Rural FM Residency Program

[MedicineZ0Z]

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?

We have a lot of call on non-inpatient months too.

I wouldn't extrapolate your experience with what you've seen of 1-2 FM residencies and apply it to others. The quality of programs drastically differs and strong programs aren't rare.

I've seen A LOT more zebras than my friends at community IM programs.

But obviously average IM > average FM at inpatient medicine. That's a no brainer.

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[YCAGA]

We have a lot of call on non-inpatient months too.

I wouldn't extrapolate your experience with what you've seen of 1-2 FM residencies and apply it to others. The quality of programs drastically differs and strong programs aren't rare.

I've seen A LOT more zebras than my friends at community IM programs.

But obviously average IM > average FM at inpatient medicine. That's a no brainer.

To kind of move this thread in a slightly different direction, but still on the topic of rural FM residency and quality of broad FM training, is there a way to “sell yourself” that your inpatient training was robust when it comes time to apply for jobs? Maybe that doesn’t even matter because a lot of places either want IM only or they don’t care if you are FM/IM.

 

[VA Hopeful Dr]

To kind of move this thread in a slightly different direction, but still on the topic of rural FM residency and quality of broad FM training, is there a way to “sell yourself” that your inpatient training was robust when it comes time to apply for jobs? Maybe that doesn’t even matter because a lot of places either want IM only or they don’t care if you are FM/IM.

Keep a very detailed procedure log including every patient you cared for, what their diagnoses were, and what level of care they required (ICU, stop down, tele, regular floor bed).

 

[hallowmann]

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...

Your list wasn't impressive enough. I've taken care of all of these except maybe acute alveolar hemorrhage (just don't remember one) multiple times, and at least half of them more than a dozen times. I've had about 9 inpatient FM rotations and will do another 2-3 before graduating. What you're describing is a typical inpatient heavy FM program.

To be completely honest, if I compared the IM training at the small community hospital I did med school rotations at to the FM program here, I'd say the FM program here has better inpatient training.

Programs vary a lot in FM, you can't really make assumptions. Our IM program has more rigorous inpatient training than our FM program mainly due to the sheer amount of additional time spent in the ICU, but compare our FM program to one unopposed community FM program down the street, and their average census is <10 with 2/3 of their patients being ones that wouldn't even come to us and would go to Obs. It's just very variable that you basically can't generalize, and have to look at programs individually.

Keep a very detailed procedure log including every patient you cared for, what their diagnoses were, and what level of care they required (ICU, stop down, tele, regular floor bed).

This. I regret not doing this from the beginning. There are plenty of procedures I don't even bother to log anymore, which is a mistake. Get in the habit of logging everything, whether it's required or not.

 

[YCAGA]

Your list wasn't impressive enough. I've taken care of all of these except maybe acute alveolar hemorrhage (just don't remember one) multiple times, and at least half of them more than a dozen times. I've had about 9 inpatient FM rotations and will do another 2-3 before graduating. What you're describing is a typical inpatient heavy FM program.

To be completely honest, if I compared the IM training at the small community hospital I did med school rotations at to the FM program here, I'd say the FM program here has better inpatient training.

Programs vary a lot in FM, you can't really make assumptions. Our IM program has more rigorous inpatient training than our FM program mainly due to the sheer amount of additional time spent in the ICU, but compare our FM program to one unopposed community FM program down the street, and their average census is <10 with 2/3 of their patients being ones that wouldn't even come to us and would go to Obs. It's just very variable that you basically can't generalize, and have to look at programs individually.


This. I regret not doing this from the beginning. There are plenty of procedures I don't even bother to log anymore, which is a mistake. Get in the habit of logging everything, whether it's required or not.

The variability of FM programs is something I think very few people realize, save for the people applying to FM, trained in FM, or weirdos like us who use SDN, Reddit, etc. Makes sense about the procedure logs. Is it appropriate to ask about rigor of inpatient experience during interviews? Also, how much ICU time could you get at your program if you wanted to stack your electives with it.

 

[YCAGA]

Lots of programs will say they have strong inpatient training...not all of them do. Same goes for OB lol. I think the right question to be asking is "how many of your graduates from the last few years are doing X"

Gotcha. Is it fair to ask for case/procedure numbers? I know a lot of general surgery programs release these stats as a point of pride. Only thing I have seen on FM websites is average numbers for OB stuff like vaginal deliveries and c-sections.

 

[MedicineZ0Z]

Gotcha. Is it fair to ask for case/procedure numbers? I know a lot of general surgery programs release these stats as a point of pride. Only thing I have seen on FM websites is average numbers for OB stuff like vaginal deliveries and c-sections.

Asking about typical patients they take care of while inpatient would help.

 

[topraman]

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...

I hope this thread doesn't descend further into FM vs IM.

The bigger, more interesting point, is what gives rise to competency? Volume is not unimportant, but it's not everything. The level of responsibility is critical, and exposure to different phases of care matters.

To answer your questions - West Coast. And quite a few of all the above, except MG crisis (only one). Probably fewer than most IM, except cardiogenic shock did tons of advanced heart failure due to meth abuse, but here's the first point, I managed these. Not a senior, not through a fellow or consultant. And that direct responsibility makes a huge difference. To be clear, our inpatient time was 12 months (3 months ICU, 9 months floor), plus 4 months EM, plus 2 months general surgery inpatient, so not just 6 months. There was also two inpatient elective months abroad, and one month inpatient pediatrics. We also did inpatient evening or overnight call through our outpatient months. Second, I managed them not only as a hospitalist, but as an emergency physician as well. There's different learning, and usually more acuity, in the latter compared to when you receive an admit that's been worked up, even partially, or stabilized. Both of these in combination provide a strong foundation. Further experience in time negates much, perhaps not all, of the training difference in volume but it's this foundation of confidence, independence, multiple perspectives, learning how to learn that sets the tone for strong competency through the rest of your career.

