Rural FM Residency Program

[Mitch Connor]

Hello everyone,

I am an OMS1 who has recently taken an interest in FM for various reasons; flexibility, variety, significant demand for the immediate future etc. Currently I am thinking about rural medicine and while I think I can make a some educated assumptions, I don't think I have figured out all the differences between urban and rural residency tracks. Ideally I would attend a program in a more rural area. Somewhere like Alaska, Montana, Wyoming. Does anyone on here have any experience with programs in the places or ones similar?

My thought process is that a rural program would teach me to stand on my own feet better as there would be less resources to refer a patient to meaning I have to be better at everything. I guess kind of the "you're it" mentality when you don't have some place big and fancy to send someone. Am I off base here?

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[cabinbuilder]

Hello everyone,

I am an OMS1 who has recently taken an interest in FM for various reasons; flexibility, variety, significant demand for the immediate future etc. Currently I am thinking about rural medicine and while I think I can make a some educated assumptions, I don't think I have figured out all the differences between urban and rural residency tracks. Ideally I would attend a program in a more rural area. Somewhere like Alaska, Montana, Wyoming. Does anyone on here have any experience with programs in the places or ones similar?

My thought process is that a rural program would teach me to stand on my own feet better as there would be less resources to refer a patient to meaning I have to be better at everything. I guess kind of the "you're it" mentality when you don't have some place big and fancy to send someone. Am I off base here?

there is a great FP residency program in Anchorage, Alaska. Anchorage is a city of about 300,000 but Alaska overall is rural/frontier and I am sure they have rotations out in the villages where you get that rural experience too as well as the big city hospital experience too.

 

[MedicineZ0Z]

Hello everyone,

I am an OMS1 who has recently taken an interest in FM for various reasons; flexibility, variety, significant demand for the immediate future etc. Currently I am thinking about rural medicine and while I think I can make a some educated assumptions, I don't think I have figured out all the differences between urban and rural residency tracks. Ideally I would attend a program in a more rural area. Somewhere like Alaska, Montana, Wyoming. Does anyone on here have any experience with programs in the places or ones similar?

My thought process is that a rural program would teach me to stand on my own feet better as there would be less resources to refer a patient to meaning I have to be better at everything. I guess kind of the "you're it" mentality when you don't have some place big and fancy to send someone. Am I off base here?

Careful with the whole rural vs urban or unopposed vs opposed. There are good and bad programs under each category. In general, unopposed is better than opposed. But there are a lot of bad unopposed programs (in both larger and smaller settings) that are very outpatient oriented/refer everything.

Some programs also look great on paper but provide a very poor real life experience. It's not that uncommon now for some rotations to be just shadowing or working with a midlevel.

 

[Mitch Connor]

Thank you for the input. I had looked at Anchorage recently and liked what I saw. I also thought the program Billings looked promising. So without going to visit every residency in person is there a good way to weed out the good from the bad? Any tell tale signs that one should avoid? I was a PA before med school and the job I had did a lot of referrals. Not looking to go backward.

 

[Splenda88]

Careful with the whole rural vs urban or unopposed vs opposed. There are good and bad programs under each category. In general, unopposed is better than opposed. But there are a lot of bad unopposed programs (in both larger and smaller settings) that are very outpatient oriented/refer everything.

Some programs also look great on paper but provide a very poor real life experience. It's not that uncommon now for some rotations to be just shadowing or working with a midlevel.

What's wrong with being outpatient oriented... Isn't FM an outpatient oriented field for the most part?

 

[MedicineZ0Z]

What's wrong with being outpatient oriented... Isn't FM an outpatient oriented field for the most part?

Outpatient oriented generally means the program sucks. Your clinic patient population complexity determines how well you learn (even if you want to do 100% outpatient only). Programs that have strong inpatient and ob tend to have a complex clinic population too as a byproduct of those things. It's like a proxy for how strong the department is in the hospital system relative to internal medicine.
Also, lack of knowledge in hospital medicine and Ob generally means you'll be worse off as an outpatient doc as well. Your general clinical acumen and comfort just won't be there. If you've taken care of patients on 300 units of insulin daily in the hospital or given massive doses of lasix to a cardiorenal patient without consulting (both things being very bread and butter), your ability to escalate therapy or take care of that same patient in the clinic is much better.

 

[Splenda88]

Outpatient oriented generally means the program sucks. Your clinic patient population complexity determines how well you learn (even if you want to do 100% outpatient only). Programs that have strong inpatient and ob tend to have a complex clinic population too as a byproduct of those things. It's like a proxy for how strong the department is in the hospital system relative to internal medicine.
Also, lack of knowledge in hospital medicine and Ob generally means you'll be worse off as an outpatient doc as well. Your general clinical acumen and comfort just won't be there. If you've taken care of patients on 300 units of insulin daily in the hospital or given massive doses of lasix to a cardiorenal patient without consulting (both things being very bread and butter), your ability to escalate therapy or take care of that same patient in the clinic is much better.

