Should we make it easier for physicians to practice independently on one year of residency?

[IMG69]

I've never understood what the difference between Family Medicine and GP is, could someone please enlighten me? Our GP's treat your run of the mill things HTN, COPD, DM, yearly checkups for Grandma, basically treat to the second line etc and refer for anything they can't manage, isn't that exactly the same as Family med? GP's are our true primary care.

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[VA Hopeful Dr]

I've never understood what the difference between Family Medicine and GP is, could someone please enlighten me? Our GP's treat your run of the mill things HTN, COPD, DM etc and refer for anything they can't manage, isn't that exactly the same as Family med? GP's are our true primary care.

Its tricky given the differences in our post-graduate medical education between our 2 countries.

In the US, after medical school, to practice you must do some amount of postgraduate training called residency. Each specialty has different programs/requirements for this. For example, an orthopedic surgeon has to do a 5 year residency to become board certified. A family doctor in the US has a 3 year residency.

A GP is someone who finished medical school but only did 1 year of residency. They are pretty rare in the US as most of us complete a full residency.

 

[IMG69]

Its tricky given the differences in our post-graduate medical education between our 2 countries.

In the US, after medical school, to practice you must do some amount of postgraduate training called residency. Each specialty has different programs/requirements for this. For example, an orthopedic surgeon has to do a 5 year residency to become board certified. A family doctor in the US has a 3 year residency.

A GP is someone who finished medical school but only did 1 year of residency. They are pretty rare in the US as most of us complete a full residency.

Yeah, i'm aware of your system I was planning on initially going practicing in the states purely because of your short specialty pathway but anyway to me FM and UK GP seem to be equivalent.

Our GP's are basically PGY3 (been in the hospital for 2 years working in 3 fields) haven't picked a specialty and then can specifically train in GP. How could anyone be competent after 1 year, I can see why they're rare. I believe it's 5 years to be a fully qualified GP here.

 

[VA Hopeful Dr]

Yeah, i'm aware of your system I was planning on initially going practicing in the states purely because of your short specialty pathway but anyway to me FM and UK GP seem to be equivalent.

Our GP's are basically PGY3 (been in the hospital for 2 years working in 3 fields) haven't picked a specialty and then can specifically train in GP. How could anyone be competent after 1 year, I can see why they're rare. I believe it's 5 years to be a fully qualified GP here.

Ah, sorry I had assumed you were not familiar with our system at all. My mistake.

 

[IMG69]

Ah, sorry I had assumed you were not familiar with our system at all. My mistake.

It seems like nurses are starting to become the Primary care in America from the daily threads about them?

 

[VA Hopeful Dr]

It seems like nurses are starting to become the Primary care in America from the daily threads about them?

Well, SDN is a bit more intense about that than is strictly accurate. They're a part of primary care, but they won't be the majority of it anytime soon.

 

[Mass Effect]

Thanks for these thoughts. I definitely do agree that it’s not the IDEAL position to be in and I agree with the points you’ve made. In my case, there are various factors that are playing a part in my decision. I wanted to do the DPC thing anyway, but now there are various reasons that are pushing me to leave residency early. DPC practice with GP status seems like still a good option.

I must be naive about FM residency. I can't imagine anything being bad enough to leave 2 years short of a guaranteed job and paycheck anywhere in the US after you've already scarified 5 years of your life and likely 200K in loans.

 

[NotAProgDirector]

Agreed. But one can still know what they don’t know after one year. Knowing what you dont know is a mindset, not a level of training. If a GP is not comfortable managing something, they need to refer out. Same as anyone else.

Actually, you don't.

6 months into my first job, I discovered how much I didn't know I didn't know.

Medicine is hard. Don't cut your training short.

 

[jdh71]

Not sure if this has been said yet: No.

/thread

 

[hallowmann]

I must be naive about FM residency. I can't imagine anything being bad enough to leave 2 years short of a guaranteed job and paycheck anywhere in the US after you've already scarified 5 years of your life and likely 200K in loans.

