Primary Care's Image Problem

[deleted87716]

http://www.nytimes.com/2009/11/12/health/12chen.html?ref=health

November 12, 2009
Doctor and Patient
Primary Care’s Image Problem
By PAULINE W. CHEN, M.D.

In my medical school class of 140, Kerry was one of the best and the brightest. Gregarious, unassuming and a dedicated fitness buff with a weakness for ice cream, she managed to sail through the weekly exams that most of us struggled with during the first two years. Later on, in the third year on the hospital wards, she quickly became what every one of us so wanted to be: the indispensable medical student.

When it came time to choose specialties in our last year of medical school, most of us thought Kerry would do what every high achiever and even the not-so-high achievers were already doing: line herself up for a coveted spot in one of the prestigious subspecialties, a field like dermatology, orthopedics, plastic surgery or radiology.

But Kerry wanted to become a primary care physician.

Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. “Kerry is too smart for primary care,” a friend said to me one evening. “She’ll spend her days seeing the same boring chronic problems, doing all that boring paperwork and just coordinating care with other doctors when she could be out there herself actually doing something.”

Unfortunately those comments would not be the last ones I would hear disparaging primary care. Even today, similar beliefs persist among medical students and trainees, though they have long since been condensed, reduced to an oft repeated acronym among those choosing specialties: I’m heading for the ROAD (radiology, ophthalmology, anesthesia and dermatology).

That ROAD has had devastating effects on the physician work force in the United States. While 50 years ago half of all physicians were in primary care, almost three-quarters are now specialists. The future implications are even more dismal. According to one study published last year in The Journal of the American Medical Association, as few as 2 percent of medical students are choosing to step away from the ROAD or from other similar “high prestige” and competitive specialties in order to pursue general internal medicine. The statistic has the power to bring even the best efforts at reform and universal coverage to a grinding halt. Even with other health care practitioners like nurses and physician assistants helping to care for as many patients as they can, universal health care will be doomed if there are not enough primary care doctors.

Experts in medical education have pointed to three reasons for this lack of enthusiasm: debt, income and lifestyle. The vast majority of medical students finish their schooling saddled with enormous educational debt — the average amount is in excess of $140,000 — and primary care remains one of the lowest-paid specialties.

In addition, with fewer doctors and more patients, as well as little reimbursement for the specialty’s growing administrative aspects — filling out insurance company and health maintenance organization forms, making telephone calls and writing e-mail messages to coordinate care with other caregivers — primary care physicians end up working longer hours than doctors in other fields just to make ends meet and fulfill patient care responsibilities. Moreover, while pressing and acute care needs arise routinely in patients with high blood pressure, diabetes and heart disease, there are rarely calls of the same urgency among patients with, for example, a skin lesion.

But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough. Despite the fact that primary care physicians remain this nation’s frontline doctors — diagnosing new illnesses, managing chronic ones, advocating preventive care and protecting wellness — medical students may continue to turn away from the practice of primary care.

Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.

That image, however, may be changing. This week in Boston at the annual meeting of the Association of American Medical Colleges, more than 100 members of the Association of Deans and Directors for Primary Care convened to discuss how their specialty might prepare to care for potentially millions of newly insured patients.

High on the group’s agenda was the need for overhauling the practice of primary care. But unlike the image held by naysayers of primary care, the changes proposed and discussed make an innovative vision of primary care practice central to some of the most exciting solutions for the country’s critical health care problems.

“We’ve got this chance now to do something and create a model of practice that will actually work for patients and attract talented students,” said Dr. Bruce E. Gould, head of the Association of Deans and Directors for Primary Care and an associate dean for primary care at the University of Connecticut School of Medicine in Farmington, Conn. “When I finished training, practice was less complex. But the systems haven’t evolved to keep pace with what we can now do for our patients.

“A lot of primary care doctors feel like they are chasing a bus that they are never going to catch. With lives hanging in the balance, that is not a good place to be.”

Steven A. Wartman, president of the Association of Academic Health Centers and a general internist who participated in the discussion, added: “Changes in the practice environment could become the single most important force on medical education. If you look at history, some of the biggest changes in medicine have been a result of changes in practice.”

One of the practice innovations is the patient-centered medical home. “For a long time, we have had this old-fashioned model of an individual doctor working with an individual patient,” said Dr. Nancy A. Rigotti, a professor of medicine at Harvard Medical School and president of the Society of General Internal Medicine. “But the model that works best for patients and doctors is a collaborative one.”

This teamwork approach could transform the very role of the patient-doctor relationship. Currently, primary care doctors often serve as a patient’s principal guide through the health care system maze. In a patient-centered medical home, the doctor would be one guide among many. A patient could turn to an entire team of physicians, nurses, physician assistants, social workers, pharmacists and other health care professionals; and each of those clinicians would in turn work collaboratively with other team members to address that specific patient’s care, concerns and health issues.

“In a patient-centered medical home, I would not be the sole proprietor,” Dr. Gould said. “Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader.”

Other members of the team would also take up responsibilities that have traditionally fallen to primary care physicians but that are more appropriate to their area of expertise. For example, scheduling and follow-up of routine preventive measures like Pap smears, colonoscopy and mammography would be the responsibility of not the doctor but a health care professional with training in electronic medical records and clinical practice support.

“With a team approach,” Dr. Gould added, “each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction.”

Dr. Rigotti said there were demonstration primary care practice projects across the country. “It’s sort of like the thousand-flowers-blooming kind of thing,” she said. “Money alone won’t make primary care fun and rewarding. We have to enjoy the practice of medicine.”

“And,” she added, “I can’t help but believe that students and trainees will be excited by seeing primary care physicians who are being creative and solving the national problem of high quality and efficient care for patients.”

I called my medical school classmate Kerry and asked her about her career decision 20 years ago. “I do remember that the expectation was that you should go on and become a specialist,” she said. She never wavered from her choice of primary care and went into practice after completing a residency in internal medicine.

“But,” Kerry said, “I kept seeing a lot of working people who wanted to take care of themselves and their health problems but who couldn’t afford it and didn’t have the insurance.” So in May 2000, she left her practice and joined two nurse practitioner colleagues to open up the Good Samaritan Free Clinic in Moline, Ill., a clinic that offers free health care to 1,000 working but uninsured adults and that counts more than 70 health care providers as active volunteers.

