Learning "Medicine" in FM

[primadonna22274]

Hi all,

I appreciate your helpful advice. I'm on the interview trail and have had some great experiences at a few solid FM programs, one unopposed 10 minutes from my house in SC. (I was able to spend a month on the inpatient team there--they liked me, I liked them, from day 1 they treated me as an intern and I felt valued.) I still have several more interviews including a couple solid IM programs and one Med-Psych (yes, to some degree I thought I would let the match make up my mind).

Here's my struggle: I really am an internist at heart. I always want to know "why" and "how". I'm not content to practice pattern recognition and if this, then that (I've been a PA for 13 years and my dissatisfaction with not knowing what I don't know led me back to med school...now I know more but still so much I don't know). I worry that spending more time on OB and peds rotations in residency (mandatory for FM, but not my interest--my main interest is geriatrics and end-of-life care and medical education) will take away from the inpatient medicine I want to learn and get really good at. On the flip side, I have been assured that there is PLENTY of inpatient time at the FM residencies I'm considering (some more than others).

Also, my favorite FM residency has hospitalist and geriatrics/palliative medicine tracks. It's almost like it was designed for me LOL.

So I would appreciate hearing from you FM folks whether you feel an FM residency is a reasonable choice for someone like me who really loves IM and adults--particularly old adults with chronic disease and complex medical management needs. A couple considerations: I'm older (almost 40), no kids, have a nice home in a lovely area and husband won't move. Also: the nearest IM program is 80 miles away (not commutable on a daily basis) and the others are between 2-3 hr away so would need a bachelorette pad. Not opposed to that as we've lived apart half of our marriage but it does get expensive maintaining 2 homes and protracted distance is very hard on any marriage.

Thanks

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[organdonor]

My advice would be to look at what some of the recent graduates of your potential programs have gone into. ALL FM programs say they have the best inpatient experience, but when all their grads who wish to be hospitalists all do fellowships, while the program down the road made three practicing hospitalists last year straight out of residency, you can draw your own conclusion.

If geriatrics is your interest then of course it would be great to go to a program where you can be exposed to that fellowship.

 

[Bacchus]

An unopposed residency is probably your best bet. My unopposed colleagues, while more stressed, seem to be getting a stronger inpatient experience than me. Geriatric fellowships, from what I gather, aren't extremely difficult to get so there is the possibility of that after residency.

 

[VA Hopeful Dr]

Yeah, since geriatrics doesn't mean more money those are not terribly difficult to get into.

As for the why - that's what medical school is for. That's why we all know the why's so much better than anyone else involved in medicine. Do I know the why's as well as my internist wife, no. But, the stuff that she catches that I miss is usually on the molecular level - tyrosine kinase changes with increase insulin resistance, and stuff like that. Its not like she knows why dobutamine is good for pulm edema in CHF exacerbation and I don't, or why ace inhibitors can cause a rise in creatinine. Plus, residency is a fair bit of self study. So if you want to know the why, you can learn it easily enough.

 

[cabinbuilder]

Hi all,

I appreciate your helpful advice. I'm on the interview trail and have had some great experiences at a few solid FM programs, one unopposed 10 minutes from my house in SC. (I was able to spend a month on the inpatient team there--they liked me, I liked them, from day 1 they treated me as an intern and I felt valued.) I still have several more interviews including a couple solid IM programs and one Med-Psych (yes, to some degree I thought I would let the match make up my mind).

Here's my struggle: I really am an internist at heart. I always want to know "why" and "how". I'm not content to practice pattern recognition and if this, then that (I've been a PA for 13 years and my dissatisfaction with not knowing what I don't know led me back to med school...now I know more but still so much I don't know). I worry that spending more time on OB and peds rotations in residency (mandatory for FM, but not my interest--my main interest is geriatrics and end-of-life care and medical education) will take away from the inpatient medicine I want to learn and get really good at. On the flip side, I have been assured that there is PLENTY of inpatient time at the FM residencies I'm considering (some more than others).

