Should Family Medicine Residency Programs be 3 or 4 years long?

[Staryy]

Should Family Medicine Residency Programs be 3 or 4 years long?


There is study in the works to compare 3 year family medicine residency programs to 4 year programs.

Should Family Medicine Residents Train for Three Years or Four?
http://www.aafp.org/online/en/home/...nal-development/20121115lengthoftraining.html

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[physicsnerd42]

Making FM 4 years sounds like a fantastic way to get fewer US med students to go into FM.

 

[Raryn]

Given that most FM don't do any ob, at that point you'd be WAY better off just doing med/ peds.

 

[Substance]

They should train for one year. Three is overkill. Four is ridiculous!

 

[wholeheartedly]

They should train for one year. Three is overkill. Four is ridiculous!

From my perspective as a pt. at a teaching hospital.... hell no

There is a very big difference between the residents at the end of year 1 vs year 3.

Ppl talk about psych saying that psych is a field that is easy to do.... if you do it poorly and want to be lazy about it. But it takes a lot of skill and know how to do it well.

I get the impression that FM is like that as well, and it doesn't get nearly the respect it deserves. I'm obviously not in position to comment on how long it should be, but 1 year is too little.

 

[Substance]

From my perspective as a pt. at a teaching hospital.... hell no

There is a very big difference between the residents at the end of year 1 vs year 3.

Ppl talk about psych saying that psych is a field that is easy to do.... if you do it poorly and want to be lazy about it. But it takes a lot of skill and know how to do it well.

I get the impression that FM is like that as well, and it doesn't get nearly the respect it deserves. I'm obviously not in position to comment on how long it should be, but 1 year is too little.

The fact that there is a big difference between a first and third year family medicine resident has less to do with the length of residency and more to do with the perfunctory nature of medical school.

 

[lowbudget]

Work hour restrictions have really affected the residency educational experience, as seen in this new study.
http://www.uofmhealth.org/news/arch...-docs-new-work-hour-restrictions-may-increase

If family medicine goes to 4 years, it will be the 1st domino to drop as everything else will go 1 more year. Hopefully, ACGME's Milestones Project will stave this off, because residents really can't afford to defer loans/earnings any longer and hospitals/government can't afford to fund the extra time.

 

[Arcan57]

The fact that there is a big difference between a first and third year family medicine resident has less to do with the length of residency and more to do with the perfunctory nature of medical school.

No.

 

[Substance]

No.

Yes.

Nurses are doing it with far less training than a 3rd year medical student.

 

[Arcan57]

The fact that there is a big difference between a first and third year family medicine resident has less to do with the length of residency and more to do with the perfunctory nature of medical school.

No.

Yes.

Nurses are doing it with far less training than a 3rd year medical student.

Debatable (not the paucity of nurse training but the skillful rendering of in-patient care), but also not at all relevant to your initial statement. Unless you included an FM residency as part of medical school, one would expect that increasing patient contacts from minimal (as an early PGY-1) to substantial (as a PGY-3) would lead to an increase in skill. If you're saying that medical school does a bad job of turning out competent doctors I'd agree with you, but the alternative would either be to lengthen med school significantly or to cut much of the basic and clinical science (at which point we might as well let PA's apply for ACGME residencies).

Of course I'm reading your initial statement regarding length of residency as comparing the idea of the prior poster's 1 yr residency with the standard 3 yr residency. If you're comparing 3 yrs to a hypothetical 4 yr FM residency then I'd agree that the jump in competency between PGY-1 and PGY-3 years would have little to do with adding an extra year, but it also makes your statement somewhat non-sensical. Please clarify.

 

[deleted87716]

Given that most FM don't do any ob, at that point you'd be WAY better off just doing med/ peds.

Why spend four years to do less? The difference isn't just OB. You won't get much exposure to gyn or outpatient procedures in med/peds, either.

 

[deleted87716]

They should train for one year. Three is overkill. Four is ridiculous!

I'm glad you wear your ignorance on your sleeve. There's absolutely no risk of anyone confusing you with somebody who actually knows what they're talking about. 😉

 

[deleted87716]

Nurses are doing it with far less training than a 3rd year medical student.