 

[MedicineZ0Z]

I hope this thread doesn't descend further into FM vs IM.

The bigger, more interesting point, is what gives rise to competency? Volume is not unimportant, but it's not everything. The level of responsibility is critical, and exposure to different phases of care matters.

To answer your questions - West Coast. And quite a few of all the above, except MG crisis (only one). Probably fewer than most IM, except cardiogenic shock did tons of advanced heart failure due to meth abuse, but here's the first point, I managed these. Not a senior, not through a fellow or consultant. And that direct responsibility makes a huge difference. To be clear, our inpatient time was 12 months (3 months ICU, 9 months floor), plus 4 months EM, plus 2 months general surgery inpatient, so not just 6 months. There was also two inpatient elective months abroad, and one month inpatient pediatrics. We also did inpatient evening or overnight call through our outpatient months. Second, I managed them not only as a hospitalist, but as an emergency physician as well. There's different learning, and usually more acuity, in the latter compared to when you receive an admit that's been worked up, even partially, or stabilized. Both of these in combination provide a strong foundation. Further experience in time negates much, perhaps not all, of the training difference in volume but it's this foundation of confidence, independence, multiple perspectives, learning how to learn that sets the tone for strong competency through the rest of your career.

I do think volume is overrated. There's a volume threshold for competency but there are a lot of bad yet very experienced docs.
you need autonomy, teaching, fine tuning and various exposures to become competent.

 

[Vivid_Quail]

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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Wow. This is both insane and impressive. How did you get so many intubations? That is the one that really sticks out to me. 125 ET is almost 4 times the minimum requirement for EM. I have read that many EM residents get <100 over 3 years and almost no one gets over 200. And you got 36 LMA's too.

I looked this up just to put it into perspective for myself:

EM ACGME Procedure Minimum (your procedure numbers in parenthesis)
Adult Medical Resuscitation 45 (?)
Adult Trauma Resuscitation 35 (?)
Cardiac Pacing 6 (?)
Central Venous Access 20 (28)
Chest Tubes 10 (1)
Cricothyrotomy 3 (0)
Dislocation Reduction 10 (2?)
ED Bedside Ultrasound 150 (138)
Intubations 35 (125 ET + 36 LMA)
Lumbar Puncture 15 (18)
Pediatric Medical Resuscitation 15 (?)
Pediatric Trauma Resuscitation 10 (?)
Pericardiocentesis 3 (?)
Procedural Sedation 15 (16)
Vaginal Delivery 10 (106 + 65!!! c-sections)

Before anyone freaks out, I am not saying that OP is now equivalent to an EM-trained doctor or that procedures are the only difficult or important part of EM. I just think it is amazing that OP was able to get near EM-minimum numbers in many areas while having much more peds, OB, and outpatient than EM does and with 1/6th or less of the dedicated EM + ICU months.

Shows how much someone can accomplish at an unopposed FM program. I am sure @topraman really went out of their way to be proactive and available for procedures...probably in the top percentiles of FM residents in terms of intubations and surgery at least. Maybe for other procedures too.

 

[topraman]

Thanks @Vivid_Quail. It is the beauty of a good unopposed program and when you have the fire in the belly because you're clear on what you are training for.

I actually was able to moonlight as an ED physician in a small mountain hospital with a solo coverage 5 bed ED during my last six months. It was surprisingly more acute than our home ED as the only thing around.

We had a really wonderful group of anesthesiologists who made us do everything from start to finish. Of my 125 ETT intubations, probably 30 or so were emergent (ED or ICU), the rest were in the OR. The OR ones were very helpful, trying out different techniques, different equipment, and some really difficult airways. It made you ready for the rest. We had one month of anesthesia mornings for an ED month, plus was in the OR daily during general surgery, where we intubated and then scrubbed in. Or on nursery, when we were called to receive the baby for an elective C/S, we would do the spinal anesthesia (OB spinals prepare you for the most difficult LPs). This is the beauty of generalist training and no competition, every month hit more than its designated rotation area.

Filling out the below list you started as we didn't log some of this / couldn't log from aways or moonlighting:

Adult Medical Resuscitation 45 (100+)
Adult Trauma Resuscitation 35 (15-20)
Cardiac Pacing 6 (3)
Central Venous Access 20 (28 +2 abroad, +2 moonlight, 3 of the lines were dialysis catheters too for CRRT)
Chest Tubes 10 (1+1 in the OR, +12 abroad)
Cricothyrotomy 3 (0 +2 trach in the OR, +2 abroad)
Dislocation Reduction 10 (2 +4-5 in the OR, +9 moonlighting)
ED Bedside Ultrasound 150 (138 +many more not logged)
Intubations 35 (125 ET + 36 LMA)
Lumbar Puncture 15 (18 +26 spinals)
Pediatric Medical Resuscitation 15 (30+ including newborns)
Pediatric Trauma Resuscitation 10 (5-10 during Peds ER)
Pericardiocentesis 3 (? +1 abroad)
Procedural Sedation 15 (16 +40-50 abroad +10 moonlighting)
Vaginal Delivery 10 (106 + 65!!! c-sections)