Also, my favorite FM residency has hospitalist and geriatrics/palliative medicine tracks. It's almost like it was designed for me LOL.

So I would appreciate hearing from you FM folks whether you feel an FM residency is a reasonable choice for someone like me who really loves IM and adults--particularly old adults with chronic disease and complex medical management needs. A couple considerations: I'm older (almost 40), no kids, have a nice home in a lovely area and husband won't move. Also: the nearest IM program is 80 miles away (not commutable on a daily basis) and the others are between 2-3 hr away so would need a bachelorette pad. Not opposed to that as we've lived apart half of our marriage but it does get expensive maintaining 2 homes and protracted distance is very hard on any marriage.

Thanks

I felt like I got plenty of hospitalist/Internal medicine training at my residency program. There were reasons behind this: Unopposed. Our PD is an Internist and was very big on IM teaching in morning report, we had 12 months of inpatient hospitalist service over the 3 years. We covered the entire hospital and usually had 25 patients avg to see on any given day. Also, half of our clinic was IM and the other half FP so we got a mixture of both. We also had a geriatric rotation that was strictly clinic. Our peds rotations were minimal and we only did outpatient peds, no inpatient. We had 1 OB rotation and 1 GYN clinic rotation - that's it. I never delivered a baby in residency - luck of the draw. We did not see pregnant patients in our residency clinic. I did lots of procedure heavy rotations kowing I would be doing rural medicine. You just want to make sure you have the flexibility within the program to learn what you want to satisfy your career goals.

 

[Bacchus]

To the above, this will only be true in an AOA FM residency. The ACGME has stricter guidelines in terms of OB training.

 

[MerickManual]

To play devil's advocate: I have exposure to a program that was unopposed FM, but everyone complained that they didn't have much autonomy during their 4 months of inpatient training due to physicians at the hospital are not used to teaching, and that the patient population was very vanilla. Just something to think about. Unopposed =/= awesome 100% of the time, so research your programs and get the insider info on programs!

 

[primadonna22274]

To the above, this will only be true in an AOA FM residency. The ACGME has stricter guidelines in terms of OB training.

I didn't apply to any AOA programs.
ACGME has recently relaxed the rules for OB in FM: no specified number of continuity deliveries and a very low minimum of OB overall. For someone like me who has zero interest in pregnant women this is good news. Basically the programs will be able to decide how they want to teach OB.

 

[primadonna22274]

To play devil's advocate: I have exposure to a program that was unopposed FM, but everyone complained that they didn't have much autonomy during their 4 months of inpatient training due to physicians at the hospital are not used to teaching, and that the patient population was very vanilla. Just something to think about. Unopposed =/= awesome 100% of the time, so research your programs and get the insider info on programs!

Very good point. The only FM programs I applied to are unopposed. They have all had strong medicine/inpatient exposure (around 12-16 mos, more available if desired). One program had internists on staff--I think a very smart idea--and another recently hired a pediatrician to coordinate the peds part of the curriculum. All have PharmDs on staff which I think is a huge boon.
It's gonna be a bit difficult to come up with my rank list but I guess it's a nice problem to have

 

[Bacchus]

I didn't apply to any AOA programs.
ACGME has recently relaxed the rules for OB in FM: no specified number of continuity deliveries and a very low minimum of OB overall. For someone like me who has zero interest in pregnant women this is good news. Basically the programs will be able to decide how they want to teach OB.

Oh, I had no idea. We're still 10 continuity and 40 total.

 

[cabinbuilder]

To the above, this will only be true in an AOA FM residency. The ACGME has stricter guidelines in terms of OB training.

So does the AOA. Things changed a lot after I did intern year. That was our only month of OB in residency. Where I went there wasn't a structured OB rotation when I started so no one had any exposure. The next year our PD changed and then the interns got a good solid month of deliveries. It was one year too late for me. Just worked out that way.