No, they aren't.

I can change the oil in my car. That doesn't make me a mechanic.

 

[Substance]

All of the ad hominem attacks are pathetic. Just stop.

What I'm trying to say is that because there is a huge need for primary care, we should be figuring out ways to get docs out there faster and more efficiently. As it stands, our current system is doing the exact opposite. Lengthening residency to 4 years will make it worse.

We need to return to the rotating internship system. All medical school students will be expecting to practice what we now call "family medicine" upon completion of the MD and a year or two of internship. For this to work we need to reduce specialty spots, and to open up the match process to people who've been out in practice for a while.

By limiting primary care access, ancillary staff will gladly fill the void for a cheaper fee.

 

[deleted87716]

we should be figuring out ways to get docs out there faster and more efficiently.

In other words, lower the bar?

We'll just have to agree to disagree on that one.

 

[DIce3]

I did a three year internal medicine residency with full focus on being a traditional inpatient/outpatient adult primary care doctor. I don't see how eight to ten months in internal medicine is similar when performed in a family medicine residency. I am not meaning to "stir the pot" or "rock the boat" but I think there is a significant difference between the average internal medicine resident and the average family medicine resident at the end of PGY3 with respect to the ability to handle without consultation many problems in adult primary care. As a result, I think at least four years is needed for similar competency for FP.

 

[deleted87716]

Meh. I work with internists. I have friends who are internists. I don't refer any more than they do. If anything, I refer less. Most of the patients I've inherited from internists had consultants out the wazoo.

Most IM programs do a pretty crappy job of preparing their graduates for primary care. In practice, that's rarely a problem, since less than 20% of IM graduates stay in general IM.

As usual, your mileage may vary.

 

[DIce3]

I have worked with many excellent FPs. I am in no way starting a flame war or indicating any decrease in overall talent of family physicians. Furthermore, I enjoy reading Blue Dog's posts. Here is what I have noticed: There is a FP and an IM residency in my current town. I have had both types of residents work under me. I see a huge difference in ability purely based upon specialty for PGY-2 and PGY-3s. When I ask a PGY-3 a MKSAP-like question, there is a very large difference in the ability to answer correctly based upon specialty. I think the difference is purely exposure time to internal medicine. I suspect that over time in practice, this gap narrows significantly.

 

[deleted87716]

]I suspect that over time in practice, this gap narrows significantly.

Yep.

Real life ain't MKSAP.

 

[septoplasty]

I have worked with many excellent FPs. I am in no way starting a flame war or indicating any decrease in overall talent of family physicians. Furthermore, I enjoy reading Blue Dog's posts. Here is what I have noticed: There is a FP and an IM residency in my current town. I have had both types of residents work under me. I see a huge difference in ability purely based upon specialty for PGY-2 and PGY-3s. When I ask a PGY-3 a MKSAP-like question, there is a very large difference in the ability to answer correctly based upon specialty. I think the difference is purely exposure time to internal medicine. I suspect that over time in practice, this gap narrows significantly.

So how does using an MKSAP question give a valid comparison if you pointed out the flaw all by yourself?

 

[galactus]

Three years of residency should suffice. Anyone who thinks FM should just be one year either has absolutely no idea what family medicine is about, or has encountered some pretty bad ones. Now the P4 programs out there for FM I'm ok with, but if you need 4 years to train an FM physician is just too much.

 

[metabolite]

From economic stand point, makes sense to try and get physicians out to practice quicker.
From patient care point of view, that's not a good idea. Furthermore, there are so many new technology coming up in medicine that if anything, docs need to learn more not less.

 

[Bostonredsox]

Meh. I work with internists. I have friends who are internists. I don't refer any more than they do. If anything, I refer less. Most of the patients I've inherited from internists had consultants out the wazoo.

Most IM programs do a pretty crappy job of preparing their graduates for primary care. In practice, that's rarely a problem, since less than 20% of IM graduates stay in general IM.

As usual, your mileage may vary.

