rural/full scope/"cowboy" programs

Discussion in 'Family Medicine' started by emedpa, Oct 21, 2002.

  1. emedpa

    emedpa GlobalDoc

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    I am considering an fp residency with an emphasis in rural medicine which includes high risk surgical ob and extensive emergency med exposure. I am looking for an unopposed program on the west coast. thus far I have found 5 such programs:
    ca:
    ventura county
    salinas/natividad
    contracosta county
    tacoma family medicine(wa)
    ohsu/cascades east(or)

    does anyone have any info/opinions on these programs not on their websites or any other programs to add to this list. thanks-e
     
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  3. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved

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    Also check out the FP program in Santa Rosa, CA. It is an unopposed FP program with a UCSF-affiliation. You'll get plenty of hands-on exposure in OB, Surgery, and Level II trauma. It is also one of the oldest FP programs in the country.

    http://www.fpresidencysantarosa.org/
     
  4. emedpa

    emedpa GlobalDoc

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    Thanks. the UW/spokane rural track looks good too-e
     
  5. UTMB09FM

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    Howdy,

    Does anyone have any updates about these type of programs?
    Perhaps in other states as well.


    Thanks!
     
  6. divinity09

    divinity09 Resident

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    Wesley Family Medicine in Wichita, KS offers incredible full-scope training that is pretty much limited by your level of energy.

    Very high volume OB including high risk. You are expected to do primary sections, as well as vacuum and forceps deliveries. The hospital is 99th percentile for deliveries in the country.

    Residents are the only trauma residents for a Level-I trauma center and there is mandatory rotations in trauma and trauma/surgical critical care in the intern and third years.

    Peds is excellent, and very high-volume inpatient experience including PICU w/ the full range of pediatric critical care procedures performed by the residents.

    Scopes include EGD's, nasopharyngoscopy, and colonoscopy, and are done during surgery rotations and longitudinally throughout for people who want more.

    Procedural training is embraced and encouraged, and again only limited by resident energy.

    The rest of the training is as expected elsewhere. Many residents end up doing international rotations. Wichita is a very reasonable town to live in with an OK airport to get where you need to.
     
  7. Lespedeza

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    Does anybody know of any programs like this that are on the East coast? It seems like a lot of these programs are regionally limited (mid-west, west coast) with the searching I've done. :(
     
  8. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    I interviewed in SC/NC/GA mostly, but look into Florence, SC Anderson, SC Spartanburg, SC Cabarrus, NC. I think you might find something to your liking there. I think VA has some pretty good programs, I just know little about that area.
     
  9. raptor5

    raptor5 Fooled by Randomness

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    JPS (TX)
    WACO (TX)
    Casper (WY)
    McKay-Dee (UT)
    Rapid City (SD)

    No specific order
     
  10. montessori2md

    montessori2md Member

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    I think if you want cowboy, you should look at Front Royal or Roanoke, but my impression is that intense procedure time is not an expectation the way it is in programs out West. That said, I know 3rd year has lots of elective time, and there is nothing to say you can't spend all of it learning to do procedures.

    Update: By word of mouth only, for what it's worth, neither of these programs are as cowboy as they once were.
     
    #9 montessori2md, May 4, 2010
    Last edited: Jan 23, 2011
  11. montessori2md

    montessori2md Member

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    What about NM, AZ, and Vancouver, Wa (SW)?

    In NC, MAHEC (Asheville, Hendersonville) unofficially says they are going to start an OB fellowship in 2011 or 2012, fellow will do ~150 C-sections. They are def. starting a palliative care fellowship as of next year. They also do tons of peds inpatient, and 5/9 of this years grads say they are going to offer full ob as part of their practice. They have 6 faculty who do L&D. If by "cowboy" you include OB, based on my conversations w/ people from just about every program in NC yesterday, MAHEC is the place to be.

    For students: several of the NC and SC residencies offer "procedure rotations" for 4th years, where all you do for the month is derm/ortho/gyn office procedures. I'm not sure if they have do do GI scopes or not as part of that, probably depends on the program.
     