A lot of FM residencies are inpatient heavy, regularly push duty hours, and then you throw in OB and limited support staff in some institutions, because FM gets undervalued. I agree, 2 more yrs isn't bad, but combine the right recipe of acute grief and/or other psychosocial stressors and quitting early and hanging a shingle can look better and better.

That said, no. It's easy enough to become a GP here. I would never have trusted myself with the vast majority of presentations after PGY1, and honestly nearing the end of PGY3, I still feel like I haven't seen or managed enough, save maybe basic preventative care and the most vanilla of psych.

 

[pawprint]

As mentioned previously, the military (particularly the Navy) already does this with GMOs and it actually works very effectively.

There's nothing out there to suggest that people in the military are getting worse care because their primary care doctor only completed 1 year of residency. GMO's are trained when to send people to higher levels of care and it works. You may not like it, but this system has been in place for awhile and works great.

Obviously there are complex patients that require somebody with higher levels of experience to manage. But thats the point of how GMO's/flight surgeons/dive medical officers are trained. Learn how to identify abnormal and send it to people who are experts at fixing it. All the normal things/low complexity issues can be handled by the GMO.

 

[Mass Effect]

As mentioned previously, the military (particularly the Navy) already does this with GMOs and it actually works very effectively.

There's nothing out there to suggest that people in the military are getting worse care because their primary care doctor only completed 1 year of residency. GMO's are trained when to send people to higher levels of care and it works. You may not like it, but this system has been in place for awhile and works great.

Obviously there are complex patients that require somebody with higher levels of experience to manage. But thats the point of how GMO's/flight surgeons/dive medical officers are trained. Learn how to identify abnormal and send it to people who are experts at fixing it. All the normal things/low complexity issues can be handled by the GMO.

I think we're mischaracterizing GMOs. Those in the military correct me if I'm wrong, but the way I understand it GMOs are those who are with specific active units. The patient population is young, likely without any medical conditions as they're heavily screened before even joining the military. They're not at all equal to FM or IM docs (the common PCP equivalent in non-military US populations). They're also usually people who either failed to match or are did an intern year --> GMO year to strengthen their residency apps.

Why would a GMO not be equivalent to a, say, NP?

 

[pawprint]

I am a flight surgeon so I am a little bit biased. GMO's are not people who failed to match, interns who do not do well during intern year aren't going to be shipped out somewhere to take care of patients as a primary care doctor. I was intern of the year at my hospital and here I am as a flight surgeon (basically a GMO for a squadron of pilots).

The military utilizes NP's and especially PA's for very similar clinical duties, however, from a legal standpoint GMO's win out in certain situations (especially things requiring investigation like aircraft crashes). The point is that the military utilizes MD/DO's with 1 year of residency to successfully manage low complexity patients. I don't know if it can translate as easily to the civilian world, but the argument that people with 1 year of residency training can't be utilized without causing harm is just not true if its done correctly.

Edit for clarificaton: GMO's are not equivalent to FM/IM docs, i totally agree with that. There are civilians though that don't have a lot of medical problems and could have a intern-trained doc as their PCM.

 

[deleted480308]

I am a flight surgeon so I am a little bit biased. GMO's are not people who failed to match, interns who do not do well during intern year aren't going to be shipped out somewhere to take care of patients as a primary care doctor. I was intern of the year at my hospital and here I am as a flight surgeon (basically a GMO for a squadron of pilots).

The military utilizes NP's and especially PA's for very similar clinical duties, however, from a legal standpoint GMO's win out in certain situations (especially things requiring investigation like aircraft crashes). The point is that the military utilizes MD/DO's with 1 year of residency to successfully manage low complexity patients. I don't know if it can translate as easily to the civilian world, but the argument that people with 1 year of residency training can't be utilized without causing harm is just not true if its done correctly.

Edit for clarificaton: GMO's are not equivalent to FM/IM docs, i totally agree with that. There are civilians though that don't have a lot of medical problems and could have a intern-trained doc as their PCM.