As I listened to Kerry talk about the clinic, I remembered what Dr. Rigotti had said earlier: “There are a lot of students who want to change the world. Primary care is advocacy one patient at a time.”

Join the discussion on the Well blog, “Giving Primary Care More Respect.”

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[RGMSU]

QUOTE - "This teamwork approach could transform the very role of the patient-doctor relationship. Currently, primary care doctors often serve as a patient’s principal guide through the health care system maze. In a patient-centered medical home, the doctor would be one guide among many. A patient could turn to an entire team of physicians, nurses, physician assistants, social workers, pharmacists and other health care professionals; and each of those clinicians would in turn work collaboratively with other team members to address that specific patient’s care, concerns and health issues.

“In a patient-centered medical home, I would not be the sole proprietor,” Dr. Gould said. “Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader.”

Other members of the team would also take up responsibilities that have traditionally fallen to primary care physicians but that are more appropriate to their area of expertise. For example, scheduling and follow-up of routine preventive measures like Pap smears, colonoscopy and mammography would be the responsibility of not the doctor but a health care professional with training in electronic medical records and clinical practice support." END QUOTE

This is part of the image problem, not the solution. We have had this conversation before. Clumping primary care physicians in with PAs, NPs, pharmacists, and social workers and eroding the physicians' responsibilities by delegating nearly all of it to other people is going to lead to a solution to the primary care physician shortage alright. They won't be needed anymore because they will have been replaced. This is one of the key concerns for medical students considering primary care - the ease with which mid-levels seem to be able to enter primary care and "take over." The more primary care physicians delegate all their responsibilities to somebody else, the more it appears that they DO NOT have a unique skill set, rather than the reverse. Same thing with primary care physicians on a team of specialists - they frequently get marginalized. Maybe it's time for primary care physicians to discover what exactly they do that cannot be done by a hundred other different professionals and define themselves around that before there's nothing left to define themselves around. And, the less necessary they appear, the more likely their salaries are to go down, not up.

 

[deleted6669]

QUOTE Maybe it's time for primary care physicians to discover what exactly they do that cannot be done by a hundred other different professionals and define themselves around that .

that would be lead the team, wouldn't it?

 

[deleted87716]

Medicine is already a team effort. However, many of the "teams" are somewhat ill-defined and ad hoc, resulting in fragmented rather than coordinated care.

The patient-centered medical home adds structure, which will hopefully improve patient care and outcomes.

It does not necessarily have to involve the supervision of mid-level providers.

 

[deleted87716]

The more primary care physicians delegate all their responsibilities to somebody else, the more it appears that they DO NOT have a unique skill set, rather than the reverse.

We're not talking about delegating responsibility. We're talking about delegating scut.

 

[RGMSU]

that would be lead the team, wouldn't it?

Perhaps, unless the team decides they don't need a leader. Or some insurance/government bureaucrat/set of bureaucratic policies takes over that role. Or a specialist physician serves as the leader of a patient's team, depending on the nature of their most significant overall problem.

 

[deleted87716]

Perhaps, unless the team decides they don't need a leader. Or some insurance/government bureaucrat/set of bureaucratic policies takes over that role. Or a specialist physician serves as the leader of a patient's team, depending on the nature of their most significant overall problem.

Or, the world really does end on December 21st, 2012 like the Mayans said.

None of that stuff is very likely to happen.

 

[RGMSU]

We're not talking about delegating responsibility. We're talking about delegating scut.

I understand that as the goal. My concerns are that attempts to delegate have not always turned out so great. Who would have predicted the groundswell of certain mid-levels trying to fight for independent practice rights in many places? Sometimes well-intentioned plans have consequences that go awry. Another concern is the effect on physician incomes. Will the medical home concept place the physician in an executive role, generate more profits, and make them appear more important as leader of the team, thereby increasing/solidifying income? Or, will it thin out the pieces of the pie so that little is left over for the physician, thereby decreasing/weakening the physician's earning power? I can see where ownership of the medical home by physicians would be profitable, as long as the right size of the group is established. This, of course, assumes that physicians are business/politically savvy enough this time to take advantage of a new opportunity instead of letting businessmen step in and steal all their profits.

 

[RGMSU]

Or, the world really does end on December 21st, 2012 like the Mayans said.

None of that stuff is very likely to happen.

I don't know. What if it's determined that a DNP or somebody can just as easily fill the role of leader of the team as an MD/DO, and do it for less money? I don't believe they really can, but if that's the public perception...?

 

[deleted87716]

Will the medical home concept place the physician in an executive role, generate more profits, and make them appear more important as leader of the team, thereby increasing/solidifying income?

Ideally, the medical home concept will include care management fees above and beyond fee-for-service payments (which most experts agree also need to be increased), which will enhance the bottom line and allow physicians to make necessary investments in technology and staff. Effective automation and delegation of non-clinical functions will free the physician up to focus on what they do best...practice medicine. Some may choose to spend more time with each patient and not increase their overall volume, while others may be able to see more patients (and make more money).

It's short-sighted to look at the medical home solely as a way to make more money, however.

 

[deleted87716]

I don't know. What if it's determined that a DNP or somebody can just as easily fill the role of leader of the team as an MD/DO, and do it for less money?

Anyone practicing primary care in an independent (e.g., non-subsidized) manner will face the same economic hurdles, whether they're an MD/DO or a mid-level. The idea that mid-levels will automatically be "cheaper" is, frankly, an erroneous assumption based solely on the illogical premise that you get what you pay for.

 

[tony montana]

The idea that mid-levels will automatically be "cheaper" is, frankly, an erroneous assumption based solely on the illogical premise that you get what you pay for.

This is not too clear, do you mind explaining it a bit more? Thanks.

 

[deleted87716]

This is not too clear, do you mind explaining it a bit more? Thanks.

Why do you think it would be cheaper to see a mid-level instead of a physician?

Because they'll charge less? Not likely, since an independently-practicing mid-level would incur overhead and practice expenses similar to a physician, and would have to charge accordingly.

Because they'll get reimbursed less from insurance companies? Not likely, since most payers already reimburse independently-practicing mid-levels at the same rates as physicians. Sure, they could come up with some kind of tiered payment system and try to force patients to see mid-levels rather than physicians, but that would likely elicit a strong protest from patients as well as the medical (and medico-legal) community.

Because they'll order fewer tests or refer to specialists less often? Not likely. In fact, it's usually the other way around.