 

[septoplasty]

I didn't apply to any AOA programs.
ACGME has recently relaxed the rules for OB in FM: no specified number of continuity deliveries and a very low minimum of OB overall. For someone like me who has zero interest in pregnant women this is good news. Basically the programs will be able to decide how they want to teach OB.

Oh, I had no idea. We're still 10 continuity and 40 total.

That's because they haven't.

They're going to decide in April 2014. At max they will decrease the continuity numbers, but this will depend on programs to determine "OB competency", meaning if your program doesn't think having 30 deliveries makes you competent, then they may say 37 regular deliveries, 3 continuity etc (hypothetical number). You'll never get away with having 30 deliveries for the entire portion of obstetrics in a 3 year FM residency. That'd be crazy.

 

[primadonna22274]

2 very different (and both OB-friendly) allopathic PDs have told me they anticipate a much lower number of deliveries (like 10-15, not yet decided) to determine competency. They like the idea because it allows for residents who want lots of OB exposure to take more OB call etc and for those who want as little as possible (me! Me! I have absolutely no interest in OB whatsoever) to spend that time in rotations that do interest them (critical care, whatever).
I guess the idea isn't set in stone yet but I warmed to FM a little more when I heard they were relaxing the OB requirement significantly.

 

[Bacchus]

2 very different (and both OB-friendly) allopathic PDs have told me they anticipate a much lower number of deliveries (like 10-15, not yet decided) to determine competency. They like the idea because it allows for residents who want lots of OB exposure to take more OB call etc and for those who want as little as possible (me! Me! I have absolutely no interest in OB whatsoever) to spend that time in rotations that do interest them (critical care, whatever).
I guess the idea isn't set in stone yet but I warmed to FM a little more when I heard they were relaxing the OB requirement significantly.

I have 8 deliveries. Relaxing it to 10-15 is not a good idea at all. There is no way I can say I'm near competent. If I delivered a patient tomorrow who had a very bad tear, ended up with a dystocia, or PPH I'd be screwed.

 

[primadonna22274]

I have 8 deliveries. Relaxing it to 10-15 is not a good idea at all. There is no way I can say I'm near competent. If I delivered a patient tomorrow who had a very bad tear, ended up with a dystocia, or PPH I'd be screwed.

I hear ya Bacchus but I am never ever ever gonna do this again after residency and won't seek OB privileges. So I don't care--but I realize my utter distaste for OB is not good policy lol

 

[primadonna22274]

To play devil's advocate: I have exposure to a program that was unopposed FM, but everyone complained that they didn't have much autonomy during their 4 months of inpatient training due to physicians at the hospital are not used to teaching, and that the patient population was very vanilla. Just something to think about. Unopposed =/= awesome 100% of the time, so research your programs and get the insider info on programs!

Thank you for this. I have had a good exposure at one program (the one closest to my home) that is unopposed. They run a VERY busy inpatient service typically 35-40/day and follow their patients into all units except for NICU. This has been the only residency in the area for 30-odd years and is well respected. Patients here are SICK so not just vanilla but all 31 flavors and then some. Very active teaching service and consultants by and large are committed and enjoy teaching as well. I was there in October and the interns were already highly autonomous (some stronger than others). Good points though and well taken.

 

[cabinbuilder]

I hear ya Bacchus but I am never ever ever gonna do this again after residency and won't seek OB privileges. So I don't care--but I realize my utter distaste for OB is not good policy lol

F####king hate OB, hated myself being pregnant. Never have, will never do it. You don't have to know it or ever deal with it as FP once you are out of residency so DO NOT WORRY. DO the minimum that is required, forget it and move on.

 

[VA Hopeful Dr]

F####king hate OB, hated myself being pregnant. Never have, will never do it. You don't have to know it or ever deal with it as FP once you are out of residency so DO NOT WORRY. DO the minimum that is required, forget it and move on.

That's not true for 2 reasons.

One, as mentioned in another thread - OB is on Boards which we have to take every 10 years.