    #10 montessori2md, May 9, 2010
    Last edited: May 23, 2010
  12. emedpa

    emedpa GlobalDoc

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    can anyone comment on unopposed/full scope D.O. family medicine programs?
    thanks
     
  13. J-Rad

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    There are three dually accredited residencies in Maine (in Bangor [EMMC], Augusta [MDFPR], and Lewiston [CMMC]). All state that they have a rural focus. At the time I was in med school (graduated '05) and by word-of-mouth only (I'm a pediatrician, not an FP) EMMC and MDFPR had much better reputations for work environment (CMMC had a "malignant" reputation at that time). The people I talked to who rotated at MDFPR and EMMC loved them and most of those that I knew who rotated there did residency there. I didn't hear many good things about CMMC. But my scuttlebutt is now 5 years old, so take it for what its worth.
     
  14. wake5233

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    What were your thoughts on the Cabarrus program? I was not able to go to that event I believe your refering to last weeekend it sounded really helpfull.
     
  15. emedpa

    emedpa GlobalDoc

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    thank you. I was looking at those so that helps.
     
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  17. montessori2md

    montessori2md Member

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    Struck me as on the suburban side. It sounded like a great place to be if you wanted to be able to shop, etc, and still get a small town experience. Their residents seemed very happy and the cost of living is pretty low. Their schedule is pretty typical intern year, and their OB service is also pretty typical. For me, b/c I'm interested in doing a lot of OB, MAHEC was more interesting.
     
  18. wake5233

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    Asheville would be a really cool place to live. All of that OB scares me away though.
     
  19. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    I really liked that program, in fact I ranked them pretty highly. I only had two concerns, one of which is particularly relevant to this thread. First, their clinic locations for residents are spread apart by a fair distance. That's just a personal thing for me, might not bother you. Second, compared with some of the unopposed places I interviewed at in SC, they seemed to be lighter on some of the more hard-core procedure stuff. It seemed much more difficult to manage a lot of scopes there than other places.
     
  20. raptor5

    raptor5 Fooled by Randomness

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    As a DO I can say that the large majority of DO only (non-ACGME) FM programs are crap if you are looking for a cowboy program. Most are ok if you want to do adult O/P with a sprinkle of peds.
     
  21. emedpa

    emedpa GlobalDoc

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    THANKS. good to know.
     
  22. amakhosidlo

    amakhosidlo Accepted

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    For parties interested in FM and following along, what does "unopposed" mean?
     
  23. emedpa

    emedpa GlobalDoc

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    no other residencies at the primary training hospital.
     
  24. JackADeli

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    Exactly. The point of "unopposed" is to state the specific residency/residents are not competing with the learning/experience requirements of residents in other specialties. So, the unopposed FM residents do not compete with Ob/Gyn residents for clinic gyn procedures or hospital procedures (i.e. csxn, deliveries, tubals, etc...). The unopposed FM residents do not compete with IM residents for central lines, general surgery for OR cases, floor procedures, chest tubes, etc.... the list goes on. But, as stated, no opposition to your learning from other residency programs' needs.
     
  25. FlameBoy

    FlameBoy Flameboy

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    MAHEC in Hendersonville, NC (not Asheville) may not be West coast, but is in the mountains of Western NC near Asheville. It is unopposed and has 2 OB/GYN docs and 3 Nurse Midwives on staff. On call you take combined Family Practice/OB/and Peds (no pediatricians in the community admit unassigned, and the FP service takes all County Health Department and unassigned OB) every night for all 3 years. You have 2 scheduled months in the ER, with the opportunity to take more. Several of the recent grads are now practicing full time EM in rural hospitals. Several more practice full scope FM with OB. It is small, only 3 interns a year, and with such a small bunch you work more your 3rd year instead of supervising interns, but you are definitely ready to practice come graduation. Many stay because of the culture and the natural beauty.
    http://www.blueridgeparkway.org/
    http://www.historichendersonville.org/attractions_area.htm
     
  26. phospho

    phospho SDN Lifetime Donor
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    Are these "cowboy" residencies hard to get into? Also, why are you so interested in them? Is it because you want to work in a hospital setting like that in the future, or is it just so you have the experience when you're out on your own someday and find yourself in a bad situation?
     
  27. GoodmanBrown

    GoodmanBrown is walking down the path.