Does that help?

 

[porsche518]

Kind of a radical idea, but so many physicians are considered Primary Care ob, peds, fm, im.

I propose we scrap the three year fm and im residency and creat a new four year primary care residency. With the traditional im and limited fm felowships coming from that. It one way to get rid of the fm stigma. Additionally fm and im share so much especially the Primary care IM residencies that it makes sense.

 

[deleted87716]

I propose we scrap the three year fm and im residency and creat a new four year primary care residency.

I fail to see how adding a year to primary care training would make it more attractive...

 

[RGMSU]

I fail to see how adding a year to primary care training would make it more attractive...

Certainly wouldn't make it more attractive to me.

 

[digitlnoize]

Certainly wouldn't make it more attractive to me.

Me either. As a current student considering all my options, I feel like I can throw in my perceptions here...

I'm going to have alot of debt. I have a wife and a daughter, so I've taken out a decent amount of loans. Granted, the wife works, and that has helped, but I'm still going to graduate with ~300k.

Fortunately, my wife makes pretty good money, so we're planning on throwing almost all of my residency income towards paying down the loans. That will help. Hopefully we'll be able to knock 100k off that during residency...Still, it's alot of debt.

I like many aspects of FM. I like the idea of caring for a variety of patients and getting to know them. Cradle to Grave...that whole thing. I like (most) people, and making long-term connections sounds good to me. I like the variety, I like preventive medicine. I'm a firm believer in fixing problems before they start, and FM appeals to me here too. Also, for some reason, people seem to enjoy talking to me. They tell me, "you're a good listener." Maybe I just know when to shut up. Regardless, I think I'd be good at this aspect of the job too.

The hours also seem to be generally good, and you can have your own office and be your own boss if you want, which is nice. Less possible for, say, an Anesthesiologist.

Things I don't like:

1. Lower Pay. I don't need to be rich, but I want to be comfortable. Granted, as someone who's never made more than 30k/year 150k seems like a crapload, but med school has been fraking hard. Really though, what bugs me more is...

2. How Undervalued FM (and prevention in general is). People would rather buy a new plasma TV than fix their health problems. Really? This is a societal problem and I'm deeply worried for the future of our country.

3. Paperwork. I don't even want to go here. I went into medicine to do medicine, not paperwork. I love computers and if it can be automated, I will do it...I'll learn to program it myself if need be...

4. Time. The normal FM office does not cut it for me. I demand time with my patients. Many doctors have never really been patients. Even as teens, future docs are more medically aware than most of the population. Like that current commercial says, "HDL...LDL, it's all just so confusing." Patient education takes time, and I hate to break it to you...but patients do not read the sheets, watch the videos, or go to the ADA website. Also, a proper H&P takes time. Seeing upwards of 20-30 patients a day is just reckless and is not helping anyone.

5. Mid-levels. People like Blue comfort me here, by saying that it'll be alright...but I'm still a little scared. I am inclined to agree with Blue...that the mid-levels will never take over primary care, but the possibility exists...and THAT is what scares me.

6. Lack of Flexibility. Well...kinda. I know that FM is very flexible. That being said, IM seems to have more flexibility. Inpatient, Outpatient, Hospitalist, Subspecialties, etc.

So there you have it. A real (2nd year) Med Student's perspective. These are the things I care about. I care less about "prestige" or "respect of specialists". I don't care about having a house on a golf course or fleet of Porches. I like my Honda, thanks.

 

[deleted87716]

It sounds like you've thought things through pretty well.

I'm going to have alot of debt.

With a debt load that large, you'll want to look at the better-paying jobs. They're out there. You may lose some flexibility in terms of geography, however. At least, until you've paid your loans down. Definitely make sure your wife keeps working.

I don't need to be rich, but I want to be comfortable.

Students should avoid picking a specialty based on current reimbursement. That's bound to change by the time you're out there working. Where primary care is concerned, that change is likely going to be for the better. For some other fields...not so much.

How Undervalued FM (and prevention in general is). People would rather buy a new plasma TV than fix their health problems. Really? This is a societal problem and I'm deeply worried for the future of our country.

However, the people who are in your office are interested enough in some aspect of their health to come see you. That's your opportunity. You aren't going to be able to solve society's problems. But you can do a lot for your patients, and they will (for the most part) value what you do.

Paperwork. I don't even want to go here. I went into medicine to do medicine, not paperwork.

Every specialty has paperwork (or "computer work" nowadays). I read a post somewhere the other day from someone who said he was going into emergency medicine because he didn't want to do paperwork. He obviously hasn't spent much time in the ED. There are things you can do to tame the paper tiger, believe me. Lots of people don't even try, unfortunately. That's where the problem is.

Seeing upwards of 20-30 patients a day is just reckless and is not helping anyone.

Actually, I'm very comfortable seeing 20-25 patients in an eight-hour day. It takes time to develop the skills that it takes to do that, of course. When you're a student, the idea seems somewhat daunting.

I am inclined to agree with Blue...that the mid-levels will never take over primary care, but the possibility exists...and THAT is what scares me.

The possibility exists only because nothing is impossible. However, it's so highly improbable that it's not worth losing sleep over. Ignorance and fear are the enemy. Educate yourself with facts, not fear-mongering.

IM seems to have more flexibility.

Not if you're talking about primary care. IM is nothing more than a gateway to specialization these days, as practically nobody is going into general internal medicine any more. Hospitalists aren't primary care, by the way, whether they trained in IM or FM.

I care less about "prestige" or "respect of specialists".

You'll gain respect by being good at your job. It doesn't matter what field you're in. People who think respect comes with a title will be disappointed, no matter what they do.

 

[RGMSU]

5. Mid-levels. People like Blue comfort me here, by saying that it'll be alright...but I'm still a little scared. I am inclined to agree with Blue...that the mid-levels will never take over primary care, but the possibility exists...and THAT is what scares me.

The more I learn how much there is to know to be effective in primary care, the less I think mid-levels are a threat at all. The amount of knowledge required to deal effectively with any problem that anybody walks in with is daunting.

 

[digitlnoize]

It sounds like you've thought things through pretty well.

I try.