Two, I get about 1-2 pregnant women every time I do Urgent Care. Obviously I won't be delivering those babies, but its useful to know OB so I can say "Yes that's just dependent edema" versus "that looks bad, you should do to L&D for monitoring".

 

[VA Hopeful Dr]

Maybe this is just me, but one of the reasons I got into FM was to be the jack-of-all-trades. I like knowing about every aspect of medicine.

 

[Bacchus]

That's not true for 2 reasons.

One, as mentioned in another thread - OB is on Boards which we have to take every 10 years.

Two, I get about 1-2 pregnant women every time I do Urgent Care. Obviously I won't be delivering those babies, but its useful to know OB so I can say "Yes that's just dependent edema" versus "that looks bad, you should do to L&D for monitoring".

Just to add, as a student where I did my OB rotation, they often said "see your PCP for that." Obviously this won't be done by everyone, but I don't want to be surprised when someone pregnant walks through the door, either.

 

[VA Hopeful Dr]

2 very different (and both OB-friendly) allopathic PDs have told me they anticipate a much lower number of deliveries (like 10-15, not yet decided) to determine competency. They like the idea because it allows for residents who want lots of OB exposure to take more OB call etc and for those who want as little as possible (me! Me! I have absolutely no interest in OB whatsoever) to spend that time in rotations that do interest them (critical care, whatever).
I guess the idea isn't set in stone yet but I warmed to FM a little more when I heard they were relaxing the OB requirement significantly.

This has been "expected" since I was an intern. It keeps getting pushed back another year every year, so I will believe that this will actually happen the day it actually happens.

 

[primadonna22274]

Just to add, as a student where I did my OB rotation, they often said "see your PCP for that." Obviously this won't be done by everyone, but I don't want to be surprised when someone pregnant walks through the door, either.

I realize as an n=1 my experience is not at all generalizable to others but as a longtime FM and EM PA, I am more than comfortable managing medical problems in pregnant women and have had plenty of experience in the ED with early pregnancy problems.

 

[VA Hopeful Dr]

I realize as an n=1 my experience is not at all generalizable to others but as a longtime FM and EM PA, I am more than comfortable managing medical problems in pregnant women and have had plenty of experience in the ED with early pregnancy problems.

True, but if you did a residency where you spent 3 years and never saw a pregnant women (IM say) then you would lose those skills pretty fast.

 

[styphon]

I realize as an n=1 my experience is not at all generalizable to others but as a longtime FM and EM PA, I am more than comfortable managing medical problems in pregnant women and have had plenty of experience in the ED with early pregnancy problems.

You would also not be covered by malpractice, or even insurance company payments - to take care of OB problems as an IM doctor. Considering OB is one of the highest lawsuit fields - not having malpractice in it would be foolish. Being a PA who had experience with it in the past will not cover you after Medical school (As a PA you were allowed to do what the MD's scope of practice was)

An unopposed residency is probably your best bet. My unopposed colleagues, while more stressed, seem to be getting a stronger inpatient experience than me. Geriatric fellowships, from what I gather, aren't extremely difficult to get so there is the possibility of that after residency.

I had a different experience than this. I was at an "opposed" program in a tiertary care hospital. I was able to see a more odd diseases(Malaria, TB: high refugee population) and I also got tons of experience in HIV management/complications. My friends at the suburban hospital program, which was unopposed had ZERO HIV patients, and dealt more with CHF/HTN problems/DM/Abd Pain/Asthma as opposed to the diseases above.

We both had the same amount of inpt experiences - about 12 months during the residency and 3 OB rotations. I ended up doing 2 OB electives - finished residency with almost 80 vaginal deliveries.

 

[cabinbuilder]

That's not true for 2 reasons.

One, as mentioned in another thread - OB is on Boards which we have to take every 10 years.

Two, I get about 1-2 pregnant women every time I do Urgent Care. Obviously I won't be delivering those babies, but its useful to know OB so I can say "Yes that's just dependent edema" versus "that looks bad, you should do to L&D for monitoring".