The main issue I see with the FM where I am is that they only rotate in cardio; they do not rotate in other consult services...

 

[MedicineZ0Z]

The main issue I see with the FM where I am is that they only rotate in cardio; they do not rotate in other consult services...

Outpatient focused usually means bare minimum on inpatient and not taking care of complexity/acuity.

 

[Cranjis McBasketball]

Thank you for the input. I had looked at Anchorage recently and liked what I saw. I also thought the program Billings looked promising. So without going to visit every residency in person is there a good way to weed out the good from the bad? Any tell tale signs that one should avoid? I was a PA before med school and the job I had did a lot of referrals. Not looking to go backward.

Theres an excel sheet with a bunch of info that you can find on reddit. Just google "Official 2020-2021 Family Medicine Residency Application"

 

[VA Hopeful Dr]

The main issue I see with the FM where I am is that they only rotate in cardio; they do not rotate in other consult services...

Things may have changed, but when I was a resident we rotated with pulmonology, cardiology, ENT, ophthalmology, dermatology, urology, psychiatry, ortho, general and vascular surgery, and a little time spent with pediatric cardiology.

 

[Splenda88]

Things may have changed, but when I was a resident we rotated with pulmonology, cardiology, ENT, ophthalmology, dermatology, urology, psychiatry, ortho, general and vascular surgery, and a little time spent with pediatric cardiology.

I was referring to IM subspecialties. You are correct that they rotate in these services.

 

[VA Hopeful Dr]

I was referring to IM subspecialties. You are correct that they rotate in these services.

Last I checked, pulm and cards are IM subspecialties.

 

[YCAGA]

Careful with the whole rural vs urban or unopposed vs opposed. There are good and bad programs under each category. In general, unopposed is better than opposed. But there are a lot of bad unopposed programs (in both larger and smaller settings) that are very outpatient oriented/refer everything.

Some programs also look great on paper but provide a very poor real life experience. It's not that uncommon now for some rotations to be just shadowing or working with a midlevel.

What is the best way to tell if an unopposed program have good inpatient training with lots of (insert focus here...peds, OB, ED/critical care procedures etc)? Talk to residents? Some programs say how many deliveries their residents get for example, but I haven’t seen ones that give all of the procedure numbers.

 

[MedicineZ0Z]

What is the best way to tell if an unopposed program have good inpatient training with lots of (insert focus here...peds, OB, ED/critical care procedures etc)? Talk to residents? Some programs say how many deliveries their residents get for example, but I haven’t seen ones that give all of the procedure numbers.

Ask what procedures the seniors feel comfortable doing alone. If they say IR or whoever does most of them, you ain't going to get training for that.
Ask about typical inpatients they take care of (acuity/complexity). If DKA isn't something you can very easily manage as an intern and is considered a "complex case" , that's an issue.
If it's unopposed, you want to know if residents run rapids and codes. There are programs where the FM residents are the first in line for the airway as well during codes and even traumas (though there is obviously some level of back up available). For Ob, I'd ask about the number of deliveries they do.
I wouldn't look at C sections if you're looking at full spectrum training. I'd also ask about responsibility on off service rotations. Big difference being on ortho and doing every injection vs shadowing a PA. Even in the ICU for example, you can be limited in your autonomy and not have any call.

For opposed, you want to know some of the same stuff as above. It's unlikely you're doing airways on the floor and running traumas in an academid center. But the other stuff (patient complexity, procedures, deliveries) should be well up there or even better than many unopposed, if it's a good program.

 

[YCAGA]

Th

Ask what procedures the seniors feel comfortable doing alone. If they say IR or whoever does most of them, you ain't going to get training for that.
Ask about typical inpatients they take care of (acuity/complexity). If DKA isn't something you can very easily manage as an intern and is considered a "complex case" , that's an issue.
If it's unopposed, you want to know if residents run rapids and codes. There are programs where the FM residents are the first in line for the airway as well during codes and even traumas (though there is obviously some level of back up available). For Ob, I'd ask about the number of deliveries they do.
I wouldn't look at C sections if you're looking at full spectrum training. I'd also ask about responsibility on off service rotations. Big difference being on ortho and doing every injection vs shadowing a PA. Even in the ICU for example, you can be limited in your autonomy and not have any call.

For opposed, you want to know some of the same stuff as above. It's unlikely you're doing airways on the floor and running traumas in an academid center. But the other stuff (patient complexity, procedures, deliveries) should be well up there or even better than many unopposed, if it's a good program.

Thanks for the reply! I didn’t know until recently that FM could ever get first dibs on airways and procedures in residency. At my med school, most or all of our exposure to FM is at academic centers where FM is very outpatient heavy and there are sub-sub specialists for every issue, especially peds and OB, but also CCM and EM.

