Is FM training spread too thin?

[predodoc]

Is the training for FM stretched too thin? Im a 3rd year and considering FM. After completing my IM, peds, and Obgyn rotations I realized I like some of all three but how do you consider yourself well trained in all three(plus others) if you only do a 3 year residency? When I look back at my Peds rotation I know I learned alot but Ive already forgotten about 75% in only 5 months. I just cant see how I would feel real comfortable with only 4-5 months of peds spread over 3 years, especially since I probably wouldnt be seeing lots of kids everyday to reinforce my knowledge.

I guess My main concern is being spread so thin over 3 years that I wouldnt feel real comfortable handling anything but the most easy and basic situations and wishing I had narrowed my training.

Anyone have the same issues?

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[justwondering]

i think FM residency prepares you for:
-common inpatient problems
-clinic

most FM ppl will end up working in clinic, and our residencies often place a lot of emphasis on clinic (especially in your last year). you end up seeing a lot of peds this way so you can be pretty comfortable with outpt peds.

we also spend a lot of time with inpt services, specialties, etc...so you get a fair amt of common inpatient issues. you also have time to do electives to bolster your knowledge in a particular area. if you want to do a LOT of inpatient work, you might want to consider Med-Peds.

med schl is very different from residency, you learn a lot more and retain more because you are given much more responsibility over pts and you are often making decisions when the attendings are not there.

 

[sophiejane]

Is the training for FM stretched too thin? Im a 3rd year and considering FM. After completing my IM, peds, and Obgyn rotations I realized I like some of all three but how do you consider yourself well trained in all three(plus others) if you only do a 3 year residency? When I look back at my Peds rotation I know I learned alot but Ive already forgotten about 75% in only 5 months. I just cant see how I would feel real comfortable with only 4-5 months of peds spread over 3 years, especially since I probably wouldnt be seeing lots of kids everyday to reinforce my knowledge.

I guess My main concern is being spread so thin over 3 years that I wouldnt feel real comfortable handling anything but the most easy and basic situations and wishing I had narrowed my training.

Anyone have the same issues?

No.

You should choose a program where you DO see kids in clinic every day, where you have a pediatrician or two on faculty, where you get high-volume OB, and plenty of sick adults on a busy hospital service.

I agree that most programs don't train you that way, but will train you adequately for a suburban practice where you do a lot of referring to various specialists. But if you want broad training that also has depth, you just have to look for the right programs, and prepare to work really hard.

 

[Ascultator]

I second the responses above. At the least, FM programs provide solid training for managing not only common conditions in patients of ALL age ranges, but also to take the first step in managing the more complicated and rarer ones (namely, to know when to refer out).

Given the breadth of family medicine, there is accordingly a greater breadth of the kind of work you do as an FP (eg: more outpatient, more inpatient, fellowships if you want to do sports med, adolescent med, etc...). So there are some variations among programs nationwide that reflect that diversity. Like sophiejane said, you can go more in depth in certain areas. Check out http://www.venturafamilymed.org/index.html to see a strong example of this (a program which I considered, which preps FP's to go into rural/underserved settings in the US or abroad to do full-scope family medicine, including OB and surgeries.)

So I think you should let your interests and goals as a potential (and I hope!) future FP be one of the deciding factors in your program choices.

Hope this helps, and best of luck with the rest of your 3rd year.

 

[Dr. Wexler]

It seems a shame to spend 2 precious months on OB when many trainees will not do OB as an attending (either by choice or inability to get privileges). I don't have a solution to propose, and I suppose to some extent this happens in training for all specialties (Peds residents doing inpatient months even if they have no desire to do any inpatient once they are done training). I realize there are many places in the country where FM docs do practice OB, but if there is going to be a trend of fewer and fewer Family docs doing OB I think the AAFP and RRC should recognize this and change the training paradigm. Perhaps making the OB requirement optional or having an OB track and a non-OB track. Just a thought.

 

[scharnhorst]

I agree 2-3 months in OB is a waste if u dont want to do OB

 

[predodoc]

Thanks everyone for the responses about FM. Im still undecided between FM,IM,EM and Derm so all the info you give is great for helping make my decision.

