What about kids? What is the difference between the care provided by a pediatrician vs. an FP?
This is another issue that depends on region. I need to point out TWO important concepts:
1) The world of residency and the world of private practice are COMPLETELY DIFFERENT WORLDS
2) MEDICINE IS REGIONAL (I cannot say that ENOUGH)
That being said, let me start off with the differences in training during residency:
PEDS - This residency consists of 3 years of KIDS ONLY less than 18 y/o. During the 3 years, one rotates through the various pediatric subspecialties (cardiology, pulmonoly, neurology, hematology-oncology, general inpatient ward, NICU, PICU, etc.) as well as continuity clinics where they follow a panel of patients throughout the 3 years. After training, there are 2 common pathways: one is a fellowship in one of the pediatric subspecialties, and the other is general pediatric practice which may be outpatient only, outpatient/inpatient mixed, or inpatient only (e.g., hospitalist).
FM - This residency consists of 3 years of various adult AND pediatric rotations. Most of the pediatric rotations will center around general peds with some subspecialty exposure. Of the 36 months of FM residency, approx. 6 of those are devoted to pediatrics and peds-related subspecialties (general outpatient peds, general inpatient pediatrics ward, NICU). In addition to that, when one is on the FM inpatient service, this will be a mixed service made up of both adults and kids of all ages, so your rounds may consist of a trip to the NICU, Labor & Delivery, as well as the adult ICU. In addition to that, one has electives in which one may choose to do an extra month of peds or a peds-related subspecialty (I did one in pediatric dermatology when I was a senior resident). Even further experience is gained through your continuity clinics, which you do from day one. In your continuity clinics, you follow ALL ages, from newborn babies to the elderly. Through the 3 years, you get a well-rounded balanced pediatric experience that mirrors the issues you will encounter in private practice. This leads me to the next question.
Family Medicine FAQ - Part 3
Wait a minute, peds residents get many more months of exposure during their training, aren't they better equipped in the private practice setting to handle kids vs. an FP?
Before answering that question, let me remind you of the two concepts I stated before:
- MEDICINE IS REGIONAL
- THE WORLD OF RESIDENCY AND THE WORLD OF PRIVATE PRACTICE CAN BE VERY DIFFERENT.
In a residency setting, peds residents see, on average, more "sicker" patients and do more inpatient work than FM residents. However, this is not the reality of private practice. In the world of private practice, peds clinic is the main source of income (unless you are a hospitalist, which in that case you are probably salaried). In an FM residency, you will get plenty of exposure to the bread & butter stuff that you will likely see in private practice. Yes, you will have some sick/critical cases, but not the same volume as your peds counterparts. The scenario changes in private practice.
For a pediatrician in private practice, 95% of the cases seen in that clinic are what we call "bread & butter" cases (well child checks/vaccinations, upper respiratory infections, otitis media, gastroenteritis, rash, ADHD, asthma, school/sports physicals, etc.). If you admit to the hospital, most admissions will be bread & butter as well (asthma exacerbation, dehydration, meningitis, pneumonia, etc.). Anything exotic or beyond the bread & butter gets a referral/consult to a specialist or possible transfer, PERIOD. The reasoning is twofold. One is LIABILITY. In this lawsuit-happy culture that we live in, you WILL be faulted for not consulting a specialist if the child had a serious condition that could have been prevented from getting worse. Second is REIMBURSEMENT. In private practice, a LARGE proportion of kids will fall under the state Medicaid program. In most places, these programs are CAPITATED HMOs. That means you get a fixed dollar amount per month per patient WHETHER YOU SEE THEM OR NOT. After you see someone for 1 or 2 visits for a particular problem, it works AGAINST you to keep on seeing them for the same problem. It is the prudent thing to refer out after 2 visits for the same problem, especially if you are on a capitated Medicaid plan. Even if the child has a fee-for-service PPO (which is not capitated), it's still prudent to refer out if the problem hasn't been solved in 2 or 3 visits. An FP in PRIVATE PRACTICE functions pretty much the same way as a pediatrician in private practice. The only difference is that you see adults as well, and you can wind up seeing the WHOLE family from grandma to grandkids (the true meaning of FAMILY practice). Because of this, the volume of kids you see in the office may not be as high as your peds counterparts. In some small towns, there are no pediatricians, so ALL of the peds work is done by FM. In the larger cities, there is a large volume of peds, thus the number of kids who are seen by FM is probably less. There isn't one specific pattern; it all depends on REGION. Irrespective of FM vs. peds, no matter where you are, a REALLY bad/sick/crashing kid WILL get shipped off to the nearest tertiary care facility, as most smaller private hospitals do not have peds sub-specialists, nor the capabilities to handle a very sick kid. I hope this puts to rest the FM vs. peds issue.
What is the difference between family medicine and internal medicine?
The main difference is that internal medicine is the specialty that deals with ADULT disease and treatment ONLY. Nobody under 18 (generally), and no OB. Family medicine deals with adult medicine, but also includes all other age groups (from newborn to elderly) and may or may not include an OB component (depending on region and personal preference of the practitioner). First, let me compare the residency training.