[quote[With a debt load that large, you'll want to look at the better-paying jobs. They're out there. You may lose some flexibility in terms of geography, however. At least, until you've paid your loans down. Definitely make sure your wife keeps working. [/quote]

Yeah, we'll see. I haven't even decided on a specialty yet, although FM is on my list, alot of other things are too. Trying to keep my options open until I get some rotations under my belt.

Regardless, we plan on paying down as much as possible during residency, then living the same way for another year or two, and sending most of my attending salary towards the debt for the first couple of years until it's gone. Hopefully, there'll be some loan repayment in the mix too...

Geographically, I have zero interest in living in the crazy expensive and low paying urban areas like NYC or wherever, and we're fairly open to anything else...although we'd PREFER to stay on the east coast, if we can...again, I don't even know what I want to do, so this is a bit premature...

Students should avoid picking a specialty based on current reimbursement. That's bound to change by the time you're out there working. Where primary care is concerned, that change is likely going to be for the better. For some other fields...not so much.

Agreed 100%. If I've learned one thing, it's that medicine changes quickly and often. I know many people DO choose careers based on reimbursement, which baffles me. I plan on doing whatever I enjoy. No matter what it is, in medicine, I'll be just fine financially.

However, the people who are in your office are interested enough in some aspect of their health to come see you. That's your opportunity. You aren't going to be able to solve society's problems. But you can do a lot for your patients, and they will (for the most part) value what you do.

Good advice. I like it. That being said, I still think someone should start a "Dateline" like show, in prime-time, which picks a different disease state each week (or night) to talk about. It'd be a hell of a better show than the Jay Leno Hour. If his band plays "Proud Mary" one more time...sigh...

Every specialty has paperwork (or "computer work" nowadays). I read a post somewhere the other day from someone who said he was going into emergency medicine because he didn't want to do paperwork. He obviously hasn't spent much time in the ED. There are things you can do to tame the paper tiger, believe me. Lots of people don't even try, unfortunately. That's where the problem is.

This is the thing that bugs me. I'm a bit of a techno geek, and the medical profession is SOOOO far behind the times. I've used some crappy EMR's and they're still 1000000 times better than paper charts. If you know how to type and use a computer that is. If you don't, then learn. It's not that hard. I find it funny that our profession can use cutting edge toys like MRI machines, but can't figure out how to make EMRs talk to each other...sometimes even within the same institution!

Actually, I'm very comfortable seeing 20-25 patients in an eight-hour day. It takes time to develop the skills that it takes to do that, of course. When you're a student, the idea seems somewhat daunting.

That's comforting to hear. That's about 3 an hour right? So 20 minutes each to see and write up each patient. I know that's very doable, but are you saying that you couldn't better address their other problems given more time.

I could easily spend 20 minutes just educating a patient about their diabetes. And their smoking. And their weight. And their...etc etc. I know that we can treat their presenting issue, and quickly run through the rest of their management in OUR heads...but I still can't see how there is time to properly educate someone in that time frame.

I'm saying I'd like to spend an hour with my diabetic patient, educating them about how glucose and insulin work, their mechanisms, glycosylation, what the pancreas does, WHY they should watch their diet, not smoke, etc. Obviously simplified, not med school level, but REAL education. I can't tell you how many patients I've seen who have no idea that glucose is found in food.

I know that this is, to some extent, a fantasy. I'll likely never get to spend an hour with a patient. I can still dream though, can't I?

The possibility exists only because nothing is impossible. However, it's so highly improbable that it's not worth losing sleep over. Ignorance and fear are the enemy. Educate yourself with facts, not fear-mongering.

I guess what most of us "uneducated" folks are worried about is that mid-levels have been somewhat successful thus far in obtaining independent practice rights. I guess it's some jealousy at work here. I could've gone to NP school with way less debt, stress, and time...and done the same job for the same money. If I was willing to live in a place with these practice rights. The worry is that they'll eventually get full rights everywhere. I personally don't see it happening either, Blue, but many med students do...and that's more what I was getting at.

Personally, I like PA's, and if I have a practice I'm gonna hire a few myself.

Not if you're talking about primary care. IM is nothing more than a gateway to specialization these days, as practically nobody is going into general internal medicine any more. Hospitalists aren't primary care, by the way, whether they trained in IM or FM.

But why not do general IM? Gives you the flexibility to open your own outpatient office, or work for a hospital, or go on to subspecialize if you get sick of the other two? Seems win/win. What's the downside? Tougher residency?

I know hospitalists aren't PC...just listing another IM option...

You'll gain respect by being good at your job. It doesn't matter what field you're in. People who think respect comes with a title will be disappointed, no matter what they do.

Amen.

 

[deleted87716]

That's about 3 an hour right? So 20 minutes each to see and write up each patient. I know that's very doable, but are you saying that you couldn't better address their other problems given more time.

I could easily spend 20 minutes just educating a patient about their diabetes. And their smoking. And their weight. And their...etc etc. I know that we can treat their presenting issue, and quickly run through the rest of their management in OUR heads...but I still can't see how there is time to properly educate someone in that time frame.

I schedule patients in 15 minute slots, except for new patients and physicals/WCCs, which get 30 minute appointments. I pretty much document my visits as I go, so there's not really much charting left to do after the patient leaves (with rare exceptions).

You don't educate everybody about everything at every visit. You pick your battles. For things like diabetes, a team approach is crucial. My nurses instruct patients about things like glucometers and insulin, and I send all of my diabetic patients to diabetes educators and nutritionists. My group offers diabetes classes on an ongoing basis. This type of training is far superior to anything I could accomplish in the office, even without time constraints.

But why not do general IM? Gives you the flexibility to open your own outpatient office, or work for a hospital, or go on to subspecialize if you get sick of the other two? Seems win/win. What's the downside? Tougher residency?

Definitely not a tougher residency. Tougher board exam, maybe...but you can study for that. For whatever reason, less than 20% of IM residents in 2003 planned to pursue a career in general IM (reference here), and I'll bet a good chunk of those intended to be hospitalists. It's probably even fewer than that by now.

 

[deleted87716]

we plan on paying [my student loans] down as much as possible during residency

Just as an aside, you may be able to deduct the interest on your student loan during residency. See: http://www.irs.gov/taxtopics/tc456.html

Once you graduate and get a "real job," you probably won't qualify for the deduction any more.

 

[deleted87716]

I guess what most of us "uneducated" folks are worried about is that mid-levels have been somewhat successful thus far in obtaining independent practice rights.