Sorry, I was having a moment that day as I re-read my posts. Hating my current assignment I am on. Counting the days.
Yes, you see a few pregnant people, yes you have to know how to deal with them in urgent care, yes you have to know what is urgent/what is "normal". Yes, I have pulled out my share of active miscarriages and clots in the ER.
I was just thinking about deliveries, prenatal, etc in FM clinic when I wrote that.
Was trying to make the point that even if you do OB in residency doesn't mean you have to incorporate it into your office practice.

 

[primadonna22274]

You would also not be covered by malpractice, or even insurance company payments - to take care of OB problems as an IM doctor. Considering OB is one of the highest lawsuit fields - not having malpractice in it would be foolish. Being a PA who had experience with it in the past will not cover you after Medical school (As a PA you were allowed to do what the MD's scope of practice was)



I had a different experience than this. I was at an "opposed" program in a tiertary care hospital. I was able to see a more odd diseases(Malaria, TB: high refugee population) and I also got tons of experience in HIV management/complications. My friends at the suburban hospital program, which was unopposed had ZERO HIV patients, and dealt more with CHF/HTN problems/DM/Abd Pain/Asthma as opposed to the diseases above.

We both had the same amount of inpt experiences - about 12 months during the residency and 3 OB rotations. I ended up doing 2 OB electives - finished residency with almost 80 vaginal deliveries.

My interests are geriatrics and palliative med. Not many pregnant folks there

 

[deleted6669]

Obviously I won't be delivering those babies, but its useful to know OB .

You never know. I delivered at an urgent care last year. lady presented with " flank pain, I think it's another kidney stone". morbidly obese, didn't know she was pregnant, had never been pregnant before( she was 19) and stated she always had irregular periods. lower abd firm on exam(although hard to tell given weight). ucg +, asked about vag bleeding and pelvic pain and she stated some earlier that day. went to do pelvic and head was crowning. delivered without complications. I have taken the ALSO course so am relatively comfortable with textbook dystocia, breech, etc scenarios. I did only 2 solo deliveries as a student on OB rotation and assisted a few others. the place I did ob was c-section crazy with a > 50% section rate( the residents needed #s) so I first assisted lots of those. I have also participated in the deliveries of several babies on international medical missions, including a c-section done with local on a lady with obstructed labor > 96 hrs following the Haiti earthquake. kid looked great.

 

[VA Hopeful Dr]

You never know. I delivered at an urgent care last year. lady presented with " flank pain, I think it's another kidney stone". morbidly obese, didn't know she was pregnant, had never been pregnant before( she was 19) and stated she always had irregular periods. lower abd firm on exam(although hard to tell given weight). ucg +, asked about vag bleeding and pelvic pain and she stated some earlier that day. went to do pelvic and head was crowning. delivered without complications. I have taken the ALSO course so am relatively comfortable with textbook dystocia, breech, etc scenarios. I did only 2 solo deliveries as a student on OB rotation and assisted a few others. the place I did ob was c-section crazy with a > 50% section rate( the residents needed #s) so I first assisted lots of those. I have also participated in the deliveries of several babies on international medical missions, including a c-section done with local on a lady with obstructed labor > 96 hrs following the Haiti earthquake. kid looked great.

Yeah, there's always that chance. Honestly sometimes the narcissistic part of me hopes for a situation where I can deliver a baby on the fly. Luckily the pragmatic part of my brain usually jumps on that pretty quickly.

 

[deleted6669]

If you keep your ALSO card up to date( and carry the cheater guide in your pocket) you are probably fine for any random ob issues that come your way in non-ob practice. I'm actually hoping to do a medical mission to Kenya in a few years that uses american PAs to do multiple deliveries/day at a rural facility. I think it would be great experience to get 50 deliveries done in 2 weeks or so. probably see a dystocia or 2, maybe a breech. would probably get to manage some post partum hemorrhage cases. I liked the OB part of my OBGYN rotation but really am not interested in the gyn side of practice like doing colposcopy(did a few), placing IUDs, etc. I learned how to do open tubal ligations which was fun. I did ob at an inner city facility with a service which was essentially run by the ob residents. very rarely saw an attending, even for sections.