“Succesfully” manage patients

the military does what they do because they won’t pay for truly trained doctors. It’s not a good care plan, it’s supply/demand. The GMO model is a bad one as is the level of autonomy by midlevels

 

[Mass Effect]

I am a flight surgeon so I am a little bit biased. GMO's are not people who failed to match, interns who do not do well during intern year aren't going to be shipped out somewhere to take care of patients as a primary care doctor. I was intern of the year at my hospital and here I am as a flight surgeon (basically a GMO for a squadron of pilots).

There's a lot out there about GMOs that say the opposite. Not doubting your experience, but I wonder if you were an exception to the rule.

The military utilizes NP's and especially PA's for very similar clinical duties, however, from a legal standpoint GMO's win out in certain situations (especially things requiring investigation like aircraft crashes). The point is that the military utilizes MD/DO's with 1 year of residency to successfully manage low complexity patients. I don't know if it can translate as easily to the civilian world, but the argument that people with 1 year of residency training can't be utilized without causing harm is just not true if its done correctly

I think they can provide care without causing harm in a population similar to the military -- young, athletic people with no major health problems and previously screened by a residency-trained MD. If they want to work on the sidelines of high school football games, great. But in the civilian world, they should not be PCPs. You will find non-residency trained docs working urgent care centers. Maybe that's where they should be (and even that I'd raise a brow about)

Edit for clarificaton: GMO's are not equivalent to FM/IM docs, i totally agree with that. There are civilians though that don't have a lot of medical problems and could have a intern-trained doc as their PCM.

With limited medical school seats and the desperate need for real PCPs and specialists, we should not waste those seats and internship slots for students planning to take this path. Those individuals can go to PA or NP school and leave medical school to those planning to treat at least a little bit of complexity.

 

[<L>]

I must be naive about FM residency. I can't imagine anything being bad enough to leave 2 years short of a guaranteed job and paycheck anywhere in the US after you've already scarified 5 years of your life and likely 200K in loans.

You nailed what's going on with this thread.

This thread is less about "I care deeply about the state of American healthcare" than it is "I'm burned out from being in the worst part of training and want to fantasize about a way to quit being a trainee" and it's more than a little transparent.

For as cynical as the attending crew is in this website, most of us have been through it and are happy to tell you that does get better and easier as you go on. Bailing on a FM residency with only two years to go is just shooting yourself in the foot and selling at the bottom of the market. Another 24 months is nothing in the total length of your career, particularly when each year of residency gets a little lighter and easier in just about every specialty.

 

[Splenda88]

I must be naive about FM residency. I can't imagine anything being bad enough to leave 2 years short of a guaranteed job and paycheck anywhere in the US after you've already scarified 5 years of your life and likely 200K in loans.

There are GPs who are making FM salary... Academia got all of us brainwashed...

 

[Splenda88]

As mentioned previously, the military (particularly the Navy) already does this with GMOs and it actually works very effectively.

There's nothing out there to suggest that people in the military are getting worse care because their primary care doctor only completed 1 year of residency. GMO's are trained when to send people to higher levels of care and it works. You may not like it, but this system has been in place for awhile and works great.

Obviously there are complex patients that require somebody with higher levels of experience to manage. But thats the point of how GMO's/flight surgeons/dive medical officers are trained. Learn how to identify abnormal and send it to people who are experts at fixing it. All the normal things/low complexity issues can be handled by the GMO.

Academia got us brainwashed so we can think we are all specialists... People will not die if we go back to the GP system.

80%+ of what FM docs take care a DM/HTN/HLD + other mundane stuffs.

 

[deleted480308]

Academia got us brainwashed so we can think we are all specialist... People will not die if we go back to GP.

They might not all die this week, but an intern has no business completely managing their own panel

 

[Splenda88]

They might not all die this week, but an intern has no business completely managing their own panel

Disagree. After a year, you are no longer an intern. There is a bid difference b/t someone who just started residency and and someone who just finished intern year.

You guys were saying 3-yr med school curriculum would be impossible when every school is change their basic science right now from 2-yr to 12-18 months...