Even so, very few nurse practitioners have any desire to practice independently. Don't be put off by a vocal minority.

 

[smq123]

But why not do general IM? Gives you the flexibility to open your own outpatient office, or work for a hospital, or go on to subspecialize if you get sick of the other two? Seems win/win. What's the downside? Tougher residency?

I know hospitalists aren't PC...just listing another IM option...

Well, FM can be hospitalists, too.

It's a matter, partly, of what type of patients do you want to see. Outpatient IM generally doesn't do a lot of women's health (although there is a track for that, if you're interested), does no OB, and is not qualified to see children.

Now, if you hate OB, then maybe IM is a good option. If you like doing a little bit of basic GYN and some OB, then FM is probably a better route.

 

[smq123]

5. Mid-levels. People like Blue comfort me here, by saying that it'll be alright...but I'm still a little scared. I am inclined to agree with Blue...that the mid-levels will never take over primary care, but the possibility exists...and THAT is what scares me.

By the way, the fear of midlevels exists for ALL specialties, not just outpatient primary care.

Work in a rural ER, and you'll likely see 3-4 PAs seeing patients in the ER.

Work in a community hospital, and who will be sewing up the patient for the attending surgeon at the end of a case? Most likely a PA or an NP.

I've heard several ophthalmologists talk about how some very vocal optometrists want operating rights. (Not that optometrists are midlevels, but the idea is the same.)

And, if you want REAL fear of midlevels, read the anesthesia forums on SDN. The fear that CRNAs will someday practice independently is quite a prominent one.

 

[digitlnoize]

Just as an aside, you may be able to deduct the interest on your student loan during residency. See: http://www.irs.gov/taxtopics/tc456.html

Once you graduate and get a "real job," you probably won't qualify for the deduction any more.

Yeah, I've heard about that, but haven't had time to look into it yet. If we can do that, we'll certainly bank the residency salary for later pay-off-ed-ness...

 

[digitlnoize]

Well, FM can be hospitalists, too.

I know, but I think this is going to get harder in the future...sorta like what's happening in EM. Especially if a new Hospitalist specialty is coming, which seems to be the talk...

 

[digitlnoize]

By the way, the fear of midlevels exists for ALL specialties, not just outpatient primary care.

Work in a rural ER, and you'll likely see 3-4 PAs seeing patients in the ER.

Work in a community hospital, and who will be sewing up the patient for the attending surgeon at the end of a case? Most likely a PA or an NP.

I've heard several ophthalmologists talk about how some very vocal optometrists want operating rights. (Not that optometrists are midlevels, but the idea is the same.)

And, if you want REAL fear of midlevels, read the anesthesia forums on SDN. The fear that CRNAs will someday practice independently is quite a prominent one.

I worked with many PA's in a suburban ER. We regularly paged other PA's for consults too (ortho especially).

Also, my wife is a dental hygienist. Incidentally, although many hygienists are fighting for expanded practice rights, she's pretty against it...maintaining that she couldn't do as good a job as the dentists...

Again, I like mid-levels for the most part, and am not really that afraid of them. As far as things I'm worried about, they're #905 on the list...

That being said, many med students are worried about it, particularly in FM for some reason. I think this comes down to the "perception" that FM is "easy" or something.

 

[DocYuki]

This thread is about primary care's image problem, right?

Well, I'm an MS3 at a fairly decent Midwest allopathic school, with a genuine interest in FM. I have an older sister, MS4, same school, who is interviewing at FM residency programs as we speak. We have always both had similar philosophies on health care and her positive outlook on FM is part of what influenced me to seriously consider it. That said, I'm sick of hearing so much crap about the specialty.

I did my FM rotation just last month (October) and really enjoyed the scope and breadth of the specialty. But talk amongst medical students, other doctors, and lately, drug reps, has been very discouraging and disheartening. I am currently rotating through a PM&R clinic for my elective month. On many occassions, I have spoken to the drug reps about FM docs or the specialty in general. One, who's brother is a local FM doc, told me flat out, "don't do it." Today, the reps were talking to my attending about how "FM docs only take home 120K/year after overhead and office expenses. They have to see 50-60 patients daily, 5 days a week just to get by" followed by laughter. It didn't help when my first patient after lunch told me, while reviewing her medical record, "Oh, my primary care doc is Dr. X.....he's good for when I have a cold or something...but I'm here to take care of my real problems."

I know this is all anecdotal, but when all I hear is negative things throughout all of medical school, it does not encourage me at all to enter the field. I have a strong belief in the whole movement of how primary care's importance in our healthcare system is understated, and how important it is to address primary care issues in patients. But again, everyone in my class is "in love" with anesthesia, derm, rads, and I feel like I'm being stared down when I ever bring up FM at all, like its a joke.

All that said, I stand by FM as an important specialty. I have a number of concerns about it, as anyone would. I'm incurring plenty of debt into the 6-figures...income is a thought on one's mind. Reimbursement currently will not be the same in the future, but can I be confident I'll live comfortably, support a family, and pay off the debt? Going through 7 years of intense post-graduate training is an awful lot to end up unsatisfied with your income. Encroachment from mid-levels, increasingly socialized medicine, "respect", being "overworked and underpaid"....these are all things on students' minds down here at the bottom of the totem pole, and its influencing people to shy away from FM.

I happen to be a relatively weak candidate, but I'm OK with that; I was never meant to be an academic rock-star. That has, in part, steered me away from the "sexy" specialties. We need FM docs and that's likely where I'm going. I like the variety of residency programs available to me in my area, and hope my real-world practice situation offers as much versatility. I don't know how healthcare will change in the future, but I think I'm going to just go for what I will enjoy and stick to it.

I just wish I could stop feeling like I'm walking into a train-wreck, because everyone tells me that's what I'm doing. Thought I'd chip in my two cents.

 

[lowbudget]

I only read half your post, but felt compelled to respond before moving on...

On many occassions, I have spoken to the drug reps about FM docs or the specialty in general. One, who's brother is a local FM doc, told me flat out, "don't do it." Today, the reps were talking to my attending about how "FM docs only take home 120K/year after overhead and office expenses. They have to see 50-60 patients daily, 5 days a week just to get by" followed by laughter.