 

[MedicineZ0Z]

Th

Thanks for the reply! I didn’t know until recently that FM could ever get first dibs on airways and procedures in residency. At my med school, most or all of our exposure to FM is at academic centers where FM is very outpatient heavy and there are sub-sub specialists for every issue, especially peds and OB, but also CCM and EM.

You should be doing your own inpatients' paras/thoras/LPs. You should also be able to get fairly comfortable with A lines and IJs in the ICU. You can get airway exposure and some trauma procedure exposure in the ED/ICU but will need dedicated anesthesia time likely to get proficient.

^ Is true for a good opposed program.

A very good unopposed program, you should be doing all of the above and be first in line.

 

[Splenda88]

You should be doing your own inpatients' paras/thoras/LPs. You should also be able to get fairly comfortable with A lines and IJs in the ICU. You can get airway exposure and some trauma procedure exposure in the ED/ICU but will need dedicated anesthesia time likely to get proficient.

^ Is true for a good opposed program.

A very good unopposed program, you should be doing all of the above and be first in line.

Are there a lot of FM programs out there where FM residents have opportunity to do LP/Thora/Airway? I am at a good IM program and I only did 4 para, 1 thora, < 10 IJ , < 10 a-line, and ZERO intubation and LP...

 

[YCAGA]

Are there a lot of FM programs out there where FM residents have opportunity to do LP/Thora/Airway? I am at a good IM program and I only did 4 para, 1 thora, < 10 IJ , < 10 a-line, and ZERO intubation and LP...

Is your IM program unopposed?

 

[Splenda88]

Is your IM program unopposed?

No.... Academic center of 1000+ beds. We have every single specialty and subspecialty you can think of.

 

[MedicineZ0Z]

Are there a lot of FM programs out there where FM residents have opportunity to do LP/Thora/Airway? I am at a good IM program and I only did 4 para, 1 thora, < 10 IJ , < 10 a-line, and ZERO intubation and LP...

I think paras/LPs are very reasonable to expect from inpatient training. Who else is doing the LPs would my question? I've done lots of neonatal, peds and adult LPs as have my coresidents. Thoras quite a bit less so but good ones will have you doing them.
Lines there is some variability. Good ones in open ICUs should give you good longitudinal exposure or at least major dedicated exposure.

I don't see any reason why FM or IM at an unopposed residency is not doing the airway if there is backup in the room.

Not sure on the total number though. I'm at an opposed program also.

 

[Splenda88]

I think paras/LPs are very reasonable to expect from inpatient training. Who else is doing the LPs would my question? I've done lots of neonatal, peds and adult LPs as have my coresidents. Thoras quite a bit less so but good ones will have you doing them.
Lines there is some variability. Good ones in open ICUs should give you good longitudinal exposure or at least major dedicated exposure.

I don't see any reason why FM or IM at an unopposed residency is not doing the airway if there is backup in the room.

Not sure on the total number though. I'm at an opposed program also.

LP is done by a procedure team. Difficult LP is done by IR ... Para is done by us (residents). Thora is done mostly by PCCM or IR if small. Airway management by anesthesia.

 

[VA Hopeful Dr]

Are there a lot of FM programs out there where FM residents have opportunity to do LP/Thora/Airway? I am at a good IM program and I only did 4 para, 1 thora, < 10 IJ , < 10 a-line, and ZERO intubation and LP...

Thoras are going to be rare in 99% of programs. For mine, LP/airway/lines/paras are going to be up to the resident in many places. I had no interest in those so I did basically zero. One of my classmates was planning to work rural so she did lots.

I'm surprised you haven't done any intubations.

 

[Splenda88]

Thoras are going to be rare in 99% of programs. For mine, LP/airway/lines/paras are going to be up to the resident in many places. I had no interest in those so I did basically zero. One of my classmates was planning to work rural so she did lots.

I'm surprised you haven't done any intubations.

We have an anesthesia program in house and the institution policy is that anesthesia should do all intubations.

 

[MedicineZ0Z]

LP is done by a procedure team. Difficult LP is done by IR ... Para is done by us (residents). Thora is done mostly by PCCM or IR if small. Airway management by anesthesia.

Who is on the procedure team? Is it not residents?

We have an anesthesia program in house and the institution policy is that anesthesia should do all intubations.

I get it for a floor rapid (where things are going downhill fast, uncontrolled setting and reversible if done well) but everywhere else it's fair game if anesthesia is back up.

I think this is institutional policy being a barrier. I've seen places that require a renal consult for hypertonic saline for example but at my place (and others), we give it routinely without a consult.

 

[Splenda88]

Who is on the procedure team? Is it not residents?

Residents and hospitalists...

 

[MedicineZ0Z]

Residents and hospitalists...

