Primary Care for Women - Family Practice VS OB/Gyn

[wiscRD]

I am torn between two specialties and am hoping for some advice. Originally I thought I'd go into family medicine because I like the idea of preventive care and taking care of people throughout their lifetime. I want a career where I form relationships with my patients, not just see them for a visit or two. Then I did my ob/gyn rotation and loved it. The rotation was at a community site, so I worked one-on-one with the doctors and my days were structured like theirs - surgery first thing in the morning, clinic all day, deliveries throughout the day. There were also random surgery days and L&D days to gain more experience in those areas. After the rotation I felt pretty confident I was going to go into ob/gyn. The doctors I worked with had patients they saw for primary care, gyn specialty care, and prenatal care, which seemed like a perfect mix. I liked the fact that you start seeing (most) women when they are healthy and you can focus on prevention. I also liked that I could become an expert in one population while still have a broad depth of knowledge.

I didn't love my peds rotation, which made ob/gyn move higher on my list. On my FM rotation I kept an open mind and had an enjoyable experience. In our area some still do OB and the practice only had a few kids a day, if any at all. When the doctors found out I was between ob/gyn and FM they would ask me more about what I wanted to do. I am not 100% sold on surgery at this point - I enjoyed what I did but I don't think I need it to be part of my practice (especially if in-office procedures are an option)...I have yet to do my surgery rotation, so we'll see. What I really want is that ongoing primary care relationship with women and to deliver babies. The FM doctors I've talked to have (accurately) pointed out that all of the ob/gyns in the area refer out to IM/FM when their patients develop chronic medical conditions. They said most of the ob/gyns in this area don't have a heavy medical management practice - they mainly just do the physicals. The area where I did my FM rotation is the area I plan to live/work after residency, so I feel that this is an important observation.

The FM doctors have been convincing, so I am considering FM again. However, I'm torn - if I go into FM is it even possible for me to focus my practice on women's health or will I need to see men and kids as well? I am a female, so most of the FM doctors I have talked to said if I marked myself that way it might be possible since young women would choose me as their primary/ob given the fact I am a young female. Would I need to do a fellowship in women's health or obstetrics?

Also, how does pay work. Ob/gyns make significantly more than FM doctors. If I were a FM doc doing a lot of OB, would my pay be adjusted appropriately? I would be working much crazier hours than office-based FM doctors and my procedures would make more money than office visits, so I am assuming the pay is adjusted accordingly. In this area most of the hospitals cover liability insurance, so that part doesn't matter as much for me.

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[Cooperd0g]

OB/Gyn makes more because they do more involved procedures and surgeries than FM which have higher payouts. Payment is based on what you do and bill for, not necessarily what your specialty association is. Of course, you trained in FM you would be hard pressed to be doing knee scopes and bill for those. But if you are trained, proficient, and can get credentialed (as needed for C sections and OB at hospitals) you will get paid the same rate for those procedures as an OB/Gyn would. If you do less than them or don't do surgeries that have high payouts then you can't bill for those things and your overall pay will be lower than an OB/Gyn. You would need the equipment to do those kinds of things - colpos and LEEPs need pretty specific equipment, but if you are focused on women's health then they would be worth the cost. If you were dead set on women's heath and didn't really care for all the surgery then you could do FM and save a year of training, but focus your electives on OB/Gyn stuff. You could also tailor your choice of residency training locations to ones that are OB heavy. If you are starting your own practice you can set it up however you want and just take women only I suppose.

 

[babdoc]

There are also high risk OB fellowships for after FM if you find you want another year of OB after a FM residency.

 

[wiscRD]

Thanks for the responses.

copperd0g - That is what I thought re: pay, but just wanted to be sure. Some of the FM residencies I am interested in are OB heavy, so that should help too. I'm glad to hear this is an option.

babadoc - I didn't know there were high risk OB fellowships for FM doctors aside from being trained to do c-sections. I will need to look into that more.

 

[MerickManual]

Thanks for the responses.

copperd0g - That is what I thought re: pay, but just wanted to be sure. Some of the FM residencies I am interested in are OB heavy, so that should help too. I'm glad to hear this is an option.

babadoc - I didn't know there were high risk OB fellowships for FM doctors aside from being trained to do c-sections. I will need to look into that more.

Yup, just that most OB fellowships for FM are not accredited. But you get great exposure and training to become more competent.

 

[babdoc]

True.

 

[styphon]

Yup, just that most OB fellowships for FM are not accredited. But you get great exposure and training to become more competent.