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    Emedpa, are you still thinking about med school? Did you pull the trigger? I haven't been to the PA Forums in awhile, where it seems you post more frequently.
     
  28. emedpa

    emedpa GlobalDoc

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    I'm thinking about the 3 yr pa to do bridge at lecom. I think I have a really good shot at it if I apply. I would just need to take the mcat at this point. still in discussion with the family as it would be a major adjustment for them.
     
  29. emedpa

    emedpa GlobalDoc

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    many of these residencies are competitive(ventura county for example, the #1 fp residency in the country in the minds of many).
    my dream job would be rural full scope fp covering the clinic as well as doing some ed shifts, rounding on my own pts in the hospital, doing my own deliveries with the ability to do crash c-sections as needed, etc
    I also do a lot of disaster and third world medicine trips so these skills would be good in that environment as well. the last trip I went on one of our er docs did a crash c-section using spinal anesthesia with a good outcome for mom and baby.
     
    #27 emedpa, Jul 11, 2010
    Last edited: Dec 29, 2010
  30. lowbudget

    lowbudget Senior Member

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    emedpa,
    I've been following your posts for quite some time & found them very interesting & balanced. I used your list as a starting point for my FM residency search. I will say, however, that after interviewing at the places you posted that your definition & my definition of #1 differs as I found Ventura deficient in many of the things I thought was important (namely, outpatient medicine) but I found that to be the case at Contra Costa & JPS also in terms of balance in the curriculum. I think it stems from a philosophical difference in training but I could tell that all 3 of those programs had strengths in other areas that surpassed the one I ended up going to. Good list, nevertheless!

    It does break my heart reading this resurrected thread that, indeed, it has been since 2002 since it was originally posted. I'm surprised to hear that you're still thinking of med school only because in the time it took for you to post & the today, you may have finished & be out doing what you said you wanted to do...

    Not to incite a riot, but whenever I tell people what I do, I hear a lot of people say that they were once premeds & have flirted with the idea of going back. I tell them that FM is a journey that, for the time being, is enjoyable & endless. When these guys tell me what sacrifices they would have to endure, I ask them what else would they otherwise be up to doing? That, training to be a doctor is the fun of it...

    So, you talk about the things you that you dream of doing... &, you've helped many people along here on SDN, including myself. So I would be remissed if I didn't ask you: What's holding you from chasing your dreams?
     
  31. emedpa

    emedpa GlobalDoc

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    fair question.
    my wife is an artist who makes < 10k/yr so she can't support us and I have small kids in excellent local schools. at present my only debt is my mortgage.
    my opportunity cost for medschool is around 1 million dollars when you figure cost of relocation, paying 3 yrs of rent/upkeep of my family before residency, school tuition and related expenses and lost income I would have made as a pa. I make significantly more than 100k/yr and figure a reasonable starting salary for the fp job I want would be around 180k/yr in a rural area. doing the #s that means I never catch up financially before retirement vs staying a pa and I miss my kids growing up. my dad was a neurologist. I was born the yr he was an intern. I have no memory of him before my 13th birthday. I don't want to be that kind of dad. if I was single I would be a double boarded fp/em doc already.
     
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  32. lowbudget

    lowbudget Senior Member

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    Ah, interesting. And, understandable. I think it's interesting how you talk about how important it is to be a part of your family as, I think, many of us in this generation of doctors feel.
     
  33. Old_Mil

    Old_Mil Senior Member

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    The thing about cowboy FM programs is this: the fund of knowlegde in medicine has become so vast that it is impossible to train sufficiently in 3 years to become a first class OB GYN, a first class Pediatrician, a first class internist, and a first class EM doctor. The flexibility of FM will allow you to become pretty good at perhaps one of these fields, but the FM resident who wants to spend most of his time in an ED is going to have to sacrifice, say, his OB training...and the FM resident who wants to be able to deliver babies and perhaps even do c-sections is going to have to sacrifice, say, ED training.

    There just aren't enough hours in the day to do it all, so I'd recommend you look for an FM program that gives you the flexibility of schedule to do what you want, rather than one that tries to mandate that you do everything.
     