So just luck then? If you need LPs done when you're on that rotation.

 

[VA Hopeful Dr]

We have an anesthesia program in house and the institution policy is that anesthesia should do all intubations.

What, do they not get enough in the OR?

Not directed at you, just seems less than ideal for a hospital with so many residency programs.

 

[Splenda88]

What, do they not get enough in the OR?

Not directed at you, just seems less than ideal for a hospital with so many residency programs.

My guess is that they do. We are talking about ~1000 beds hospital... I just don't get why our institution have that policy

 

[YCAGA]

No.... Academic center of 1000+ beds. We have every single specialty and subspecialty you can think of.

Isn’t that kind of your answer? Why would IM/FM get to intubate over anesthesia, EM off-service or critical care fellows? Not saying it should be that way, but it’s a pretty easy to make a counter-argument if you are a PD for those non-IM programs. I know a PGY-3 IM resident who got her first intubation in the ED because she was married to an EM resident and they did it as a favor since she wanted to try. Otherwise IM intubating was unheard of at this 600+ bed academic hospital with all specialists and sub-specialists.

 

[Splenda88]

Isn’t that kind of your answer? Why would IM/FM get to intubate over anesthesia, EM off-service or critical care fellows? Not saying it should be that way, but it’s a pretty easy to make a counter-argument if you are a PD for those non-IM programs. I know a PGY-3 IM resident who got her first intubation in the ED because she was married to an EM resident and they did it as a favor since she wanted to try. Otherwise IM intubating was unheard of at this 600+ bed academic hospital with all specialists and sub-specialists.

It makes sense anesthesia should be first in line... But they rotate at two other 300+ beds hospital. I was talking to one of their residents (a CA1) in December and she told me she has done well over 100 intubations already. If she has done well over 100 in her first 6 months of anesthesia residency, she probably will be doing well over 700+ by the time she graduates. Not sure how many intubations one needs to be competent though, but I think airway management, central line, a-line, para, and thora should be part of IM core competency.

 

[MedicineZ0Z]

It makes sense anesthesia should be first in line... But they rotate at two other 300+ beds hospital. I was talking to one of their residents (a CA1) in December and she told me she has done well over 100 intubations already. If she has done well over 100 in her first 6 months of anesthesia residency, she probably will be doing well over 700+ by the time she graduates. Not sure how many intubations one needs to be competent though, but I think airway management, central line, a-line, para, and thora should be part of IM core competency.

I'm honestly certain that most of these policies originate from some bad outcome, which may have been purely coincidence. Some hospitals are very lenient on who can do what. Others are very strict on specific things and not others. I think prior exps shape up new policies to a degree (hospital reacts to some bad outcome).

I think having anesthesia there as back up and using VL to intubate is very reasonable. They can also require some prior training in simlab (like we do for central lines and other things) before doing it on real people.
Being at an academic center, I've gotten chest tubes and bronchs as well. Comes down to whether or not the fellow wants it and if it's late in the year, they could careless it seems.

 

[monkeymedic]

You should be doing your own inpatients' paras/thoras/LPs. You should also be able to get fairly comfortable with A lines and IJs in the ICU. You can get airway exposure and some trauma procedure exposure in the ED/ICU but will need dedicated anesthesia time likely to get proficient.

^ Is true for a good opposed program.

A very good unopposed program, you should be doing all of the above and be first in line.

Agree with this 100%. I was at an unopposed urban program, Level 1 Trauma Center, and the only difference between my program and another one in the next city over that had other residencies was the fact that I was first in line vs them being second or third call. When you are at a busy hospital with multiple codes and rapids per day, whether or not you are opposed or not doesn't matter other than your ego for being first or second. If you get enough procedures, you get enough procedures.

I still remember the day that at lunch we were 5 responses deep already when a 6th came in that would likely need a line. The other senior and I were both hoping the other got there first because we were both very busy and didn't want to do a line. The med students auditioning with us were very surprised (and impressed) that by halfway through our second year we had so many procedures we were already getting tired of them!

 

[YCAGA]

Agree with this 100%. I was at an unopposed urban program, Level 1 Trauma Center, and the only difference between my program and another one in the next city over that had other residencies was the fact that I was first in line vs them being second or third call. When you are at a busy hospital with multiple codes and rapids per day, whether or not you are opposed or not doesn't matter other than your ego for being first or second. If you get enough procedures, you get enough procedures.

I still remember the day that at lunch we were 5 responses deep already when a 6th came in that would likely need a line. The other senior and I were both hoping the other got there first because we were both very busy and didn't want to do a line. The med students auditioning with us were very surprised (and impressed) that by halfway through our second year we had so many procedures we were already getting tired of them!

Was this family medicine? What family medicine program is unopposed at a Level 1 Trauma Center?! Sounds awesome. Feel free to PM me if you don't want to share publicly.