I have to agree. My weakest skill is outpt medicien, namely seeign 25 pts in a clinic effectively so that I cvould actually make money should I be an outpt internist. We are prepared to be hospitalists, nocturnists and fellows. I would say its more like 10% go into outpt primary care.

As for the OP, there is no reason for FM or IM to be any longer than 3 years. The weak PGY-3 FPs I have met, came from programs that were setup poorly and did not expose them to enough IM. Too many months on ortho and ent etc. The programs that had a strong IM foundation in intern year and then branched out into OB peds and other electives in pgy2 and 3 produced much stronger FP attendings. In my experience, I have met several brilliant outpt internisits, but they do not manage peds, ob, gyn or do much other than cardiovascular disease prevention and such, the typical IM problems. Most dont do joint injections, chronic pain, etc etc. The more complete doc I have met in the outpt world is a strong FP. The opposite can be said on the wards. I have worked with 10 excellent IM hospitalists for every 1 decent FP hospitalist. But these are not slights against either, they are to be expected. I spent almost 24/36 months on the wards day/night and in the MICU. I spent 1/2 day a week in clinic and did 2 total pure outpt months. It is nearly 100% reversed for my FP counterparts. We are a product of our training. And 3 years of training is plenty for an FP to be a great outpt doc.

 

[VA Hopeful Dr]

I have to agree. My weakest skill is outpt medicien, namely seeign 25 pts in a clinic effectively so that I cvould actually make money should I be an outpt internist. We are prepared to be hospitalists, nocturnists and fellows. I would say its more like 10% go into outpt primary care.

As for the OP, there is no reason for FM or IM to be any longer than 3 years. The weak PGY-3 FPs I have met, came from programs that were setup poorly and did not expose them to enough IM. Too many months on ortho and ent etc. The programs that had a strong IM foundation in intern year and then branched out into OB peds and other electives in pgy2 and 3 produced much stronger FP attendings. In my experience, I have met several brilliant outpt internisits, but they do not manage peds, ob, gyn or do much other than cardiovascular disease prevention and such, the typical IM problems. Most dont do joint injections, chronic pain, etc etc. The more complete doc I have met in the outpt world is a strong FP. The opposite can be said on the wards. I have worked with 10 excellent IM hospitalists for every 1 decent FP hospitalist. But these are not slights against either, they are to be expected. I spent almost 24/36 months on the wards day/night and in the MICU. I spent 1/2 day a week in clinic and did 2 total pure outpt months. It is nearly 100% reversed for my FP counterparts. We are a product of our training. And 3 years of training is plenty for an FP to be a great outpt doc.

Completely agree with this. My wife is an IM resident and I am an FP resident, and this is exactly what we've noticed. Despite being a year behind me (I'm PGY-3), she is already way beyond my abilities when it comes to inpatient management - especially in the ICU. Conversely, her outpatient exposure is very limited - especially for acute care issues.

 

[Silent Cool]

LOL,

As soon as I saw this thread all is could think of was the blog from medicinesux in which he posted this:

http://medicinesux.wordpress.com/2010/06/09/yay-4-year-family-medicine-residency/

 

[Frank Nutter]

4 years is totally insane. Might as well just kill off physician-provided primary care entirely.

 

[AStark]

In Canada almost every residency is longer than in the US... except for FM which is 2 years. Usually residents do a PGY-3 to specialize in emerg, geriatrics, hospitalist care, sports med, obs, palliative care, etc, but certainly can just enter office-practice right away. And 20 years ago when we still had the rotating internship, you could practice as a GP after one year of an arguably more intense internship.

In the meantime, IM is at least 4 years (3 years core IM + 1 year of General IM or 2-3 years of specialty fellowship). I don't know whether training should be longer, but it applies for things like EM, Anesthesia, and pretty much every other speciality residency, all of which are 5 years in Canada.

I'm really not sure why any FM program needs to be 4 years. At some point people simply need to learn on the job and sometimes that can only take the form of independent practice.

 

[bradycakes]

Why wouldnt they want 4? Its another year of doc labor at minimum wage. Thats why they love fellows

Canada, please. What type of hours u working those 4? And your salary and fringe benefits? Only residents in the us have the slave wage system from what I've seen.

