless there's evidence that points to the contrary.

I also think it's interesting that you said that "few" FM docs are including peds and OB. Is this a general impression that you have? Because in 2008, 87% of FM docs surveyed practice pediatrics and 27.7% of FM docs do OB. http://www.aafp.org/online/en/home/aboutus/specialty/facts/4.html

So that's 9 out of 10 FM docs see kids and 1 out of 3 do obstetrics, which is more than a "few" in my opinion. And the 1/3 for OB was more than I expected. I mean, I would have thought it was 1 in a million. But... that's why we have these statistics... to dispel myths. You can check out the regional breakdown in that same survey. AAFP is really good about updating it frequently.

Lastly, I think it really depends on what you consider "limiting" yourself and FM, out of all the specialties given its breadth, is by definition and by comparison less limiting. If you define "limiting" as a specialty where the board won't allow you to do a subspecialty that will train you to do procedures that will result in you making a crapload of money... then, yes, FM is limiting in that sense.

But for me, if the patient is human and is from planet Earth, I feel like I can have a decent first shot at taking care of them. In that sense, I don't think FM is limiting at all. Quite the contrary.

I think it all depends on how you look at things.

I'm not gonna talk you out of what you want to do. I'm not sure if there is such a thing as a "better option". I think there may be a "better option"... for *you*... but I don't think either FM or IM-PC is superior to one or the other.

I just want you to look at things from a different perspective than what others may be leading you to think.

Good luck.
 
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spyyder

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Hey. Thanks for the feedback, I really appreciate it. I am just trying to get perspective before making one of the biggest decisions of my life. Its nice get someone's opinion on the topic. My experience with what FP docs do is limited so much of what I said is anecdotal. Understandably the approach to patients is much different between IM and FM and thus its reflected in the training.

Perhaps you might be able to answer another question for me. If the FM residency have such a large breath of knowledge (clinical knowledge and procedures) how come so few FP clinics attempt to offer more than just basic services? For example FM can do basic radiology, stress testing, GI, derm, etc. Why do they choose to refer out instead of performing in-house? Competition? Cost? Demand?
 

lowbudget

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Skill/training and money.

All that stuff is expensive to provide and unless you can expect a reasonable rate of return on your investment, people won't do it. And if people can't get a good return, they won't invest the time to train and learn it. I mean, it's like you said, if you can predict that in the future you will not be doing any OB or scopes, why bother learning it? It just doesn't seem like a good business decision, right? To waste time and money doing something that you can't see yourself doing?

Well, my counterargument is that people aren't that great with predicting the future in the first place! Look at the weatherman! I mean, if we were so smart to know today what we will do in the future, we'd all be rich (think: stock market)...

(And of course, it also depends on the contracts you sign over whether you can/should provide a service or if it makes sense. There're multiple factors that contribute. There's cost, benefit, medical appropriateness.)

How do you know today that you don't want to do OB, or Peds, or Interventional Cardiology, or Neurology, or whatever... in the future?



Oh and by the way, this is not the biggest decision in your life. It's just one of the many decisions in your life.
 
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radslooking

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if you are pretty sure you want to do primary care, I would say FM. I don't see many advantages to doing primary care track IM. All it does is limit you to adults. If you want the options for adult specialties, then IM. I'm not sure how else I'd break it down.

To be honest, I'm not sure why you'd do primary care track IM versus regular IM. It seems to me it would make you less competitive for specialties if you wanted to do it. Anyone can do primary care as an IM.
 
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spyyder

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if you are pretty sure you want to do primary care, I would say FM. I don't see many advantages to doing primary care track IM. All it does is limit you to adults. If you want the options for adult specialties, then IM. I'm not sure how else I'd break it down.

To be honest, I'm not sure why you'd do primary care track IM versus regular IM. It seems to me it would make you less competitive for specialties if you wanted to do it. Anyone can do primary care as an IM.
Why would you be less competitive? You still take the same boards and go through the same rotation, but you are also better trained in outpatient care and procedures. I would say you be more sought after because you have a different approach to patient care. I think this kind of mindset would be more valued by a specialty. I will have to look it up, but I came across a study that found pass rates of primary care (IM) students to be higher than categorical students. There are many adults only general practices. You could do med/peds for one extra year and be double boarded and better trained in both areas. I am not dead-set on primary care, just want to keep my options open. I feel like this would be the best path.
 

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If you are sure you want to do primary care and don't mind seeing children, go ahead and do FM. The preparation for primary care is probably a little better than IM- though you need to find a good program, one that will expose you to a lot of procedures.

However, with FM there are few escapes from primary care- you can do sleep med, but FM residents are relatively noncompetitive for sleep medicine fellowships. Be sure you will be happy in the primary care hellhole before doing a family medicine residency. If you aren't sure, do IM
 

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Ahhhhhhhh Blue Dog and lowbudget- you guys are like my online mentors.

I just finished a month of Outpatient IM; all old people all the time. Plenty of walking trainwrecks. I used to be intimidated by a dozen medications, now it takes a good 20 or so before my eyebrow twitches.


The big difference I could see from FM is that:
1. The doctor's loved pathology. They just loved the zebras and talked about weird cases with a sense of nostalgia.
2. The term Geriatrician and Internal Medicine are synonomous in my mind.
3. For the most part- FP docs pick up Urgent Care shifts on the weekends. For internal, they mostly picked up hospitalist shifts.

On to inpatient-we'll see how this month goes. Day 1 sucked.
 

radslooking

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Why would you be less competitive? You still take the same boards and go through the same rotation, but you are also better trained in outpatient care and procedures. I would say you be more sought after because you have a different approach to patient care. I think this kind of mindset would be more valued by a specialty. I will have to look it up, but I came across a study that found pass rates of primary care (IM) students to be higher than categorical students. There are many adults only general practices. You could do med/peds for one extra year and be double boarded and better trained in both areas. I am not dead-set on primary care, just want to keep my options open. I feel like this would be the best path.
I plead a slight amount of ignorance as I don't have a ton of knowledge of how good the training is in primary care track IM programs. I do know that community based IM's are at a relative disadvantage to other IM's because of less acute care experience. I was extrapolating that to be true to primary care track IM programs which may or may not be true. I'd ask some fellowship directors of cards, GI etc. They may or may not care.
 

lowbudget

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I plead a slight amount of ignorance as I don't have a ton of knowledge of how good the training is in primary care track IM programs. I do know that community based IM's are at a relative disadvantage to other IM's because of less acute care experience. I was extrapolating that to be true to primary care track IM programs which may or may not be true. I'd ask some fellowship directors of cards, GI etc. They may or may not care.
Well, I don't know much about PC-IM either, but FWIU is that people do pursue fellowships after doing PC-IM. And there are university PC-IM tracks out there. The only difference between PC-IM and categorical IM is that PC-IM does more outpatient rotations than categoricals.