CS is important too until NBME decides to make it virtual... Lol

 

[NotAProgDirector]

80%+ of what FM docs take care a DM/HTN/HLD + other mundane stuffs.

80% of ANY job is mundane. You earn your salary dealing with the other 20%. And often someone who is undertrained can't tell the difference between the 80/20.

 

[Splenda88]

80% of ANY job is mundane. You earn your salary dealing with the other 20%. And often someone who is undertrained can't tell the difference between the 80/20.

I expect nothing less from someone who is in academia...

 

[deleted480308]

I expect nothing less from someone who is in academia...

Just trying to get some context here, are you a resident /attending or med student?

 

[Splenda88]

Just trying to get some context here, are you a resident /attending or med student?

IM PGY2...

 

[<L>]

IM PGY2...

lol.

 

[deleted480308]

IM PGY2...

And you think you are fully qualified to run your own panel right now with no quality differences between you and your attendings?

 

[Splenda88]

And you think you are fully qualified to run your own panel right now with no quality differences between you and your attendings?

If you are at the end of IM PGY2 and your attending is changing your overall managements most of the time when you are admitting, there is something wrong with you or your program...


The question should be if there is a noticeable quality difference between myself and a PGY3 that is about to graduate

 

[deleted480308]

If you are at the end of IM PGY2 and your attending is changing your overall managements most of the time when you are admitting, there is something wrong with you or your program...

“Most” is an important word. As @NotAProgDirector mentioned, it’s the 20% that makes you worth your salt

 

[Splenda88]

“Most” is an important word. As @NotAProgDirector mentioned, it’s the 20% that makes you worth your salt

I guess I should have put a quantifier (20% of the time)... When I say changing, I mean tweaking...


This list includes 90%+ of inpatient admissions... If a rising PGY3 does not know how to manage these, your program is not good.

1. Chest pain
2. CHF exacerbation, HTN emergency
3. COPD/Asthma exacerbation/PNA
4. UTI/Pyelo
5. Altered mental status
6. Alcohol withdrawal
7. Afib
8. GI bleed, cirrhosis (SBP)
9. Hepatitis, Pancreatitis, cholecystitis, cholelithiasis etc...
10. AMS
11. Sepsis/Septic shock
12. AKI/ESRD
13. DKA
14. Cellulitis/Osteomeyelits
15. Seizure/Status epilepticus
16. Stroke (neuro)
17. MI (cardio)
18. Intubated patients
19. DVT/PE

Another 5%+ is social admit...

 

[Mass Effect]

There are GPs who are making FM salary... Academia got all of us brainwashed...

Has nothing to do with academia. There's a reason GPs have trouble getting employed jobs, included on insurance panels, and hospital privileges.

 

[Splenda88]

Has nothing to do with academia. There's a reason GPs have trouble getting employed jobs, included on insurance panels, and hospital privileges.

These are the two main reasons...

 

[Doohickey550]

For me, I do believe of course that a graduate of a three year program has more experience and knowledge than after PGY1. This is obvious. But the question is whether someone who starts working after PGY1 will acquire the same amount of knowledge and experience on their own. I believe that the latter option is very viable. Most of my learning today is self taught as I see patients. 90% of what I’m learning is without being taught by an attending. If I’m out on my own, I’ll need to be even more on my toes. The steep learning curve as an attending/solo practitioner will exist whether after 1 year or 3 years. Yes, a PGY1 is less experienced, but can he make up for that by using appropriate resources? That’s pretty much what I’m doing now as a resident anyway.
I am planning to do DPC where the above mentioned insurance and hospital privilege issues don’t apply. I’ll also have sufficient time in that setting to look things up if needed.
What there really needs to be is an alternate pathway to board certification like there once was. Work for a certain number of years following internship, earn a certain number of CME credits, and then take board exam to qualify.

 

[VA Hopeful Dr]

What there really needs to be is an alternate pathway to board certification like there once was. Work for a certain number of years following internship, earn a certain number of CME credits, and then take board exam to qualify.