 

[hallowmann]

Are there a lot of FM programs out there where FM residents have opportunity to do LP/Thora/Airway? I am at a good IM program and I only did 4 para, 1 thora, < 10 IJ , < 10 a-line, and ZERO intubation and LP...

Hmm, honestly I've done more paras than you. I haven't done a thora. <10 a-lines is also about right. I think like only 1 intubation, but others that were looking for them have done handfuls. Placed plenty of LMAs, extubated a few in the ICU (for both good and unfortunate reasons), and bagged plenty, but not a ton of actual intubations. They seemed to happen the most for us in the ED or ICU. I've done a bunch of LPs on babies/kids, but I just haven't needed to on an adult yet. Bad luck maybe? Don't remember ever doing an IJ honestly.

I think there is a lot of variety depending both on your experiences and specific policies of the hospital/comfort of your attending. I've gotten very lucky with some procedures and not so lucky with others, and honestly part of it is me not really trying, because I don't see myself doing inpatient medicine in the future.

 

[topraman]

I wanted to share my residency procedure logs to provide some more perspective to this discussion. First, this isn't nor should not be representative. But I think it can be helpful for a few reasons in support of the potential of our specialty. Note that I attended a really good unopposed program and was within that was on one end of those proactively seeking out additional training and with a clear reason why (global health, rural medicine goals). I largely stopped logging office procedures (excisions, injections) after intern year, this does not include procedures during 2 elective away months, and also did not log many others fully which became high volume or once I met our internal privileging requirements (such as with ultrasound, vent management, ekg, chest xray, etc).

Some points I want to make
1) Family medicine is diverse, and we should not extend the limitations of your experiences to our colleagues or our specialty as a whole
2) Procedure numbers are helpful, but also critical and harder to capture is true independence, back up or not, can you assess the need for the procedure or alternatives, can you perform the procedure in a complicated patient or emergent setting, have you managed procedure related complications that can arise or are competent to do so if needed
3) Procedures cross train so low numbers in a single specific procedure can still give rise to competency, e.g. assisting open urology cases prepared me for bladder complications in a difficult c-section, etc. Paras, thoras, LPs, have their own specifics, but generally inserting needles and removing fluid is a skill that cross-trains
4) You have to supplement doing the procedure with preparation before and after, reading and reviewing thoroughly, do the procedure or op note yourself and from scratch (not templates) to both have the opportunity and cement the learning
5) Yes, I really did 3 ex-laps as the primary surgeon, we had great teachers, it was my final year, one was for a strangulated hernia, and 2 gastric perforations. Can I handle anything I find? No but I can get in and out of an abdomen safely. Useful for my post-partum tubals as well.
6) Some of what I experienced 3 years ago is no longer possible now, old attendings retiring, more outpatient requirements, hospital rule changes, so I'm grateful for the moment in time I had

 

[Splenda88]

I wanted to share my residency procedure logs to provide some more perspective to this discussion. First, this isn't nor should not be representative. But I think it can be helpful for a few reasons in support of the potential of our specialty. Note that I attended a really good unopposed program and was within that was on one end of those proactively seeking out additional training and with a clear reason why (global health, rural medicine goals). I largely stopped logging office procedures (excisions, injections) after intern year, this does not include procedures during 2 elective away months, and also did not log many others fully which became high volume or once I met our internal privileging requirements (such as with ultrasound, vent management, ekg, chest xray, etc).

Some points I want to make
1) Family medicine is diverse, and we should not extend the limitations of your experiences to our colleagues or our specialty as a whole
2) Procedure numbers are helpful, but also critical and harder to capture is true independence, back up or not, can you assess the need for the procedure or alternatives, can you perform the procedure in a complicated patient or emergent setting, have you managed procedure related complications that can arise or are competent to do so if needed
3) Procedures cross train so low numbers in a single specific procedure can still give rise to competency, e.g. assisting open urology cases prepared me for bladder complications in a difficult c-section, etc. Paras, thoras, LPs, have their own specifics, but generally inserting needles and removing fluid is a skill that cross-trains
4) You have to supplement doing the procedure with preparation before and after, reading and reviewing thoroughly, do the procedure or op note yourself and from scratch (not templates) to both have the opportunity and cement the learning
5) Yes, I really did 3 ex-laps as the primary surgeon, we had great teachers, it was my final year, one was for a strangulated hernia, and 2 gastric perforations. Can I handle anything I find? No but I can get in and out of an abdomen safely. Useful for my post-partum tubals as well.
6) Some of what I experienced 3 years ago is no longer possible now, old attendings retiring, more outpatient requirements, hospital rule changes, so I'm grateful for the moment in time I had

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Where is this program? You have done more procedures than most IM residents in the US...