Also, Any one know of programs in the SouthEast that you've heard are great programs and train well? I Know I can probably find it by searching but If you feel like posting Ill definatly appreciate it

 

[razorback58]

As many of you in FP know we have to have 10 continuity deliveries in OB. I am in a community based program and we are at the mercy of private doctors who really are not thrilled with out presence. We spend every morning writing their floor notes and discharges only to get in on deliveries when and if we can to get our numbers. The nurses in OB typically are real bitches and are very secret and controlling with their patients.

The continuity deliveries can be a nightmare when you are trying to get your delivery staffed by people that did not follow the patient or cares about your patient. It become very hard when you need one of the OB docs to do a c-section for you. You have no power to make any decisions, yet nobody is really making decisions..... I HATE THAT. It leaves you looking like a moran in front of the patient because they are told so many things by different people. This is fresh on my mind because it just happened to me the other night.

The RRC in FP should really re-think the continuity delivery requirments. It creates a hardship on EVERYBODY.

I think OB should be an elective and not a requirment. We should spend more time doing GYN procedures. It would be okay to spend a month doing deliveries in case you are faced with one on an airplane, in the ED or something. If you really want to do OB do a FP OB fellowship. Even then, you cannot even start to match the training and experience an OB resident gets.

YES THIS IS A HUGE WASTE OF OUR TIME in the long run. Time would be better spent on derm, peds office, GYN, simple procedures and such. Or just go hang out in the ED and do your thing there. You will see EVERYTHING.

 

[drwatson]

To respond to the OP; most programs allow between 3-6 months of electives (usually around 4-5 months). You can use that time to become more comfortable in things that you see having in your practice. If you think you will do a lot of derm procedures take a derm month and plastics month. If you think you will do sports do some Ortho and Sports months. If you are going rural then do an extra month of OB or Peds.

I heard of one resident who signed with a rural hospital and they needed someone who could do colonoscopies. So she used her electives to get certified in scopes. A unique situation to be sure but just goes to show you can use that elective time and tailor it to whatever your career needs might be.

 

[sophiejane]

As many of you in FP know we have to have 10 continuity deliveries in OB. I am in a community based program and we are at the mercy of private doctors who really are not thrilled with out presence. We spend every morning writing their floor notes and discharges only to get in on deliveries when and if we can to get our numbers. The nurses in OB typically are real bitches and are very secret and controlling with their patients.

The continuity deliveries can be a nightmare when you are trying to get your delivery staffed by people that did not follow the patient or cares about your patient. It become very hard when you need one of the OB docs to do a c-section for you. You have no power to make any decisions, yet nobody is really making decisions..... I HATE THAT. It leaves you looking like a moran in front of the patient because they are told so many things by different people. This is fresh on my mind because it just happened to me the other night.

The RRC in FP should really re-think the continuity delivery requirments. It creates a hardship on EVERYBODY.

I think OB should be an elective and not a requirment. We should spend more time doing GYN procedures. It would be okay to spend a month doing deliveries in case you are faced with one on an airplane, in the ED or something. If you really want to do OB do a FP OB fellowship. Even then, you cannot even start to match the training and experience an OB resident gets.

YES THIS IS A HUGE WASTE OF OUR TIME in the long run. Time would be better spent on derm, peds office, GYN, simple procedures and such. Or just go hang out in the ED and do your thing there. You will see EVERYTHING.

I don't think you can assume your situation, as unfortunate as it is, is the norm. It's very different at my program, where we do 80% of the deliveries in the hospital (from our own clinic) and community OBGYNs are actually glad we're there. They share call and we take care of their pts only on occasion. We'll sometimes do their deliveries for them if they can't make it in time. We have OBGYNs on our faculty who are dedicated to us and our patients only, so there is always someone to help you do a section, and to teach while they do it.

My continuities have been some of the most satisfying experiences of my intern year. I really like taking care of a pt then delivering her, then taking care of mom and baby afterwards. This is why I chose FM.

Just wanted to give another perspective. That's the thing about FM, there are so many ways to do it and train for it--it's REALLY important to find out as much as you can about the details of how programs work before you rank them, or you'll be dissatisfied. If you don't care about OB, try to find a program that is light on OB, or where you can do a "low" OB track.