For IM residents, ALL rotations are in adult medicine and subspecialties. There is NO OB or peds. The only interaction with pregnant patients will be as a consultant for women in labor & delivery who develop a medical problem on top of their pregnancy (e.g., out-of-control diabetes, cardiac problems, etc.). As an IM resident, you will get more ICU exposure then the FM residents, and you will get to do more of certain procedures then the FM residents (central lines, Swan-Ganz catheters, etc.)
FM residents not only do adult medicine rotations, but pediatric rotations as well. They also have to do certain months of Labor & Delivery, where they not only play an active role in delivery and management of pregnant women, but also the management of medical conditions on top of the pregnancy that may occur (with the appropriate consultations, of course). Another difference is what occurs after residency. IM residents can do a fellowship in the various subspecialties, whereas FM has a limited number of fellowships. These have been described earlier in this document.
Here is the interesting twist...
In the world of PRIVATE PRACTICE, these differences are not as profound as in residency. The reason being is that as a private practitioner, your malpractice insurance as well as your hospital privileges WILL NOT cover the broad range of things you once did as a resident, especially when there are enough specialists around to do them. YES, an IM resident has put in more central lines than an FM resident, and floated more Swans, etc., but in private practice, you will be HARD PRESSED to find ANY private practice general internist who does those things for the reasons described above.
In a nutshell, when it comes to the private practice world of an IM doc vs. an FP, basically BOTH FPs and IMs on a daily basis handle the SAME bread & butter type of adult cases (hypertension, diabetes, thyroid disorders, upper respiratory infections, gastroenteritis, heart disease, rashes, etc. - which will make up 90+% of your office day), and are reimbursed the SAME from Medicare and managed care insurance companies. A level 3 outpatient visit (there are 5 possible levels) - (a.k.a. 99213) is reimbursed the SAME whether you are an internist or an FP. Anything beyond bread & butter management is referred out for the SAME reasons as I described in my peds vs. FM comparison.
When it comes to inpatient medicine in the PRIVATE PRACTICE world, FM and IM function the same way as well. Both handle bread & butter admissions (exacerbation of CHF, chest pain-r/o MI, sepsis, MI, altered mental status, pneumonia, nursing home "trainwrecks", etc.) and BOTH will obtain the appropriate consults when warranted - no difference. Did the internist get more experience managing a vent in residency? YES, but again, you are going to have a VERY hard time finding an internist in private practice who manages his own vents without calling pulmonology consult, because if there is a bad outcome because you didn't get a consult, you WILL get nailed!
FM and IM are both employed interchangeably by hospital staffs as well as managed care companies. ONE exception is in places that do not have any IM sub-specialists (cardiology, pulmonology, gastroenterology, etc.), the local internist may be the one who has to do certain procedures (reading echocardiograms, placing central lines, floating Swan-Ganz cathethers, stress tests, bone marrow biopsies, etc.), primarily because there is no one else around to do it. This phenomenon exists primarily in small towns with NO sub-specialists.
What is the difference between FM residency and Med/Peds residency, and what is the significance in private practice?
Basically, Med/Peds is a combination residency that combines IM and peds
into a 4-year residency (half medicine rotations, half peds rotations). These programs do not include OB rotations or general surgery. At the end, one must obtain and maintain board certification in BOTH specialties (that means 2 separate exams, plus CME and recertification). In FM, there is just ONE board certification to maintain. For Med/Peds, after residency, one may elect to do a fellowship in either an adult, pediatric, or a combined adult/peds subspecialty. In FM, there are limited fellowships which have already been described.
Here is where the differences end. In the world of private practice, BOTH function the same. The only difference is IF the FP decides to include OB in his/her practice, then the med/peds doc cannot cross-cover. BOTH groups will handle the same type of bread & butter adult and peds cases with the APPROPRIATE referrals to specialists when warranted. There is no difference in insurance reimbursement between the two for a particular case.
Family Medicine FAQ - Part 4
What about the OB component of FM? What is the difference between care provided by an FP vs. an OB-Gyn?
Here is where the results are VARIED based on REGION. While FM does require certain rotatoins in Labor & Delivery, the experience varies by the program and location. An FM resident will get more OB experience in an UNOPPOSED residency vs. a university-based one with OB residents. After residency, many FPs elect NOT to incorporate OB in their practice (including yours truly). This is done primarily because of the numerous liability issues involved (your malpractice premium will SKYROCKET if you include OB). Plus, it may be VERY difficult to get the necessary hospital privileges to do OB (all dependent on region). Furthermore, you'd BETTER have a sufficient volume of OB work to justify and offset the increase in your malpractice premium or you will LOSE money.
In those areas of the country where FPs do OB, they work together with the OB-Gyns and share call coverage for Labor & Delivery. FPs who do OB commonly handle routine non-complicated pregnancies and deliveries. Complex situations are automatically referred to an OB-Gyn or transferred to a tertiary care facility. SOME FPs in certain areas have C-section privileges, and some don't. It all depends on regional and local politics as well as the training of the individual practitioner.