How many stroke, STEMI, meningitis, autoimmune encephalitis, diffuse alveolar hemorrhage, new onset of afib, cardiogenic shock, myasthenia crisis, acute chest syndrome, Ogilvie syndrome (my very first patient in residency) patients etc... have you managed?

These might be the difference between IM/FM. Nothing is wrong with any specialty, but they are different...

 

[MedicineZ0Z]

Where is this program? You have done more procedures than most IM residents in the US...


How many stroke, STEMI, meningitis, autoimmune encephalitis, diffuse alveolar hemorrhage, new onset of afib, cardiogenic shock, myasthenia crisis, acute chest syndrome, Ogilvie syndrome (my very first patient in residency) patients etc... have you managed?

These might be the difference between IM/FM. Nothing is wrong with any specialty, but they are different...

Agree, it's also a lot of surgical Ob.
We don't get those kinds of numbers either but do get the broad exposure.

I'm also curious on the bolded. I've managed just about all of those thus far (I've seen myasthenia gravis managed by my coresident) but I think that's a byproduct of being in a referral center more than anything.

I'd suspect he's also managed a lot of stuff inpatient and outpatient that's often done by specialists too.

 

[Splenda88]

Agree, it's also a lot of surgical Ob.
We don't get those kinds of numbers either but do get the broad exposure.

I'm also curious on the bolded. I've managed just about all of those thus far (I've seen myasthenia gravis managed by my coresident) but I think that's a byproduct of being in a referral center more than anything.

I'd suspect he's also managed a lot of stuff inpatient and outpatient that's often done by specialists too.

You are 8 months into PGY2 and you have managed all those! Are you really FM?

How many inpatient rotations have you done so far?

 

[Splenda88]

2nd year FM resident, have taken care of most of the above. Stroke in its various flavors, new a fib, and acute chest are pretty bread and butter for our service. Meningitis and cardiogenic shock are common enough that most of us have managed them at least a handful of times. Also see plenty of sepsis (pneumonia, cellulitis, UTI, nec fasc, you name it), some very bad, CHF, COPD, DKA, PE, NSTEMI, EtOH withdrawal, post-arrest, OD, renal failure, all kinds of fun electrolyte abnormalities, bad cirrhosis/hepatorenal syndrome, and obviously COVID all of which most folks are at least mostly comfortable with by the end of intern year. Also see some weirder stuff now and again. Lol who do you think we're taking care of in the hospital?

Taking care of one or 2, I understand that. I don't believe for a second that someone who has done 6 months inpatient medicine has taken care all of those multiple times...

 

[YCAGA]

Taking care of one or 2, I understand that. I don't believe for a second that someone who has done 6 months inpatient medicine has taken care all of those multiple times...

Both FM residents listed some of the most common inpatient admissions to a medicine service??? Do you think they just take care of stubbed toes at community hospitals? Have you ever studied/worked outside of a quaternary center?

Also an IM residents like you knows that patients don't present neatly with just CHF or new a-fib and nothing else going on. Seeing 20 different presentations 5 times each doesn't mean 100 separate patients. You can learn management of 2, 3, or 4 of those conditions with a single patient that only goes to the hospital when they are falling apart.

 

[Splenda88]

So are you saying I'm lying? Lol

My program has 9 months total on our adult inpatient service, plus taking care of our own clinic patients whenever they get admitted even if we're off service, plus specialty rotations that include some inpatient stuff (ICU, cardiology, etc.). Inpatient rotations for OB/peds as well, some of which translates to adult inpatient medicine. I have personally managed stroke, a fib, acute chest, CHF, COPD, DKA, EtOH wd, post-arrest, sepsis, OD, renal failure, all so many times in the inpatient setting that I couldn't even count anymore. I'm honestly a little surprised that you think it's unusual that someone spending even 3 months on an inpatient service wouldn't see those things more than once, it's not uncommon for me to take care of multiple patients with those problems in the same one month block.

Every FM program is different. The saying on the interview trail is "if you've seen one FM program, you've seen one FM program." My program is known for strong inpatient training. We're unopposed, open ICU, have a sick/underserved patient population, and at a medium-sized hospital that's a referral center for our area and doesn't have to transfer too many folks out. About 50% of our graduates in the last few years are doing hospitalist work or a mix of inpatient and outpatient. Our inpatient adult service is staffed entirely by graduates from our program, and I would say maybe close to half of the non-teaching hospitalists here are graduates of our program as well. Obviously there are other FM programs that in no way prepare their graduates to provide inpatient care. But I don't think there's any statement you can make about any aspect FM training that's applicable to all - or even most - FM programs in the country.

I am not saying you are lying... I think you are at an atypical FM program... Ours has 28 wks of adult inpatient (MICU included). I know they see bread and butter stuff, but they are unprepared for hospital medicine.