No, there doesn't.

We have a perfectly good way to get board certified. Over 4000 people do it every year - it's called graduating residency.

 

[Doohickey550]

No, there doesn't.

We have a perfectly good way to get board certified. Over 4000 people do it every year - it's called graduating residency.

Well, obviously it’s difficult for folks who did spend all that time to recommend the alternative, but that doesn’t mean it’s not viable. And I believe that it is. The only thing that keeps getting me is the idea that if for some reason God doesn’t grant me success in my DPC practice, I may be up a creek in terms of other good work options.
That said, I’m so done with residency right now that I can even handle dropping clinical medicine completely at that point. Might be worth pursuing a second degree in the interim though just so that I have marketable skills as an MPH or something.

 

[deleted480308]

Well, obviously it’s difficult for folks who did spend all that time to recommend the alternative, but that doesn’t mean it’s not viable. And I believe that it is. The only thing that keeps getting me is the idea that if for some reason God doesn’t grant me success in my DPC practice, I may be up a creek in terms of other good work options.
That said, I’m so done with residency right now that I can even handle dropping clinical medicine completely at that point. Might be worth pursuing a second degree in the interim though just so that I have marketable skills as an MPH or something.

Or you could tough out one of the easiest of all specialties in terms of work load during residency for two more years and make >200k till you die. But what do I know?

 

[VA Hopeful Dr]

Well, obviously it’s difficult for folks who did spend all that time to recommend the alternative, but that doesn’t mean it’s not viable. And I believe that it is. The only thing that keeps getting me is the idea that if for some reason God doesn’t grant me success in my DPC practice, I may be up a creek in terms of other good work options.
That said, I’m so done with residency right now that I can even handle dropping clinical medicine completely at that point. Might be worth pursuing a second degree in the interim though just so that I have marketable skills as an MPH or something.

And that's fine, but don't pretend that you can duplicate residency with some CME and an up-to-date subscription.

 

[Candidate2017]

And you think you are fully qualified to run your own panel right now with no quality differences between you and your attendings?

Splenda said they are a PGY2, almost PGY3. By mid-year, the IM PGY2s are expected to run the IM service at my hospital. I don't ever recall seeing any IM attendings really change any PGY2's plans. The IM PGY3s are sequestered in the lounge playing Xbox or otherwise doing a victory lap over their upcoming fellowship or attending job.

Depending on the attending, there may or may not be a quality difference. And research shows outcomes are better with newly minted attendings.

 

[Candidate2017]

Thanks for these thoughts. I definitely do agree that it’s not the IDEAL position to be in and I agree with the points you’ve made. In my case, there are various factors that are playing a part in my decision. I wanted to do the DPC thing anyway, but now there are various reasons that are pushing me to leave residency early. DPC practice with GP status seems like still a good option.

If you're not thrilled about your current FM program and want to eventually do DPC, why not transfer to a clinic-heavy (chill) residency? Get more clinic experience in PGY2 and moonlight in PGY3 to get a taste what its like to do things on your own. Getting medical experience is just half of residency. The other half is getting experience in how or how not to run a med practice.

Each waypoint in training (graduating med school, getting a full license, graduating residency/board eligible, board certified) opens exponential opportunities. Believe it or not, you've finished most of the hard stuff. Residency goes by quick and will be the last time you get to experiment and hone your craft on someone else’s time and dime.

 

[deleted480308]

Splenda said they are a PGY2, almost PGY3. By mid-year, the IM PGY2s are expected to run the IM service at my hospital. I don't ever recall seeing any IM attendings really change any PGY2's plans. The IM PGY3s are sequestered in the lounge playing Xbox or otherwise doing a victory lap over their upcoming fellowship or attending job.

Depending on the attending, there may or may not be a quality difference. And research shows outcomes are better with newly minted attendings.

if you're done learning as a pgy2 your program is failing you

 

[throwaway1000000]

If you're not thrilled about your current FM program and want to eventually do DPC, why not transfer to a clinic-heavy (chill) residency? Get more clinic experience in PGY2 and moonlight in PGY3 to get a taste what its like to do things on your own. Getting medical experience is just half of residency. The other half is getting experience in how or how not to run a med practice.

