Scope of practice

[duckie99]

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I was wondering if you guys could elaborate some on what your scope of practice entails. I understand FM is mostly primary care in an office setting but how easy/hard is it to get shifts in the ED once in a while or also contract with nursing homes to see patients there just to name a couple examples? Would you say FM has the most flexibility in how one is able to practice medicine?

 

[cabinbuilder]

I was wondering if you guys could elaborate some on what your scope of practice entails. I understand FM is mostly primary care in an office setting but how easy/hard is it to get shifts in the ED once in a while or also contract with nursing homes to see patients there just to name a couple examples? Would you say FM has the most flexibility in how one is able to practice medicine?

My current job I am the only doctor at a frontier hospital in Nevada (more remote than rural). I cover clinic and ER during the day, am on call for ER 24/7 for the two weeks I am there, and take care of any inpatients that I admit.

There are no nursing homes where I work. I have done nursing home in the past an hate everything about it. Nursing home care is usually rounding once a month on every patient but you get faxes all day every day from the staff for every little thing. I personally think nursing home care is hateful.

Yes, family practice is very versatile. You can pretty much set it up how you want. Clinic, urgent care, ER, hospitalist, nursing home, OB, pain management. Any or all in any combination you want.

 

[kdur]

I am currently a 3rd year on a FM rotation in a rural location. The docs there practice full scope medicine. Here's what my day was like one day this week (the doc I was with was on call that day).

Came in early in the morning and check on a laboring pt. About 8:30 head to clinic. Saw about 5 pts with various complaints; back pain, URI, med checks...

930 OB pages because baby is having some prolonged decels. Doc checks her out and heart rate comes back up.

Back down to clinic to see a guy with an acute abdomen. After blood work and CT turns out he has an appy. consult surgeon.

Get paged to ER for a pt w/ syncopal episode. Work him up.

Back to clinic. More med management, chronic illness and a guy who cut his finger on a table saw. Suture the lac.

Ob pages again. Baby still having decels but stablizes.

More clinic.

Ob again. Mom's ready to go. Starts pushing. Takes about an hour. Head comes part way out, then goes back in. Comes out and kind of stays put. Doc jumps in and does various manuvers to release the shoulder dystocia. Out comes baby but requires a bit of encouragement to breath. Everything turns out fine.

Back to clinic and a few more ED pts.

The next day was pretty much the same except this time the baby was breech and the doc had to do a c-section.

Pretty cool stuff.

 

[duckie99]

I am currently a 3rd year on a FM rotation in a rural location. The docs there practice full scope medicine. Here's what my day was like one day this week (the doc I was with was on call that day).

Came in early in the morning and check on a laboring pt. About 8:30 head to clinic. Saw about 5 pts with various complaints; back pain, URI, med checks...

930 OB pages because baby is having some prolonged decels. Doc checks her out and heart rate comes back up.

Back down to clinic to see a guy with an acute abdomen. After blood work and CT turns out he has an appy. consult surgeon.

Get paged to ER for a pt w/ syncopal episode. Work him up.

Back to clinic. More med management, chronic illness and a guy who cut his finger on a table saw. Suture the lac.

Ob pages again. Baby still having decels but stablizes.

More clinic.

Ob again. Mom's ready to go. Starts pushing. Takes about an hour. Head comes part way out, then goes back in. Comes out and kind of stays put. Doc jumps in and does various manuvers to release the shoulder dystocia. Out comes baby but requires a bit of encouragement to breath. Everything turns out fine.

Back to clinic and a few more ED pts.

The next day was pretty much the same except this time the baby was breech and the doc had to do a c-section.

Pretty cool stuff.

not gonna lie sounds pretty sweet.

couple questions though:
1. FM docs can get trained to do c-sections? I know they aren't terribly complicated but I thought that was pretty much reserved for obgyn docs.
2. I know you are in a pretty rural area but is this kind of stuff (or at least similar variety to a degree) even feasible in an area, say on the edge of a suburb? Any attendings or residents here know?


I'm a 4th year trying to see what I want to do. Want mix of EM type stuff without having to only be in the ED 100% of the time and clinic work. I was thinking FM with EM tacked on afterwards (maybe they'd let me do accelerated residency if already certified FM?) just so I can have a clinic practice 3-4 days/week while pulling ED shifts 2-3 days/week. If I only do EM residency I am doomed to the ED. I realize I could do IM instead but sort of fear I don't get the breath necessary for clinic as I am not big on fellowships which I see as the only reason to do IM.

I only say do both because I don't want to live in super rural area but also not big inner city and I am afraid that EDs in areas like that want a EM board certified doc though I am not sure if that is always the case. Anyone actually know? Thanks all.

 

[kdur]

FM docs can be trained to do c-sections. The one of the docs I was with went to a residency that had huge OB volume and trained in c-sections. There are also OB fellowships for FM docs. Another doc I am precepting with had a general surgeon proctor him on sections. So it can be done but it's usually only feasible in rural locations, seldom see it in urban/suburban locations.