And for all the old timers, you werent holding down the debt we do. Per the LCME statutes, physician research and clinical income are supposed to subsidize the education of of students. But the switch got flipped when you get in bed with corporate america and broke ass gov that did the same.

Past med school debt, you know somethings wrong when on 3/18 I believe a congressman passed a bill asking for transparency in GME funding . When one of them gets to that point its the confirmation you really didnt need that that money gets siphoned out of our country's investment healthcare education

 

[AStark]

Canada, please. What type of hours u working those 4? And your salary and fringe benefits? Only residents in the us have the slave wage system from what I've seen.

Well, see for yourself here: http://carms.ca/eng/r1_program_salaries_e.shtml

Salaries are certainly a bit higher, though it's worth noting that health insurance as a benefit is much less valuable in Canada since all physician/hospital services are publicly funded.

Hours aren't any better. On surgery and IM as a clerk, I pretty much always worked at least 80 hours per week.

 

[danielmd06]

I have to agree. My weakest skill is outpt medicien, namely seeign 25 pts in a clinic effectively so that I cvould actually make money should I be an outpt internist. We are prepared to be hospitalists, nocturnists and fellows. I would say its more like 10% go into outpt primary care.

As for the OP, there is no reason for FM or IM to be any longer than 3 years. The weak PGY-3 FPs I have met, came from programs that were setup poorly and did not expose them to enough IM. Too many months on ortho and ent etc. The programs that had a strong IM foundation in intern year and then branched out into OB peds and other electives in pgy2 and 3 produced much stronger FP attendings. In my experience, I have met several brilliant outpt internisits, but they do not manage peds, ob, gyn or do much other than cardiovascular disease prevention and such, the typical IM problems. Most dont do joint injections, chronic pain, etc etc. The more complete doc I have met in the outpt world is a strong FP. The opposite can be said on the wards. I have worked with 10 excellent IM hospitalists for every 1 decent FP hospitalist. But these are not slights against either, they are to be expected. I spent almost 24/36 months on the wards day/night and in the MICU. I spent 1/2 day a week in clinic and did 2 total pure outpt months. It is nearly 100% reversed for my FP counterparts. We are a product of our training. And 3 years of training is plenty for an FP to be a great outpt doc.

Well said.

 

[goofball]

If FP became a 4 year residency, why would any US grad go into FP?

 

[deleted87716]

If FP became a 4 year residency, why would any US grad go into FP?

It hasn't stopped them from doing med-peds (also four years, for a smaller scope of training, with the added cost and inconvenience of two board certifications and re-certifications).

 

[VA Hopeful Dr]

It hasn't stopped them from doing med-peds (also four years, for a smaller scope of training, with the added cost and inconvenience of two board certifications and re-certifications).

Granted my n is small, but almost all of the med-peds people I've met choose that over FM for the possibility of fellowships. Admittedly in everything but allergy this is then a waste of half of their training, but I think the point is a valid one.

 

[deleted87716]

Granted my n is small, but almost all of the med-peds people I've met choose that over FM for the possibility of fellowships. Admittedly in everything but allergy this is then a waste of half of their training, but I think the point is a valid one.

Med-peds is a waste if you're just going to ultimately specialize in either adult or pediatric medicine. I suppose if you're completely confused, it's the ultimate hedge.

 

[gutonc]

Med-peds is a waste if you're just going to ultimately specialize in either adult or pediatric medicine. I suppose if you're completely confused, it's the ultimate hedge.

There are a few scenarios where it makes sense (AYA oncology, Endocrine, Pulm with a CF/Transplant focus and Congenital Cards are the easy examples) but otherwise you're right and I've never quite understood it.

 

[se20001984]

FM should be 2 yrs with loan forgiveness

 

[VA Hopeful Dr]

FM should be 2 yrs with loan forgiveness

Incorrect

 

[jkhamlin]

If family medicine goes to 4 years, it will be the 1st domino to drop as everything else will go 1 more year. Hopefully, ACGME's Milestones Project will stave this off, because residents really can't afford to defer loans/earnings any longer and hospitals/government can't afford to fund the extra time.