 

[Splenda88]

I wouldn't say mine is atypical, because I don't think there are "typical" FM programs. Like I said...you've seen one FM program, so you've seen one FM program. I interviewed at a number of programs with similar training to mine. Again there's plenty of FM programs out there that don't prepare you well for inpatient work, but there's also plenty that do.

You are telling me there are a lot FM program at big tertiary centers that are inpatient heavy as IM... I am familiar with 3 to be precise.

 

[Splenda88]

You don't have to be at a "big tertiary center" to have good inpatient training. My hospital is not a tertiary center - maybe on the border between secondary and tertiary, but I can guarantee you've never heard of it unless you're from the area - none of the things you listed are unheard of at our shop and several of them are extremely common admitting diagnoses. Same goes for a lot of the other programs I interviewed at. The vast majority of patients, even very sick ones, do not need to be, and are not, at "big tertiary centers." You think every stroke and new a fib patient goes to a tertiary center?? In fact I am genuinely curious what the heck kind of patients you have at your hospital that you consider those things to be anything but bread and butter lol.

There are plenty of mid-size hospitals (~100-500 beds) in medium/smaller cities with good specialist support that manage these things on a daily basis, and often the FM programs at these types of places are unopposed. My hospital falls into that category and I can count on one hand the number of patients we've had to transfer out to a higher level of care since I've been here. Just because it's not a fancy specialty center with a university title on it, doesn't mean you don't get solid training to take care of pretty sick patients. In fact the training for FM is often BETTER at these types of places because FM doesn't get treated like the red headed stepchild like it sounds like is the case where you are.

I'd echo @memdoctobe, have you ever been to a hospital that's not a big academic center?

My med school main hospital was a community hospital and I only saw bread and butter stuff there (CHF, pancreatitis, HTN emergency, PNA, COPD... I rotated at 3 big academic center in 4th year and my residency is at the biggest academic center in the state, but we do 1 month inpatient at a community hospital--422 beds as a PGY2 and the stuff I saw there were the typical things. Patient with DKA, sepsis etc... go to ICU. If you are on a vent, you suppose to go to ICU at that community hospital. We don't do these things where I am.

 

[YCAGA]

I am not saying you are lying... I think you are at an atypical FM program... Ours has 28 wks of adult inpatient (MICU included). I know they see bread and butter stuff, but they are unprepared for hospital medicine.

If you are blown away with residents getting experience in treating (to quote @cj_cregg) "sepsis (pneumonia, cellulitis, UTI, nec fasc, you name it), some very bad, CHF, COPD, DKA, PE, NSTEMI, EtOH withdrawal, post-arrest, OD, renal failure, all kinds of fun electrolyte abnormalities, bad cirrhosis/hepatorenal syndrome"...what do you do at your IM residency?! Inpatient treatment of blood glucose of 111 or BP of 131/81?

Your replies in this thread are such a weird combination of being on a high horse about the rigor of IM inpatient training compared to FM while at the same time not believing that FM residents get the incredible, mind-blowing, unrealistic, Harvard-Stanford super-fellowship experience of treating the 10-15 conditions than any med student half way done with their IM rotation knows the basics of.

I would not even be surprised if an ortho resident came into this thread and said they got experience with a lot of those conditions during their general surgery intern year. I mean we are literally talking about some of the most common, if not the most common, non-surgical reasons for admission.

 

[Splenda88]

If you are blown away with residents getting experience in treating (to quote @cj_cregg) "sepsis (pneumonia, cellulitis, UTI, nec fasc, you name it), some very bad, CHF, COPD, DKA, PE, NSTEMI, EtOH withdrawal, post-arrest, OD, renal failure, all kinds of fun electrolyte abnormalities, bad cirrhosis/hepatorenal syndrome"...what do you do at your IM residency?! Inpatient treatment of blood glucose of 111 or BP of 131/81?

Your replies in this thread are such a weird combination of being on a high horse about the rigor of IM inpatient training compared to FM while at the same time not believing that FM residents get the incredible, mind-blowing, unrealistic, Harvard-Stanford super-fellowship experience of treating the 10-15 conditions than any med student half way done with their IM rotation knows the basics of.

I would not even be surprised if an ortho resident came into this thread and said they got experience with a lot of those conditions during their general surgery intern year. I mean we are literally talking about some of the most common, if not the most common, non-surgical reasons for admission.

These are typical things...

I am talking about things like acute intermittent porphyria, LAM, automimmune encephalitis, diffuse alveolar hemorrhage etc... The zebras.

I am not against IM fellowship to be available to FM residents as well... I even think all the IM fellowships should also be open to FM because of the overlap b/t the two specialties...

 

[YCAGA]

Where is this program? You have done more procedures than most IM residents in the US...


How many stroke, STEMI, meningitis, autoimmune encephalitis, diffuse alveolar hemorrhage, new onset of afib, cardiogenic shock, myasthenia crisis, acute chest syndrome, Ogilvie syndrome (my very first patient in residency) patients etc... have you managed?