 

[kdur]

Also. The physicians at this rural hospital often moonlight in the ED (usually on weekends). I also know of a recent FM grad (from a largely rural program) who got hired as a FT ED doc. FM has great flexibility.

 

[AlmostJesus]

FM docs can be trained to do c-sections. The one of the docs I was with went to a residency that had huge OB volume and trained in c-sections. There are also OB fellowships for FM docs. Another doc I am precepting with had a general surgeon proctor him on sections. So it can be done but it's usually only feasible in rural locations, seldom see it in urban/suburban locations.

There are also areas in the midwest where the FP docs are doing lap choles and lap appys along with c-sections.
The place I know of where this happens is 70 miles from the nearest surgeon. The hospital does have a surgeon on staff, but having two of the FPs that can do the bread and butter emergency surgeries and c-sections helps keep call well distributed. I guess the malpractice rate is significantly higher for obvious reasons but they still are able to benefit from doing the surgeries

 

[ztaw15]

I have said this before, but I am in a large urban area where there are some very active full scope FM guys practicing. There are some that staff the ED (though they do only ED work), and others have practices with lots of OB, Peds, inpatient, and good volume on office procedures and urgent office visits for things like lacs/casting (which is really nice to save your patient a three hour ED visit, at minimum, for a short stop to the office) One guy does screening colonoscopies and simple EGDs, and a few do their own C/Ss.

One thing I will make painfully clear though, is that these guys are not acting like cowboys. They don't take complicated OB pts planning on a big deal type of C/S. These are generally simple pregnancies, but with a prior C/S and want elective repeat, or simple SVDs that end up needing a C/S.

As for the colons/EGDs, these are on otherwise healthy people who need a screen or have GERD Sxs, not GI bleeders or crohns/diverticulitis Pts.

They will do PFTs and Stress tests in office, but they are not holding themselves out as specialists for complex patients.

So, just keep that in mind. As for the ED docs, they pretty much act exactly like the other EM trained guys, though this is a non-trauma center and on the occasion when a trauma has come by it is usually the EM trained guy - if there - that would jump on it.

 

[cabinbuilder]

There are also areas in the midwest where the FP docs are doing lap choles and lap appys along with c-sections.
The place I know of where this happens is 70 miles from the nearest surgeon. The hospital does have a surgeon on staff, but having two of the FPs that can do the bread and butter emergency surgeries and c-sections helps keep call well distributed. I guess the malpractice rate is significantly higher for obvious reasons but they still are able to benefit from doing the surgeries

Same thing in Montana, North Dakota, South Dakota. FM doing C-sections, scopes, appy, GP, etc. No surgeon for 100's of miles, someone has to pick up the slack.

 

[AlmostJesus]

Same thing in Montana, North Dakota, South Dakota. FM doing C-sections, scopes, appy, GP, etc. No surgeon for 100's of miles, someone has to pick up the slack.

The place Im talking about is in North Dakota.

Coming from a small town, there is something to be said for going into the small town family practice role. Becoming the "village doctor" by working in a small town seems as though it would have a fair amount of benefits... Tons of respect, a variety of experiences to keep things interesting without as much burn out risk as specialties such as EM, and the full practice opportunities. That being said, the disadvantages such as the heavy call requirements, lack of backup, and the negative parts about living in a small town (disadvantaged schooling, everyone in your business, the lack of peers, distance to services/stores) make it a true cost/benefit analysis.

 

[tkim]

I only say do both because I don't want to live in super rural area but also not big inner city and I am afraid that EDs in areas like that want a EM board certified doc though I am not sure if that is always the case. Anyone actually know? Thanks all.

The closer you get to a city, the more this will be the case.

 

[Ineedhopenow]

This is a great thread. I'm commenting here to keep it in my history. Thanks everyone.

 

[cabinbuilder]

The place Im talking about is in North Dakota.

Coming from a small town, there is something to be said for going into the small town family practice role. Becoming the "village doctor" by working in a small town seems as though it would have a fair amount of benefits... Tons of respect, a variety of experiences to keep things interesting without as much burn out risk as specialties such as EM, and the full practice opportunities. That being said, the disadvantages such as the heavy call requirements, lack of backup, and the negative parts about living in a small town (disadvantaged schooling, everyone in your business, the lack of peers, distance to services/stores) make it a true cost/benefit analysis.

All this is true. My job now I work in Frontier Nevada for 2 weeks 24/7 call to the ER and do clinic during the day M-F. IT is HARD but I get paid super well and the hours and days fly by. I live in OREGON where my husband and kids stay while I am gone because they love their 6A school and tons of opportunities. The town is sooo desperate for a woman provider that I was innundated with patients the first week. Over all I saw ~300 patients over the two weeks between the two entities. Got them all dictated before I left. Still working on the esigning.

 

[ztaw15]

I want to mention that when I said there are lots of FM/IM guys in the EDs in my area, I realized that all the younger/newer guys are EM trained, so probably now that there is a good supply of EM trained folks to replace the older guys, it is not as attractive to sign on FM/IM trained people.