Yay. More hoops and requirements and bureaucracies and expenses and continuous recertifications and time away from working and making a living and time away from our families and friends and time away from patient care and pointless didactics no one pays attention to and meaningless boxes to check and government oversight and micromanagement by uneducated pinheads and government agencies with their hands in our pockets and legalities and liabilities to threaten our livelihoods.

Meanwhile, the out of control profession of lawyers remains essentially unregulated and the politicians who come up with much of this nonsense remains completely unregulated..

No thanks.

 

[jkhamlin]

FM should be 2 yrs with loan forgiveness

Incorrect

Wow. Flawless reasoning from both...

 

[jkhamlin]

Med-peds is a waste if you're just going to ultimately specialize in either adult or pediatric medicine. I suppose if you're completely confused, it's the ultimate hedge.

More in depth training and opportunity is a waste? How so? And actually, it's the way to go. Unfortunately, it's one of the best kept secrets out there.

It's funny, so many physicians who AREN'T med/peds trained say this, but med/peds trained physicians and residents are VERY satisfied with their training.

 

[VA Hopeful Dr]

More in depth training and opportunity is a waste? How so? And actually, it's the way to go. Unfortunately, it's one of the best kept secrets out there.

It's funny, so many physicians who AREN'T med/peds trained say this, but med/peds trained physicians and residents are VERY satisfied with their training.

Granted its a very small n, but the med-peds guy at my hospital actively discourages med students from going that route.

 

[primadonna22274]

I am one of those torn between FM and Med-Peds. I would be totally happy to never do OB and I like the dual training and dual certification. My ultimate goal is medical education so I want broad-based training but I know I would have that with FM as well. The only fellowship I'm likely to do is palliative med which I can do from many specialties. Help!

 

[oldbearprofessor]

Med-peds is a waste if you're just going to ultimately specialize in either adult or pediatric medicine.

Aww shucks, the med-peds folks love u 2 BD.😍

The med-peds folks I know have a wide range of careers and are overwhelmingly satisfied with the combination they've chosen. Anyone interested in the field should go out and talk with them, not hear about it as a "waste" of a field from someone in a different field.😎

One thing to consider is "Do you wish to be a pediatrician?" Do you wish to be involved in the AAP and its efforts/agenda?

 

[Raryn]

Med-peds is a waste if you're just going to ultimately specialize in either adult or pediatric medicine. I suppose if you're completely confused, it's the ultimate hedge.

Except in Med-Peds, you really learn how to take care of sick people. You might be able to argue (maybe!) that you don't get as much training in how to take care of well patients, but if I was a child/adult in the hospital or had any chronic condition more complicated than simple HTN+/-HLD+/- uncomplex DM, I'd prefer someone IM or Peds trained to manage me.

 

[physicsnerd42]

Med-peds is a waste if you're just going to ultimately specialize in either adult or pediatric medicine. I suppose if you're completely confused, it's the ultimate hedge.

I somewhat agree that if you're going to do a fellowship it is a waste. That being said, if I wanted to do primary care for adults and kids I'd do med peds over FM. Med-peds does leave open the possibility of fellowships if I end up changing my mind about primary care. It also gives much more training in peds and in taking care of very sick patients than FM does.

I honestly think that instead of FM extending training to 4 years, the training should just be kept at 3 years and the components of training that most FM docs don't use (surgery, OB) should just be dropped. If you really want to deliver babies or do appys then do a fellowship.

 

[DIce3]

"Med-peds is a waste if you're just going to ultimately specialize in either adult or pediatric medicine."

I think this is correct. An extra year of internal medicine is much more valuable than two years of pediatrics if you are planning on doing an adult subspecialty. Adolescent medicine and Allergy might be exceptions.