 

[Peeshee]

I agree about the OB part of FP residency, especially for those who don't want to do OB after the finish residency. I also think the requirement should be changed and residents should be given an option whether or not to get training in OB. I think the FP residency needs to be more tailored according to the resident's interests and not just piling stuff on us. The med. student is right that we are spread thin and sometimes you don't feel that you have adequate training in any one area. I didn't realize this until AFTER I got into FP residency. If you are already feeling that way even before residency starts, I would suggest you choose a more specialized field or at least choose a residency that will allow you to tailor your interests.
Residency really is about YOUR training and preparing you for your future practice. Why do we need to do stuff that we will never use (or will never want to use) in the future?

 

[EdibleEgg]

This is an often debated topic in family medicine. First, to the OP,family medicine is not spread too thin. You have to look at the focus of the speciality, which is delivering continuity primary care. A good Family Medicine residency will prepare you for hospital care, emergencies, procedures, and obstetric care, but the focus is really ambulatory medicine. I know I'm a little biased, but when you look at the hours in training devoted to the way most primary care physicians actually practice, family medicine is actually very focused. If you compare US healthcare to other countries, who arguably have better health care for less money, the bulk of the care is provided by general practioners who have less training than the average family physician. In my residency, we averaged approximately 3 half days of continuity clinic per week over the three years, but the internal medicine residency averaged less than one half day per week (their clinics were canceled during busy months like ICU). I know of several IM guys who felt unprepared when starting an office based practice.

You have to understand that FP's don't claim or want to know everything about everything. For example, I believe you can easily come out of a FM residency completely qualified and prepared for low risk obstetrics, even C sections in the right environment. However, you are not going to know nearly as much about gyn onc, repro endo, or several of the other areas that the OB/GYN residencies spend a great deal of time on. But it's unfortunate that ego's often get in the way of acknowledging that FP's can provide a great deal of care that often overlaps with the care given by specialists.

To the OB issue, if you keep wiping away small amounts of your scope of practice you may not be happy with what you have left. Also, during my times times of urgent care moonlighting, I have often been very happy that I have had a good deal of ob training when taking care of pregnant patients with other issues.

 

[anxietypeaker]

Hey, so im only a lowly undergrad....and also...please keep in mind my question is to educate...NOT flame a fire:

And so, keeping in mind family med specialty is extremely focused on ambulatory care (which seems cool to me), whats the purpose of a family nurse practitioner? I thought they were also focused on ambulatory care.

Note: I heard the family practitioner can work with more complicated issues? Assuming the family practitioner is working only in clinic, what sort of "complicated" issues arise in clinic that a family nurse pract. wouldn't deal with? Any examples?

PLEASE DONT FIGHT CUZ OF THIS POST. MY QUESTION IS ESSENTIALLY WHATS EACH PROFESSION'S ROLE IN THE CLINIC...NOT WHICH IS BETTER/ETC ETC.

 

[iatrosB]

Hey, so im only a lowly undergrad....and also...please keep in mind my question is to educate...NOT flame a fire:

And so, keeping in mind family med specialty is extremely focused on ambulatory care (which seems cool to me), whats the purpose of a family nurse practitioner? I thought they were also focused on ambulatory care.

Note: I heard the family practitioner can work with more complicated issues? Assuming the family practitioner is working only in clinic, what sort of "complicated" issues arise in clinic that a family nurse pract. wouldn't deal with? Any examples?

PLEASE DONT FIGHT CUZ OF THIS POST. MY QUESTION IS ESSENTIALLY WHATS EACH PROFESSION'S ROLE IN THE CLINIC...NOT WHICH IS BETTER/ETC ETC.

That's a good question. You are also correct in that FM is trending toward ambulatory focused medicine. Keep in mind however, many FM docs still practice both outpatient and hospital medicine and NP's normally do not do inpatient work.

You're correct that NP's can handle much of the bread and butter FM (sinusitis, anxiety, URI, otitis, simple procedures...), but tend to struggle with the more complicated patients. Examples are the hypertensive diabetic with renal/cardiac disease. Patients are getting increasingly older and having more long term co-morbidities. The more problems that get pilled on, the more "complicated" a patient is.

At the end of the day, there is a great need for both NP's and FM's in the ambulatory setting.

 

[Old_Mil]

Just wanted to give another perspective. That's the thing about FM, there are so many ways to do it and train for it--it's REALLY important to find out as much as you can about the details of how programs work before you rank them, or you'll be dissatisfied.