 

[Bacchus]

If you keep your ALSO card up to date( and carry the cheater guide in your pocket) you are probably fine for any random ob issues that come your way in non-ob practice. I'm actually hoping to do a medical mission to Kenya in a few years that uses american PAs to do multiple deliveries/day at a rural facility. I think it would be great experience to get 50 deliveries done in 2 weeks or so. probably see a dystocia or 2, maybe a breech. would probably get to manage some post partum hemorrhage cases. I liked the OB part of my OBGYN rotation but really am not interested in the gyn side of practice like doing colposcopy(did a few), placing IUDs, etc. I learned how to do open tubal ligations which was fun. I did ob at an inner city facility with a service which was essentially run by the ob residents. very rarely saw an attending, even for sections.

I'm finishing ALSO tomorrow. It's been helpful and I feel more comfortable. Wish I had it before my OB rotation this year.

 

[deleted6669]

Our FM residents do it before they start OB. I was the only non-resident in the class when I took it.

 

[cabinbuilder]

Yeah, there's always that chance. Honestly sometimes the narcissistic part of me hopes for a situation where I can deliver a baby on the fly. Luckily the pragmatic part of my brain usually jumps on that pretty quickly.

Somehow that just doesn't seem normal.

 

[VA Hopeful Dr]

Somehow that just doesn't seem normal.

You know, my wife says the exact same thing...

 

[Bacchus]

Yeah, there's always that chance. Honestly sometimes the narcissistic part of me hopes for a situation where I can deliver a baby on the fly. Luckily the pragmatic part of my brain usually jumps on that pretty quickly.

I don't think there's anything wrong with this, haha. Its one of the more enjoyable experiences of medicine...until there is a PPH, dystocia, etc., haha. Which, to be honest, I don't know if they're as bad as the amount of paperwork awaiting me when I am done with a delivery.

 

[drcrispmd]

I'm pgy 3 FM and have done well over 100 deliveries and many repairs. I was doing repairs 3 months into intern year. My program is unopposed and we currently provide 24/7 coverage to the 2 OB practices in town along with our own OB patients. If you hate OB please do not rank a program high that is heavy OB if you hate it. Hearing you complain nonstop over the amount of OB when you knew about it coming in is very annoying to your fellow residents.

 

[Bacchus]

I'm pgy 3 FM and have done well over 100 deliveries and many repairs. I was doing repairs 3 months into intern year. My program is unopposed and we currently provide 24/7 coverage to the 2 OB practices in town along with our own OB patients. If you hate OB please do not rank a program high that is heavy OB if you hate it. Hearing you complain nonstop over the amount of OB when you knew about it coming in is very annoying to your fellow residents.

Do you happen to do residency in PA? This sounds like a program I interviewed at.

 

[primadonna22274]

I'm pgy 3 FM and have done well over 100 deliveries and many repairs. I was doing repairs 3 months into intern year. My program is unopposed and we currently provide 24/7 coverage to the 2 OB practices in town along with our own OB patients. If you hate OB please do not rank a program high that is heavy OB if you hate it. Hearing you complain nonstop over the amount of OB when you knew about it coming in is very annoying to your fellow residents.

Yeah, I wouldn't have applied to nor ranked a program like that. I kind of weeded those out. No thanks.

 

[drcrispmd]

No I am not in PA. I actually wanted a program heavy in OB and would choose this program again.

 

[primadonna22274]

And fortunately there is lots of variety in FM programs so I can choose one that's medicine heavy and OB light

 

[drcrispmd]

And fortunately there is lots of variety in FM programs so I can choose one that's medicine heavy and OB light

Yes there is a wide variety. You need to pick one that matches the most with your interest. Some choose strictly on location and end up not being happy and complaining all the time. I got my first choice and have been a very happy resident for 2.5 years (6 months to go!).