 

[AlmostJesus]

There are still openings out there for FP trained docs for ER, especially in the ~20,000-50,000 pop. cities. I know for SD, there are multiple openings for FP trained docs in EM positions with both health systems.
I do agree though, it is likely that these positions are going to get fewer and far between, but rural areas are never going to have the volume to sustain an EM doc. Thus smaller towns will always have openings for FPs to do EM, it just depends on how low of a volume you care to see.

 

[Roguelyn]

It's not all that hard to do a mix of office and EM. Or even all EM. We've had residents take full-time EM jobs, without an EM fellowship, in close suburbs of Cleveland, Detroit and Chicago. They've had to get ATLS training prior to starting, but otherwise that's it.

If you look into the OB fellowships for FM they are really all about getting you trained to be primary surgeon on C/Ss and tubals. There are a ton of jobs for FM with OB. These jobs aren't all in crazily rural areas either.

 

[duckie99]

It's not all that hard to do a mix of office and EM. Or even all EM. We've had residents take full-time EM jobs, without an EM fellowship, in close suburbs of Cleveland, Detroit and Chicago. They've had to get ATLS training prior to starting, but otherwise that's it.

If you look into the OB fellowships for FM they are really all about getting you trained to be primary surgeon on C/Ss and tubals. There are a ton of jobs for FM with OB. These jobs aren't all in crazily rural areas either.

That's interesting. I understand the training advantages of doing FM w or w/o fellowship for having a mix of office/ED time or even med office/only OB (no gyn surg) type practice instead of EM residency or OBGYN residency, respectively. But I don't necessarily understand how it is advantageous to do FM over EM if you basically just want to do EM? Maybe just later in life have ability to do FM office work?

 

[ztaw15]

Agreed with the above. I think anyone who ultimately wanted to do solely EM would be pretty unhappy in FM residency, and would be better served just doing EM. I see a fellowship more as an option for someone who either changed their mind and wanted the extra training, or more likely someone who decided to go practice in an area where there was a need for partial coverage and felt like they needed extra training.

Going into FM knowing you want to finish and do only EM is probably a recipe for discontent.

 

[Roguelyn]

I think people find out that o/p FM is mostly about paperwork and high throughput and not so much about actually seeing patients and get disenchanted with it. Then you get all these recruitment offers for EM making nearly twice as much or more without call, shift work. It's certainly a nice option from a lifestyle point of view.

I don't know if people do this...but it's easier to get an FM spot than an EM spot. So maybe there are folks doing FM as a backdoor route to EM.

 

[deleted87716]

I think people find out that o/p FM is mostly about paperwork and high throughput and not so much about actually seeing patients and get disenchanted with it.

You must be thinking of EM.

If your FM practice is all about paperwork and throughput, you're doing it wrong.

 

[Roguelyn]

You must be thinking of EM.

If your FM practice is all about paperwork and throughput, you're doing it wrong.

I am very hopeful that it won't be when I'm out of residency.

 

[tkim]

You must be thinking of EM.

Now, now.

 

[Leukocyte]

I think people find out that o/p FM is mostly about paperwork and high throughput and not so much about actually seeing patients and get disenchanted with it.

From my personal experience, I would have to say that for the most part, you are right. As much as I disagree with the idea that medicine is a business, the fact is, in a capitalist society, it is a business like any other. So unless you are a private FM doc working for yourself (not an employee of a medical group), you will always be under pressure to meet productivity endpoints. And yes, the truth is that in general, the time spent filling in the medical records in the EMR, answering messegaes, and filling out paperwork is for the most part more than the time spent with the patients.

Then you get all these recruitment offers for EM making nearly twice as much or more without call, shift work. It's certainly a nice option from a lifestyle point of view.

Yes, EM / Urgent Care pays far more than FM, in general... but the downside is that in EM / Urgent Care one has to deal with more stress and more malpractice liability. EM is NOT easy, and many Urgent Care centers are now becoming mini ERs (due to pressures from the medical group administration to see as many cases as possible). In my opinion, a patient with chest pain should never be seen in an Urgent Care, but in the real word of medical business, many Urgent Care docs feel "obligated" to see those patients. Looks might be decieving, and getting an EKG, CXR, and a single set of cardiac enzymes to "rule out" cardiac chest pain is just crazy. A chest pain patient should be ruled out properly in an ER.

I don't know if people do this...but it's easier to get an FM spot than an EM spot. So maybe there are folks doing FM as a backdoor route to EM.

Although there are some FM docs who are allowed to work in some community hospital ERs...I do not think it is a smart idea for a person to do a FM residency if he/she wants to work in the ER. Emergency Medicine is a high medical liability field. If something goes wrong, and the FM doc who works in the ER is sued, then that FM doc would have very little ground to stand on. If one wants to work in the ER, then he/she should do a EM residency. It might have been OK in the past for IM and FM docs to work in ERs, but in this day and age of advanced medical specialization and high rates of malprcatice suits...it is a very risky thing to do.