  34. digitlnoize

    digitlnoize Rock God

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    I've been wondering about this myself. I understand that much of rural medicine demands that one doc does everything, to a certain degree...however, what DO you loose in quality of service? Maybe you can't become a first-class FM/EM/OB/IM/Peds in 3 years, but can you make 2nd class? Is that good enough for the rural areas, who would otherwise have nothing? I don't really think so, but I've never been interested in being a Cowboy anyways.

    For those interested, the dental community is having a similar discussion regarding allowing expanded duty hygienists in rural areas. The argument being that even a temporary or crude filling placed by a hygienist is better than nothing...same arguments could be made for NP/PA practice rights in rural/underserved areas as well...
     
  35. lowbudget

    lowbudget Senior Member

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    Well, that's exactly the thing... in that FM we don't view the world fitting into these little boxes that academics force upon us. Does FM = IM + Peds + OB/GYN + EM...? No. It's a field of it's own.

    Did I spend multiple months taking care of kids with AML & its associated complications of chemo? Or, adults with renal failure due to scleroderma? No, but a first-class pediatrician & internist would but so what? These patients would congregate their care in large academic centers anyways & wouldn't be considered necessarily appropriate for a rural center anyways.

    What it amounts to is the cowperson FP fills the ecological niche/needs of their community. And for some of these things (like procedures), you need training. Your goal isn't to be the best internist-pediatrician-obestrician-etc the community has ever seen. Your goal is to be the best family doctor.

    Point well taken, if you spend all your time learning 1 thing, you take away time from something else & that's my criticism of some of these programs too. But, if you can envision the skillset (or patient exposure) you will need to have prior to residency, you can find the best residency is right for you. That transcends any individual box that you can fit an FP into.
     
  36. raptor5

    raptor5 Fooled by Randomness

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    I agree
     
  37. emedpa

    emedpa GlobalDoc

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    most of the cowboy programs have more ob time, more surgical time, more inpt rotations and more em time in addition to the mandated # of clinic hrs.
    how do they do this?
    80 hr weeks x 3 yrs not 80/60/60 like some cushier programs.
    take a look at the ventura rotations:
    http://www.venturafamilymed.org/curr.html
    compare that to some other cushy programs with basically a tough intern yr then 2 easier yrs with night float coverage and most time spent in clinic. that's great if you want to work at kaiser doing outpt family medicine only m-f 9-5 for the rest of your life but if you want to work with inpatients or in a rural facility you need stronger skills in my humble opinion.
     
  38. EdibleEgg

    EdibleEgg Member

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    I don't provide second class or crude care. I guess you can make the argument that it is temporary..... There is a huge role in health care for the expanded generalist; many countries (the ones that have better health care outcomes for less money) see that. I'm not an EM/OB/PED/IM/ORTHO/GYN/ENDO/CARDS doc, I'm a Family Physician. My skills and scope overlap with all of those fields. For example, I can manage a boxer's fracture as well as anyone, but I don't think that makes me an orthopod. I don't try to do joint replacements. My cecal intubation rate and adenoma detection rate are better than the published GI numbers, but I don't think that makes me a gastroenterologist.
     
  39. FlameBoy

    FlameBoy Flameboy

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    I was going to go to PA school, it was what 18 delta's did in the Army, was all lined up to go to Duke, but after a couple of years at night school, my profs asked me, why not apply to Med school? Why not?, because it took 7 years minimum not 2, the hours sucked, and it would cost a buttload of cash (the VA was willing to send me to PA but not to Med school). In the end, I guess I wanted to be the the guy who made the last decision, the leader of my Med team. I'm now 6 figures in debt, making about 40% more than a PA, and have never looked back. There are rewards to making it to MD, the best is, no one signs your notes but you, it's your orders hopefully healing the sick and injured, for better or worse. And for the most part, the rest of the world still respects you for your effort. I would of had a good, satisfied life as a PA, but I believe you should reach for what you can accomplish, not for what makes sense. We only get our allotted 70something years, gotta make them count. Live like you might die tomorrow, learn like you will live forever.

    Of course, after spouting all that crap, I just realized my kids were out of high school before I started med school. I guess we all have to sort it out on our own.
     