Reason #500,001 why I never listen to drug reps: They're liars, they're exaggerators, and they're regurgitators. They're borderline, histrionic and will say anything to get attention and tell a good story. They pretend they know everything when in fact they know nothing. Worse yet, they don't know what they don't know. Pretty sad state of affairs. The ONLY thing. Might I stress... ONLY thing I will listen to a drug rep talk about is which restaurant in town has the best steak, dessert, and martini. Other than that, they're useless. And big pharmas agree. That's why the whole lot of them are getting fired and that's why they're increasingly more and more aggressive in the bullcrap they peddle.

That being said, it's this widespread perception that's fueling the incredible growth and interest in family medicine. For the first time ever in the history of politics, conservatives and liberals agree that the health care system needs to be primary care based and that family doctors are underpaid for the social value that they deliver. Hands down. This comes from a political insider. It goes up from here. If you're a medical student, welcome to good timing. If you're interested in radiology, you're late.

It didn't help when my first patient after lunch told me, while reviewing her medical record, "Oh, my primary care doc is Dr. X.....he's good for when I have a cold or something...but I'm here to take care of my real problems."

Dude... you're at a PM&R's office. What real problem may that be? Complex regional pain syndrome? Fibromyalgia? Vicodin refill? Is the pain pump beeping?

Please, you are not hurting my feelings by seeing a real doctor, mmmkay?

 

[DocYuki]

Seriously though, I appreciate your insights.

I'm just worn out from hearing nothing but crap about FM, and not just reps but as I said, other students, other docs.

The one thing has been mentioned on here again and again though that I think is quite true is the timing issue. I do think it's a decent time to go into FM (though people don't realize it), and too late for some of the specialties.

 

[deleted87716]

DocYuki: Good post. Your concerns are not unusual. Frequently, students interested in FM lack good role models. Academic family medicine typically represents the worst-case scenario: disorganized, overburdened clinics filled with non-compliant Medicaid patients, and over-utilization of in-house specialty services. I know...I saw it when I was in med school, too.

I would suggest that you spend some time working with family physicians in the community. Get out of the academic clinics and get a glimpse of FM in the real world. It's not as bad as you think. In fact, it's a whole lot better than you think...at least, it can be. It's really up to you.

Oh, and don't listen to anything specialists say about FM. They don't know squat.

 

[smq123]

Oh, and don't listen to anything specialists say about FM. They don't know squat.

I don't understand specialists who downplay primary care. They must either dislike money or not be very bright.

I'm an FM resident in an area that is saturated with competing specialty groups. The specialists try to have a good relationship with the FM residents because they know that, if insurance permits, we will refer patients to the specialists that we have a good relationship with. If we're on inpatient, and we need a consult, we will specifically request specialists that we know will keep in contact with us and have at least some respect for what we do. It's different in academics, I agree, because it all has to stay in the same hospital system, but in the real world, it's a whole other story.

 

[medicienne]

I had a student rotating with me who said why make 100K when you can make 200K. Unfortunately this seems to be the general mentality here among medical students.

 

[deleted87716]

Found on KevinMD, in response to a blog post about the article referenced in the OP:

In the UK the discrepancy is the other way with Primary Care doctors earning higher salaries and having more professional autonomy.

IMHO the brightest and the best should be encouraged to take a career in Primary Care is this is the hardest specialty to practice at a consistently high level.

Promoting and delivering quality Primary Care is almost certainly the best way to help deal with the spiralling costs of modern health care and also still deliver good medical and pastoral care.

Encourage the least talented doctors to take up highly specialist medical careers. Some of these specialties don't even require you to be able to talk to people.

Effective Primary Care practice requires a much broader palette of skills such as interpersonal intelligence, intrapersonal intelligence, verbal-linguistic intelligence, as well as the recognized professional standard of logical-mathematical intelligence.

The quote by Robert A. Heinlein comes to mind:

"A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects."

Replace "human being" in the above quote with "primary care doctor" or any other medical specialty and "primary care doctor" fits best.

Conflict of interest declaration – the author is not a Primary Care doctor.

 

[digitlnoize]

I had a student rotating with me who said why make 100K when you can make 200K. Unfortunately this seems to be the general mentality here among medical students.

The money thing is certainly a big issue. Although most salary surveys I've read put the mean closer to 150-180k...

I, personally, don't need a crapload of money...but it'd certainly be nice! And again, I am going to pick what makes me happy...

But what do you say to those students who really, really, care about the bucks? Why should THEY go into FM over Derm or Cards or other things that pay 500k+?

 

[smq123]

The money thing is certainly a big issue. Although most salary surveys I've read put the mean closer to 150-180k...

I, personally, don't need a crapload of money...but it'd certainly be nice! And again, I am going to pick what makes me happy...

But what do you say to those students who really, really, care about the bucks? Why should THEY go into FM over Derm or Cards or other things that pay 500k+?

If that's all that they really care about, they can go into derm and cards. <shrug> Not everyone has to be in FM, and FM doesn't want everyone, either.

Although, if they want things that pay >500K, they shouldn't have gone into medicine, period. And you never really know what's going to happen to any particular specialty's salaries. CT surgeons were making 400K a year, easily, until cardiology started doing their own stents and caths. So you never know.

 

[lowbudget]

I don't understand specialists who downplay primary care. They must either dislike money or not be very bright.

It's posturing, at least in the academic setting. Everyone's competing for the brightest students; and one way to compete is to bad mouth. And, if you as a student, never leave the front porch of your medical school, you wouldn't know any better. Agreed with you. At my old residency program, FM residents were commodities. Specialist attendings were dying to partner up with the residents, explicitly for the cliche education and teaching, but in reality implicitly for the money... and the future business when the residents graduate.

That said Blue Dog has a great point. When you're competing for the best/brightest, those students will look at many things, one of which is money, but also the educational product they receive. ROAD specialties can afford to poorly train residents because the health care infrastructure favors them and pays them well. Even the dumbest, barely passed radiology resident will earn $550 bajillion dollars. And, that said, even the best trained FP can't deviate too far out from the mean.

I think as we continue to train FP doctors of high caliber, those graduates will go out into the world and time and time again demonstrate their social value. And with that, the gap will narrow. It's already starting; and we're all just waiting for the flood gates to open.

But all that starts with academic family medicine... mainly, medical school mentorship, 3rd year clerkship, and even premed outreach. We have to deliver a superior educational product; or else everything is just talk. So, I too encourage students and residents to go out, travel the world, and see how family doctors blend into the community and thrive. It's easy to form an opinion soon after.