OB/MFM whatever you want to call it fellowship is not recognized by ABFM at all. But many of these programs guarantee you a number of c-sections to be able to get priviledges at most hospitals. This would be the best if you want to do very heavy OB FM - as you OB's would be more willing to share call with you as you would not really need back up.

 

[drcrispmd]

East TN state university Bristol FM is a very heavy OB experience. Residents have graduated and done OB and C/S. Great opportunity for GYN electives as well. Unopposed. Residents provide 24/7 l&d coverage for one group and almost that much coverage for the other group OB/GYN group in town. Message me if you have any questions.

 

[DiseaseCare]

Quite frankly, if you're struggling between ObGyn and FP/FM/GP, do ObGyn. I would not even recommend GP/FP/FM as backup just so you get ObGyn experience if match doesn't work out.

This is how I put it to those who are vacillating: as an FP/FM/GP you can manage all primary care, but easily be blocked from ObGyn; as an ObGyn, you can manage all women's reproductive health issues, but cannot be as easily blocked from managing all primary care (with the exception of perhaps Peds).

I'm sure a lot of GPs will protest, but we all went through similar medical school learning and some (depending on country) had to go through GP training before ever getting to their specialty of choice. As a result, you can do much of what a GP does if you're motivated. So yes, you can be the ObGyn who sees the woman for Htn, T2DM, migraine, acne, etc. and no one will care as long as you're following guidelines, which isn't hard to do, and appropriately referring out. And no worry about malpractice insurance (primary care providers get sued the least) or hospital privileges either for primary care (except perhaps admitting patients, which even for a GP isn't a given with all the IM hospitalists around forming groups less likely to hire FPs).

Offended or not convinced? Think of how legislation is increasingly giving more autonomy to "mid-level providers," so PAs and especially NPs. And rightly so in my opinion: We need all the help we can get in this wasteful, inefficient system.
Furthermore, like it or not, FM doing OB is on the decline (training- and practice-wise), as are rural hospitals that are more likely to grant privileges to nonspecialists.

And for those wondering, I'm a current FM resident wondering if perhaps IM or Med/Peds may have been a better option. I'll get my OB fix when I go global to where desperation for medical practitioners is such that you will be delivering babies and perhaps even doing Caesareans if you're motivated to learn because no one cares about foolish turf wars - just get the work done, and if I know and you don't, I'll show you and you can help lighten the load. That's real medicine.

 

[VA Hopeful Dr]

Quite frankly, if you're struggling between ObGyn and FP/FM/GP, do ObGyn. I would not even recommend GP/FP/FM as backup just so you get ObGyn experience if match doesn't work out.

This is how I put it to those who are vacillating: as an FP/FM/GP you can manage all primary care, but easily be blocked from ObGyn; as an ObGyn, you can manage all women's reproductive health issues, but cannot be as easily blocked from managing all primary care (with the exception of perhaps Peds).

I'm sure a lot of GPs will protest, but we all went through similar medical school learning and some (depending on country) had to go through GP training before ever getting to their specialty of choice. As a result, you can do much of what a GP does if you're motivated. So yes, you can be the ObGyn who sees the woman for Htn, T2DM, migraine, acne, etc. and no one will care as long as you're following guidelines, which isn't hard to do, and appropriately referring out. And no worry about malpractice insurance (primary care providers get sued the least) or hospital privileges either for primary care (except perhaps admitting patients, which even for a GP isn't a given with all the IM hospitalists around forming groups less likely to hire FPs).

Offended or not convinced? Think of how legislation is increasingly giving more autonomy to "mid-level providers," so PAs and especially NPs. And rightly so in my opinion: We need all the help we can get in this wasteful, inefficient system.
Furthermore, like it or not, FM doing OB is on the decline (training- and practice-wise), as are rural hospitals that are more likely to grant privileges to nonspecialists.

And for those wondering, I'm a current FM resident wondering if perhaps IM or Med/Peds may have been a better option. I'll get my OB fix when I go global to where desperation for medical practitioners is such that you will be delivering babies and perhaps even doing Caesareans if you're motivated to learn because no one cares about foolish turf wars - just get the work done, and if I know and you don't, I'll show you and you can help lighten the load. That's real medicine.

This may be some of the worst advice I have ever seen.

 

[deleted87716]

This may be some of the worst advice I have ever seen.

I stopped reading after he said "GP."

 

[HipsterLorax]

I think it's very possible to develop a practice where you focus on women's health as a family doc. There are a couple FPs at my program that have academic interests in specific things related to women's health, thus their practices are largely composed of women.