  40. primadonna22274

    primadonna22274 Senior Member

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    I'm really starting to like the Cascades East program in K Falls, OR, and have been following the Hendersonville, NC program for some time (have family in both K Falls and Asheville). I had been leaning toward IM/geri but after discussion with 2 dear friends (both FP docs in OR) this past week leaning back towards the flexibility & reimbursement practicalities of FM. Definitely would prefer an unopposed community program with lots of inpatient experience as that's where I feel the weakest. There is also the procedurally-heavy McLeod program (Florence, SC) but I think once I leave SC I won't likely return. I must admit I am homesick for the west...one week at home was not enough!
    I have next to zero interest in OB :laugh:
    LIsa
     
  41. Horseradish99

    Horseradish99 Old World Primate

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    Lisa,

    Feel free to send me a PM. I just finished residency in K Falls and am now doing rural FP with OB about an hour northeast of Asheville, NC.

    Scott
     
  42. primadonna22274

    primadonna22274 Senior Member

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    How fortuitous! Thanks, I will send you a PM.
    Lisa

     
  43. montessori2md

    montessori2md Member

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    Re: why "cowboy"

    While I agree that you can't learn "everything", I also think that's overlooking the point of rural FP. My goal is not to replace specialist care, but to avoid unnecessary/low yield referrals to specialists. I don't want to do a crappy patch job (as the dental ex. above). I do want to make sure I know how to do as much as I can of the small stuff (outpatient ortho, sutures) and the emergent/critical care stuff as possible. I'm considering remote rural practice and I want to be able to 1) keep my patients alive when the nearest level I trauma ctr may be hours away and 2) help my patients feel as well as possible without sending them up the road 100 miles to see a specialist.

    A lot of little old ladies out in the boonies would rather sit at home and suffer than make the trek. I can whittle down those trips to 1-2x/year instead 1-2x/month, by doing joint injections and managing her CHF meds. If I can help deliver babies and keep women from sitting in the car for an hour in labor, I'm happy to do that.

    If you're planning on setting up practice down the block from a big academic center, I'm not sure why you'd care, unless you're sick of trying to get your patients into a specialist because they're booked for 3 months solid ;)
     
  44. rachmoninov3

    rachmoninov3 Senior Member

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  45. fhockeyplayr

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    This conversation is most likely cold and I'll be surprised to get a response, but I am a 3rd year osteopathic med student looking for some up-to-date information about the whereabouts of these cowboy programs. I'm looking for a FM residency program that trains docs for broad-scope practice (OB (C-sections perhaps), ED perhaps, colonoscopies, and overall, as many procedures as possible). I plan on living rural, and although I am from eastern upstate NY, I am currently a TX resident. I'm very interested in learning about the residency options closer to my folks in NY. I read the descriptions of some of the programs in Maine and North Carolina that were described above, but would welcome any more information about these and other programs in the NE. Surely there must be something in PA, NY, VT, NH...?
     
  46. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved

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    Did you check out John Peter Smith?
     
  47. Ericslv

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    I don't have much info on this but I want to say that this was one of the best questions asked in Student doctor network. More questions on the level of training at different programs should be asked. It would be nice to have a database of what programs do what and what they are like before med students apply. I wish I had this when I was applying.
     
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  48. primadonna22274

    primadonna22274 Senior Member

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    #46 primadonna22274, Oct 31, 2015
    Last edited: Oct 31, 2015
  49. OzelloPiRat

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    THIS is exactly what I have been looking for! Great explanation! I was a nurse for 12 years before starting medical school and I am now an OMS-II. At OMED a couple weeks ago I was able to speak to the Alaska Family Medicine Residency representative and fell in love with the idea of being a comprehensive physician. Most of the FPs I have experience with outside of academia only do the basics and send you to specialist for every thing else. So to see that my idea of a true family physician is not just being taught, but practiced, has just spun my world.
    THANK YOU!!!!
     
    leviathan2 likes this.
  50. fhockeyplayr

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    primadonna22274 likes this.
  51. leviathan2

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  52. cabinbuilder

    cabinbuilder Urgent Care Physician
    Physician

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    This is exactly the type of medicine I have practice in the frontier for the past 5 years. I was there at that OMED lecture about the Alaska program. Too bad it wasn't in place when I was in residency.
     
    OzelloPiRat likes this.

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