These might be the difference between IM/FM. Nothing is wrong with any specialty, but they are different...

To go back to your original comment calling out these FM residents, you mixed in zebras with extremely typical stuff (in bold). 5/10 of the stuff you listed is bread and butter, and I feel comfortable saying that as a medical student so you know it's very basic. Then when the FM residents replied with their own lists which mostly fall under typical inpatient admissions, you said you couldn't believe it.

As an aside, I would say acute chest syndrome is common-ish at my local hospitals but that is because of the patient population which I realize is probably not true nationally.

Edit: no idea why I bolded myasthenia crisis at first...I need to get off my computer and go to sleep lol

 

[Splenda88]

To go back to your original comment calling out these FM residents, you mixed in zebras with extremely typical stuff (in bold). 5/10 of the stuff you listed is bread and butter, and I feel comfortable saying that as a medical student so you know it's very basic. Then when the FM residents replied with their own lists which mostly fall under typical inpatient admissions, you said you couldn't believe it.

As an aside, I would say acute chest syndrome is common-ish at my local hospitals but that is because of the patient population which I realize is probably not true nationally.

Edit: no idea why I bolded myasthenia crisis at first...I need to get off my computer and go to sleep lol

I didn't not want to write a long list, hence I used etc... Anyway, I am glad FM residents are getting robust inpatient training. I guess my experience with a couple places do not convince me of that.

It's like OBGYNs who like to sell them self as PCP, and then consult you for asthma exacerbation on a 26 yrs old that is at 36 wks gestation... Really!

 

[VA Hopeful Dr]

I didn't not want to write a long list, hence I used etc... Anyway, I am glad FM residents are getting robust inpatient training. I guess my experience with a couple places do not convince me of that.

It's like OBGYNs who like to sell them self as PCP, and then consult you for asthma exacerbation on a 26 yrs old that is at 36 wks gestation... Really!

It's multifactorial. FM residencies are highly variable. Some are very weak in breadth of pathology, but some so very well.

My experience has been that more often than not, the FM programs at tertiary hospitals do less because all the other residencies get all the good stuff. Obviously not universally true.

 

[Splenda88]

We have an open ICU, so we manage those cases as the primary team regardless, but unless the patient is septic enough to need pressors/intubated I'm putting them in a telemetry bed, not the unit. DKA usually goes to the unit but sometimes the floor if beds aren't available. Vented patients are always in the ICU.

I mean you kinda seemed to imply that it was shocking that a family practice would manage more than 2 patients with stroke, STEMI, a fib, and acute chest over 6 months lol. At my community hospital which is smaller than the one you mentioned above we still see plenty of zebras. Zebra doesn't always necessitate transfer if you have the specialist support you need in house, which lots of larger community hospitals do. We've had PRES, hepatorenal syndrome/bad cirrhosis, neuro behcets, weird RTAs, endocarditis with a huge abdominal abscess, and more all on our service the last few times I've been on. Perfectly able to manage these in partnership with our specialists. Lots of weird stuff on the peds side too - we get a lot of kids with chronic/congenital diseases, vents/gtubes for various reasons, hemophilia, seeing a lot of MIS-C/Kawasaki spectrum stuff lately, CF, hydrocephalus, etc. Like I said have only had to transfer out a handful of folks to a higher level of care,and not any of the ones I listed above.

I will say it also probably matters what city/environment you're in. If you have a ton of hospitals in town who have carved out their highly specialized niches, or if you're part of a big university health system, they're probably going to send people to the flagship hospital a little more easily when it's right across town. For us we're shipping people 2-4 hours away when we transfer to a higher level of care, and there's not really anybody else in the area who can manage patients who are sicker or need more specialists.


Hoooooooo boy don't get me started on this. Our OB triage patients are all seen by the family practice resident on call for L&D that day. If I had a nickel for every patient they send into triage with stuff like back pain, ear infections, non-gynecologic abdominal pain, etc basically to get them seen by a family doc... One of the midwives had a patient who presented to the office with a rash (which was like....very classic contact dermatitis), so she decided to get an ANA, which came back positive. No other symptoms. Sent her into triage and told me she wanted the pt to be admitted "for an inpatient derm and rheumatology consult." I was like my friend, we need to try a little hydrocortisone cream and have a chat about your expectations of dermatologists and rheumatologists before we pull this trigger lol

Lol.. I did not imply two... More like 10+ so you know the pathology very well...

 

[Splenda88]

This was the conversation - I listed a bunch of stuff that's pretty common, and you said you couldn't believe that a family medicine resident would have taken care of those things multiple times in 6 months.

Should have been more careful with my writing... But I meant more than twice.


Guys, I have no issues at all with FM... I always think you guys are mile away from IM in term of outpatient. Maybe my program does not do a good job in that realm