Why make $100k when you can make $200k? Sounds like a no brainer, really... 200k>100k... but if you think about it, it's very possible that $200k won't be there tomorrow.

 

[sylvanthus]

Im a first year that has been debating family medicine, but am being turned off to it for a couple reasons. First, if I were to do it, I would want to be able to have my own private practice in a rural area and do a bit of everything. But, with the declining reimbursements and very few people in private practice now, it seems like this would just not be a possibility. I would not want to work in a group setting and be forced to see 40 patients in a day to make it by.

I think the allure of family medicine is to spend more time with patients and know them over the years. Many medical students are seeing that family practitioners are overworked and have very little time with patients. So, that pretty much wipes out one of the main reasons of going in to primary care.

On a side note, I went to get a full physical recently and the primary care provider half-assed her way through my physical and spent very very little time with me. I know this is a personal example and doesn't in any way reflect on other providers. But, this kind of thing does make a huge impact on people's perceptions of family medicine

Also, I have seen many primary care providers just refer patients away to a specialist because they cannot deal with the patient or are worried about being sued. So, why would medical students want to go into a field where they just refer anything difficult away to someone else, spend little time with each patient, get paid less than other specialities, be forced to work in a group setting due to declining reimbursements, and essentially do the same job as an NP or PA who has 1/2 the training and debt? It seems like now, the best way to go into primary care is just to become a PA or NP as the training is much shorter, the debt is less, and the job is essentially the same in the end.

Even because of the above reasons, I am still thinking of doing a combined residency and perhaps doing EM/FM. That way I have more options and can still do FM down the road if things change and I get burned out of EM.

 

[RGMSU]

So, why would medical students want to go into a field where they just refer anything difficult away to someone else, spend little time with each patient, get paid less than other specialities, be forced to work in a group setting due to declining reimbursements, and essentially do the same job as an NP or PA who has 1/2 the training and debt? It seems like now, the best way to go into primary care is just to become a PA or NP as the training is much shorter, the debt is less, and the job is essentially the same in the end.

Even because of the above reasons, I am still thinking of doing a combined residency and perhaps doing EM/FM. That way I have more options and can still do FM down the road if things change and I get burned out of EM.

I don't agree with everything factually in your post anyway, but I'm just scratching my head as to how EM is much different from FM in any of the respects you just mentioned?

 

[smq123]

Im a first year that has been debating family medicine, but am being turned off to it for a couple reasons. First, if I were to do it, I would want to be able to have my own private practice in a rural area and do a bit of everything. But, with the declining reimbursements and very few people in private practice now, it seems like this would just not be a possibility. I would not want to work in a group setting and be forced to see 40 patients in a day to make it by.

I think the allure of family medicine is to spend more time with patients and know them over the years. Many medical students are seeing that family practitioners are overworked and have very little time with patients. So, that pretty much wipes out one of the main reasons of going in to primary care.

On a side note, I went to get a full physical recently and the primary care provider half-assed her way through my physical and spent very very little time with me. I know this is a personal example and doesn't in any way reflect on other providers. But, this kind of thing does make a huge impact on people's perceptions of family medicine

Also, I have seen many primary care providers just refer patients away to a specialist because they cannot deal with the patient or are worried about being sued. So, why would medical students want to go into a field where they just refer anything difficult away to someone else, spend little time with each patient, get paid less than other specialities, be forced to work in a group setting due to declining reimbursements, and essentially do the same job as an NP or PA who has 1/2 the training and debt? It seems like now, the best way to go into primary care is just to become a PA or NP as the training is much shorter, the debt is less, and the job is essentially the same in the end.

Even because of the above reasons, I am still thinking of doing a combined residency and perhaps doing EM/FM. That way I have more options and can still do FM down the road if things change and I get burned out of EM.

I think the key to your points is that you're still an MS1. That's not meant as a put-down, but I don't think you've had a chance to see that many of your concerns are true of medicine in general, not just FM.

For instance, your point about NP/PAs doing your job with half the training - as I've said in the past, the fear of midlevels exist for ALL specialties. Many rural EDs are now staffed mostly by PAs, and not by physicians. (So I'm a little confused as to why you think being EM/FM will help....). Anesthesia is notorious for the argument against increased practice rights for CRNAs. OB has its CNMs, surgery has its PAs, and even for ophtho, some optometrists have been fighting for operating rights. And some of the radiologists will talk your ear off about "outsourcing" radiology films to India and China, where teleradiologists are willing to work for a fracton of what a US radiologist will work for. Fear of encroachment by other health care professionals is true for all of medicine.

Sure, some PCPs do refer away - although that's more an issue of your comfort level as a physician. This is true of general surgery as well. General surgery, and even, to an extent, general urology, are starting to fall by the wayside because they're so hyperspecialized now. Even though there is a pressing need for general surgeons in this country, many people leave a general surgery residency uncomfortable in procedures besides basic appendectomies, cholecystectomies, and hernia repairs. Many people feel that you pretty much HAVE to do a fellowship after general surgery.

I'm sorry that your PCP blew you off during your physical. But you're right - that's person specific, not field specific. When I rotated on surgery, there was one surgeon who would basically walk in, say to the patient, "Yep, it looks like you're going to need surgery! If you have any questions, ask my nurse!" and then walk right back out. I've seen EM doctors, pediatricians, anesthesiologists, orthopedic surgeons, etc., do exactly the same thing. Your personality will dictate how you interact with patients, not your specialty.

And sure, you have to see a certain number of patients to make ends meet. This is, again, true for all specialties. I rotated in an outpatient urology office. Holy crap - he was double booking, zooming from room to room, didn't even have a dedicated hour for lunch...his staff just ate at their desks. He barely had enough time to drink a cup of water during the day, much less go to the bathroom. (Ironic for a urologist, I know.) Again....this is the healthcare system we all practice in.

Anyway, what I'm saying is try to keep an open mind. You have valid concerns, but they're concerns that stretch across all of medicine.

 

[deleted87716]

Im a first year that has been debating family medicine, but am being turned off to it for a couple reasons.

Again, don't believe everything you hear.

with ... very few people in private practice now ... I would not want to work in a group setting and be forced to see 40 patients in a day to make it by.

Approximately half of family physicians are in private practice, whether it's solo or an FM group (source: http://www.aafp.org/online/en/home/aboutus/specialty/facts/4.html - look under "practice owner.")