Each waypoint in training (graduating med school, getting a full license, graduating residency/board eligible, board certified) opens exponential opportunities. Believe it or not, you've finished most of the hard stuff. Residency goes by quick and will be the last time you get to experiment and hone your craft on someone else’s time and dime.

Yeah.Honestly you can do whatever you want, but for most people not finishing is residency is a very poor decision in terms of your career. Regardless of whether you think you are learning more in the remaining of your residency, you would be better off finishing your residency and using that full board certification/license to your advantage.

 

[Mass Effect]

And research shows outcomes are better with newly minted attendings

That's because newly minted attendings are scared of hurting patients. Chances are residents who think they know it all after PGY 1 don't share that burden of fear.

 

[Splenda88]

That's because newly minted attendings are scared of hurting patients. Chances are residents who think they know it all after PGY 1 don't share that burden of fear.

Where is the research that back that up?

 

[Splenda88]

Splenda said they are a PGY2, almost PGY3. By mid-year, the IM PGY2s are expected to run the IM service at my hospital. I don't ever recall seeing any IM attendings really change any PGY2's plans. The IM PGY3s are sequestered in the lounge playing Xbox or otherwise doing a victory lap over their upcoming fellowship or attending job.

Depending on the attending, there may or may not be a quality difference. And research shows outcomes are better with newly minted attendings.

I thought that happened only in my program, but it happens in the last 6 months of PGY3

My program is tough but it prepares us pretty well for what is coming

 

[Mass Effect]

Where is the research that back that up?

Not everything needs research. Sometimes, it's ok to just have an opinion based on real life.

 

[Splenda88]

Not everything needs research. Sometimes, it's ok to just have an opinion based on real life.

Expert opinion huh!

 

[VA Hopeful Dr]

That's because newly minted attendings are scared of hurting patients. Chances are residents who think they know it all after PGY 1 don't share that burden of fear.

I also have to wonder if clinical inertia doesn't play a role. When you're first out, every patient is new to you so you're less likely to just continue their current treatments.

 

[Mass Effect]

Expert opinion huh!

Common sense doesn't need a citation.

 

[The wise one]

I doubt you know what you are saying.

There point is that we may be spending too much time in residency while that time may not be that beneficial to our ability to practice medicine. Didn’t seem too difficult to grasp IMO

 

[zero0]

For me, I do believe of course that a graduate of a three year program has more experience and knowledge than after PGY1. This is obvious. But the question is whether someone who starts working after PGY1 will acquire the same amount of knowledge and experience on their own. I believe that the latter option is very viable. Most of my learning today is self taught as I see patients. 90% of what I’m learning is without being taught by an attending. If I’m out on my own, I’ll need to be even more on my toes. The steep learning curve as an attending/solo practitioner will exist whether after 1 year or 3 years. Yes, a PGY1 is less experienced, but can he make up for that by using appropriate resources? That’s pretty much what I’m doing now as a resident anyway.
I am planning to do DPC where the above mentioned insurance and hospital privilege issues don’t apply. I’ll also have sufficient time in that setting to look things up if needed.
What there really needs to be is an alternate pathway to board certification like there once was. Work for a certain number of years following internship, earn a certain number of CME credits, and then take board exam to qualify.

This could be a viable alternative. Unfortunately, medicine is dominated by the "I had to suffer through a broken system and so should they" mindset so I doubt anything will ever get fixed. Residency training really has become a runaway scam for cheap labor.

 

[VA Hopeful Dr]

This could be a viable alternative. Unfortunately, medicine is dominated by the "I had to suffer through a broken system and so should they" mindset so I doubt anything will ever get fixed. Residency training really has become a runaway scam for cheap labor.

Or maybe, just maybe, there's a fair number of us who actually think residency does a good job training physicians (not universally of course, but not all programs are equal).