Also, if you are in or near a more rural area, it's definitely doable to do a lot of OB. There's a small rural practice that we can rotate at that does 25 deliveries/month..

 

[cabinbuilder]

If you are that into women's health I would do OB/GYN. Take with a grain what people are saying about more rural areas letting FP's still deliver. Again, that comes down what your definition of "rural" is too. This practice is quickly going by the wayside as more complicated pregnancies are referred out to a larger center. If you want to deliver babies then I would strongly urge you to do the specialty that trains you what to do when that big emergency happens and you have the knowledge to save both patients instead of being out there alone in an "oh **** moment" wishing there was someone to call.

 

[serendipity16]

If you really are dedicated to the FM route, You should strongly consider a fellowship. They train you how to deal with obstetrical emergencies. Depending on the program, your OB numbers when you finish are comparable to ob/gyn residents. You must do your research though, since not all programs are equal. Washington state has several strong programs including one at Swedish.

There is also a 4 year FM/OB residency at UC Davis.

 

[linguistafeliz]

I actually think that it depends a lot on where you think you might want to practice long term. From what you have written in your post I would agree that Family Medicine with a focus on OB makes the most sense. You definitely would not be required to see children--I have even met family physicians who spend 90% of their time working as pure laborists (e.g. on the labor and delivery ward).

In FM, if you choose to focus on OB and go to a good program, you will spend 3-4 years training and with a big focus on chronic conditions, maternity care, C-sections, etc. and I would argue that the Peds training could actually make you a better OB doctor as you will be familiar with care and conditions of newborns and be better able to advise mothers, and even take see their babies for a few visits (if you choose not to do full-scale Peds).

That said, in many parts of the country, OBs have a stranglehold and family physicians (while generally able to provide prenatal care) may not be able to secure privileges to deliver and do C-sections. People make a big deal about urban vs rural not being able to deliver/etc., but I think this not as important because you can go to an Academic center w/ family medicine and still do deliveries/C-sections. However geographical area may be important. I would think about where you eventually want to practice and ask residents/ physicians in that area about what it's like. In general I expect the west coast, the midwest, and parts of the rest of the country are more friendly towards FM doing deliveries/C-sections.

 

[linguistafeliz]

Also would add that since Obgyn is a very surgical specialty (you are being trained to be a surgeon) I would look hard at the Gyn surgery aspect of it and make sure that if you do decide to do Obgyn, that you are comfortable with the idea of spending a good portion of your time in residency learning to do "benign" gyn and gyn-onc surgeries.

 

[styphon]

Also would add that since Obgyn is a very surgical specialty (you are being trained to be a surgeon) I would look hard at the Gyn surgery aspect of it and make sure that if you do decide to do Obgyn, that you are comfortable with the idea of spending a good portion of your time in residency learning to do "benign" gyn and gyn-onc surgeries.

I am back to comment again, 2 years later.

The above is the reason why I went into FM instead of OB. I love OB procedures, but I was not interested in Gyn surgery at all. I also noticed a large majority of the OB's in our area, "semi-retire" and just do GYN surgeries/consults 8-5 M-F and totally drop the OB part. That sounded horrible to me, hence my choice.

That said, in many parts of the country, OBs have a stranglehold and family physicians (while generally able to provide prenatal care) may not be able to secure privileges to deliver and do C-sections. People make a big deal about urban vs rural not being able to deliver/etc., but I think this not as important because you can go to an Academic center w/ family medicine and still do deliveries/C-sections. However geographical area may be important. I would think about where you eventually want to practice and ask residents/ physicians in that area about what it's like. In general I expect the west coast, the midwest, and parts of the rest of the country are more friendly towards FM doing deliveries/C-sections.

This statement has some inaccuracies. You cannot bill for "prenatal care" alone as it is paid in one lump sum along with the delivery costs. Doing prenatals without being involved in deliveries and without a written contract with the person delivering will actually cost you money as each visit will be at a loss of income. It is possible to make a contact with an OB who deliveries that you will do prenatal care, and they deliver and they will give you some of the lump sum back- but good luck with that.

Also moving into an OB dominated area does not make it harder to get privileges if you have the numbers in training, as they can not deny it based on the FM specialty. What you will have a problem with is getting enough patients to make it worth your while, as most will choose the OB over you.

 

[deleted87716]

It is possible to make a contact with an OB who deliveries that you will do prenatal care, and they deliver and they will give you some of the lump sum back- but good luck with that.

You'd also have to be very careful not to run afoul of Stark (fee-splitting).