The average number of patients seen per week in primary care is somewhere in the 80-100 range, which works out to 20-25 per day even if you only work four days per week. (Source: http://www.aafp.org/online/en/home/aboutus/specialty/facts/5.html ).

Many medical students are seeing that family practitioners are overworked and have very little time with patients.

Chances are, they're seeing this in the academic family medicine clinics that unfortunately characterize the typical med school and residency outpatient experience. That is not the typical real-world situation for most of us, however. Family physicians spend more time with their patients than pretty much any other type of physician, even given the time constraints inherent in the system.

Also, most family physicians spend around 40 hours per week seeing patients (source: http://www.aafp.org/online/en/home/aboutus/specialty/facts/14.html ).

I went to get a full physical recently and the primary care provider half-assed her way through my physical and spent very very little time with me.

N=1. Go to somebody else next time.

I have seen many primary care providers just refer patients away to a specialist because they cannot deal with the patient or are worried about being sued.

Perhaps at times, but at least they have the option to do that. Most specialists are going to be stuck with 'em. You do what you're comfortable and capable of doing. It's an individual thing. I don't see that as a negative.

You certainly won't have that option in EM.

 

[sylvanthus]

.

 

[sylvanthus]

Im not trying to bash FM by any means, so I hope people don't take offense. I am just pointing out, as a medical student, what I have heard and seen that influences my specialty choice in the future.

 

[lowbudget]

Im not trying to bash FM by any means, so I hope people don't take offense. I am just pointing out, as a medical student, what I have heard and seen that influences my specialty choice in the future.

I think it's a misconception that patients want to spend hours upon hours in the clinic talking to their family doctor. What I've seen is that people want to get in and get out... and be taken care of. I have plenty of patients who need a lot of time, which is why I manage my time by banging through the simple stuff. Besides, if patients are truly *that* complicated, their issues probably can't be all addressed in 1 visit anyways; although I do have a few patients who think I'm a miracle worker and can solve all their problems.

If you felt like some of your issues weren't addressed during your physical, you should go back and bring them up. Your family doctor's not a mind reader. And it doesn't do you any good by holding a grudge.

I think you should scrutinize other specialties to the same extent you have FM. You're MS1, so you have time to do that. My guess is that you won't find much difference, just variations on the theme.

 

[smq123]

Im not trying to bash FM by any means, so I hope people don't take offense. I am just pointing out, as a medical student, what I have heard and seen that influences my specialty choice in the future.

No offense taken. What all of us are trying to say is just, as lowbudget said, keep an open mind. Many of your worries about FM, you'll find, are worries that you would have in OB/gyn, anesthesia, surgery, EM, etc.

 

[deleted87716]

Blue Dog, the threads you've made, such as this one, the 10 myths, and Obama "gets it," have been very helpful. Your posts are very encouraging for someone interested in Family Medicine. Thank you.

You're welcome.

 

[JackADeli]

...I propose we scrap the three year fm and im residency and create a new four year primary care residency. With the traditional im and limited fm felowships coming from that. It one way to get rid of the fm stigma...

I fail to see how adding a year to primary care training would make it more attractive...

I think we are talking about two seperate things.... One is making it "more attractive" the other is an image problem or stigma.... i.e. the statements of "too smart for..."

I fail to see how adding a year to primary care training would make it more attractive...

Certainly wouldn't make it more attractive to me.

Me either. As a current student considering all my options...

...I like many aspects of FM. I like the idea of caring for a variety of patients ...Cradle to Grave...that whole thing.

...I don't need to be rich, but I want to be comfortable. Granted, as someone who's never made more than 30k/year 150k seems like a crapload...

...I know that FM is very flexible....

The more I learn how much there is to know to be effective in primary care...The amount of knowledge required to deal effectively with any problem that anybody walks in with is daunting.

...I guess what most of us "uneducated" folks are worried about is ...I could've gone to NP school with way less debt, stress, and time...and done the same job for the same money.

...But why not do general IM? ...What's the downside? Tougher residency? ...

...Definitely not a tougher residency. Tougher board exam, maybe...

...I think this comes down to the "perception" that FM is "easy" or something...

This thread is about primary care's image problem, right?

Well, I'm an MS3 at a fairly decent Midwest allopathic school, with a genuine interest in FM.

I happen to be a relatively weak candidate, but I'm OK with that...

I just plucked out some of the sentiments posted in this thread.
A few points and/or perceptions that come out....

An FP needs broader training then say IM/Pedes. Yet FP training is at least the same duration as IM residency ALONE and its "board" certification is ... "easier". I suspect the same is true about comparison to OB/Gyn or Pediatrics. I would be interested in knowing the relative USMLE score required to be "competitive" for FP?

The issue is a matter of the "stigma" vs recruitment "attractiveness" of FP/FM. What has been presented in this thread supports (true or not) the perception of other specialists that FP is a specialty composed of folks that have less degrees of competitiveness (lower scores/lower grades) and lesser training in the numerous fields they practice. Let's face it, FP is a shorter route to the Med/pedes then a Med/Pedes residency.... and then you add OB/Gyn on top??? IM & Pedes feel it takes a minimum of 4yrs to be adequately trained to do those two disciplines (integrated). FP adds disciplines on top of Med/pedes, does it in 3 years, does it with less "competitive" trainees, and certifies with a potentially "easier" exam... For FP to be "attractive" to this caliber of applicants, it seems you can not require longer training and can not require a more difficult board certification process.

Thus, you have the perception and/or stigma....

..."Kerry is too smart for primary care"...

0.02
JAD

 

[deleted87716]

IM & Pedes feel it takes a minimum of 4yrs to be adequately trained to do those two disciplines

Med-Peds isn't a specialty. It's a dual residency in internal medicine and pediatrics. It's four years' long because that's what it takes to satisfy the requirements of both the internal medicine and peds boards. A dual residency in FM and anything else takes four years or more, too.

 

[digitlnoize]

Med-Peds isn't a specialty. It's a dual residency in internal medicine and pediatrics. It's four years' long because that's what it takes to satisfy the requirements of both the internal medicine and peds boards. A dual residency in FM and anything else takes four years or more, too.

I think he may have been saying that if it takes 4 years to do IM and Peds, then why is it only 3 to do FM (which can see adults, peds, and OB)...