Secondly, residents at the end of IM residency tend to be much more capable than residents at the end of IM/Peds in the practice of internal medicine. Again, I think that last year of mostly subspecialty training is invaluable to the practice of internal medicine. By the end of PGY3 IM, the resident has rotated through all subspecialties plus several of them two and three times. The IM/Peds folks never complete a full cycle. This means that the IM/Peds doctor may have never done a single rotation in ID, endo, and rheum. FP, of course, is a dramatically more limited training program in adult primary care.

 

[primadonna22274]

Except in Med-Peds, you really learn how to take care of sick people. You might be able to argue (maybe!) that you don't get as much training in how to take care of well patients, but if I was a child/adult in the hospital or had any chronic condition more complicated than simple HTN+/-HLD+/- uncomplex DM, I'd prefer someone IM or Peds trained to manage me.

This is the appeal to me. After 13 years as a PA, more than half of that in outpatient FM, I know how to take care of well patients. I want to get better at sick, especially inpatient.

 

[oldbearprofessor]

Secondly, residents at the end of IM residency tend to be much more capable than residents at the end of IM/Peds in the practice of internal medicine.

Is there any objective evidence for this statement? Your opinion is duly noted of course and you may well be reflecting the opinion of many in the IM field.

Interestingly, I have NEVER heard anyone on the pediatric side say the same thing about the pediatric skills of med-peds graduates. Doesn't mean that some don't think it, but I've not heard it and I don't see it. In general, my view is that the med-peds folks bring to pediatrics a perspective and experiences that enhance their performance in pedi, even neo. I'm sorry if it isn't true in the other direction but would like to see some objective evidence about this before I am sure it is a universal truth.

 

[DIce3]

I think it is important to point out that this is only my opinion and would not consider it a consensus statement. Both IM and IM/Peds have the opportunity to go through cardiology, renal, GI, and pulmonary a couple of times. I can tell you that the months I spent on benign heme, liver, bone marrow transplant, renal transplant, rheum, endocrine, and ID have been invaluable to my current practice as have the extra critical care months. These "extra electives" were invaluable to my education as a general internist.

 

[group_theory]

I think it is important to point out that this is only my opinion and would not consider it a consensus statement. Both IM and IM/Peds have the opportunity to go through cardiology, renal, GI, and pulmonary a couple of times. I can tell you that the months I spent on benign heme, liver, bone marrow transplant, renal transplant, rheum, endocrine, and ID have been invaluable to my current practice as have the extra critical care months. These "extra electives" were invaluable to my education as a general internist.

I rotated through all those electives that you listed as a med peds resident ... Both on the medicine side and on the pediatrics side. While we have fewer electives compare to our categorical residents, they are not nearly as rare as you would think. We don't do as many wards month as categorical (but overall, more wards and ICU months compare to categoricals)

There are a lot of overlaps between the two sides, and I have found situations where having knowledge of both fields were helpful.

The studies have shown that the board pass rates were similar between MedPeds and categorical residents. Studies show that more than half end up seeing both adults and kids in their practice. A quarter end up doing fellowships.

The thing about MedPeds ... I am a pediatrician, trained in pediatrics. I can tell a parent that I am their child's pediatrician. I am an internist, trained in Internal Medicine. I can tell that parent that I am their Internist. Doesnt matter if inpatient or outpatient. The vast majority of MedPeds programs occur in university hospital settings (the few that are not university hospital settings are large university affiliated community hospitals) where there are medicine programs and pediatrics located on site.

No argument here that Family Medicine residents are better trained on outpatient care and management. Since MedPeds residents spent a lot of their time on the inpatient side, that is where they feel more comfortable.


I would say MedPeds have less broad and more depth in our training compare to my family medicine colleagues, who have more broad training. Some may feel it is a waste ... Others may appreciate it. To each their own, with their pluses and minuses.

But the line between adults and kids are getting blurred. Kids getting diabetes, PEs from too much video games, etc. Adults with single ventricle physiology, or adult Cystic Fibrosis with multiorgans involvement, adults surviving with metabolic defects, etc. they all need a good doctor (or team of doctors centered around a medical home)


I think family medicine should stay 3 years ... They are more than adequately trained and have shown that 3 years is enough. MedPeds is a different beast, with a lot of overlap, but a different beast altogether.