For those of you who have been there and done that, what are some of the questions to ask to get this information?

 

[sophiejane]

For those of you who have been there and done that, what are some of the questions to ask to get this information?

1. what is the average number of patients seen in clinic per week, and what types of patients are you going to see ? (almost all kids and OB, lots of sick older people, middle class insured--this one is rare for training pgms b/c most with good insurance see private docs)

2. What kind of supervision do you have on call or overnight, or on hospital services in general? Is there active teaching during rounds and on call, or is it so busy you just try to get the work done?

3. If you are interested in OB, how are deliveries done? Are the patients solely your "own", meaning continuity pts that you or faculty see in clinic, or do you rely on private OBGYNs "alllowing" you to labor and deliver their pts in the hospital? (The latter is not a good setup if you want strong OB experience).

4. What is the relationship like with local specialists you rotate with? Are you treated like a medical student and mostly shadow, do they scut you out, or is it truly a teaching and learning situation where you follow pts and do procedures?

5. How is the division of labor? Is it all dumped on the intern or is there more of a team approach?

These are just a few. I would strongly recommend spending 2 weeks to a month at your top three programs during 4th year. There is no better way to truly know what you are getting yourself into. Interviews and even second looks can be very deceiving.

 

[dirtridndoc]

And this is precisely why, 3 years in FP residency, I am doing a second residency in EM. I am tired of OB continuity, I am sick of endless clinic hours, well-baby checks, being a social worker and psychiatrist and I have no desire to ever be on call again. My interest has always been rural EM and I thought that I would feel qualified to practice EM in a rural setting after my FP training but our training IS spread too thin. There is too much emphasis on OB and clinic and only 2 scheduled EM rotation in 3 years. Even in our third year, when we are supposed to get electives in areas that will enhance our careers, we are hammered with clinic and do not get ample time to work with our community attendings in the ED, surgery, ICU, etc...But... we get 6 long, painful weeks 600 miles away for "high-risk" OB - which very few of us will ever do again and we are required to do 4 weeks rural FP in our home state - even though few of us stay here.

For those of you going through the Match, if any of these things bothers you now, it will only get worse in residency. If you have any doubt that FP is NOT for you, do your self (and your future FP program) a favor and choose something else. Don't get me wrong, I'm glad I have my FP training as it will serve me well in rural EM, but it has been a miserable experience. Granted, a lot of it is my particular program, but a lot is about lifestyle and what makes medicine personally satisfying to you. I have the utmost respect and admiration for those of you who are idealistic and committed enough to want to pursue Family Med. I just hope that after 3 years of FP residency, you still have those qualities.

Best of luck in the Match. Choose wisely.

 

[sophiejane]

...Even in our third year, when we are supposed to get electives in areas that will enhance our careers, we are hammered with clinic and do not get ample time to work with our community attendings in the ED, surgery, ICU, etc...But... we get 6 long, painful weeks 600 miles away for "high-risk" OB - which very few of us will ever do again and we are required to do 4 weeks rural FP in our home state - even though few of us stay here.

...Granted, a lot of it is my particular program, but a lot is about lifestyle and what makes medicine personally satisfying to you.

This is why I keep telling people to really look closely at curricula and what that is going to mean to your future practice. I made a big chart comparing the required and elective rotations at my top 3, and even though the RRC mandates certain number of weeks in the core rotations, you'd be surprised at the variation between programs.

I strongly urge anyone interested in FM to really think about your future practice, and get some concrete ideas down before you ever even interview, much less rank programs. Look carefully at curricula and see if they are going to serve you well or will be just another hoop.

If you really do have something specific like rural EM in mind, you should think about a program that doesn't require 6 weeks of HROB, for example (especially at a remote location), and where you can get the elective time you need to accomplish your goals. Go for an urban program at a hospital with plenty of trauma, for example. I don't think rural programs necessarily train you best for rural practice.

Do choose wisely, but know that because of the breadth of our training and the spectrum of possible practice opportunities when you are done, you really do have to do a lot more thinking and planning before you ever start interviewing than people who choose fields with a narrower focus.

Personally, I love that flexibility about FM, but you darn well better be sure you know what want when you get out before you choose a program.