Starting a primary care track?

[RealHLA11]

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I was wondering if any of you had experience in starting a new residency track? I am currently a PGY-1 IM, and I am interested in primary care, but my program does not have a primary care track. I feel that the experience I will get in my 3 year residency as is will be less than sufficient in preparing me for a primary care career, esp. outpatient. How much work would it be to create a type of primary care track (if not a full track, then an at least an emphasis) to help myself in this goal, and help future residents in this regard? Any help much appreciated!!

 

[Crayola227]

oh Lord

well obviously key will be talking to your PD about this and trying to get as much outpt rotations as you possibly can with your elective time
also see if any rotations they have on the docket for you can be made into outpt, say an ER month not technically required for accreditation/boarding that they program includes, which might be where you're not technically needed (unlike a wards month for example)... maybe could be changed

maybe the program would be willing/able to extend your program to add on some more outpt time...??
maybe they could schedule you for more clinic days/shift days around to give you more clinic and someone else less while still meeting work hour and ACGME requirements

otherwise I wouldn't stress it too much, there's other strategies too for filling in that gap
being a junior partner in a group practice
post residency observorship
even fellowships that could help this issue
or just winging it which is what most do (I know, wrong answer but reality)

 

[NotAProgDirector]

You're not creating a primary care track at your program.

Just use your elective time to do outpatient experiences (Rheum, Endo, Outpatient GI and Cards, Ortho can be helpful for learning splinting etc). You can ask if you can do more continuity clinic on your outpatient / elective blocks.

And the honest truth is that you only learn half of what you really need to know in residency, and the other half in your first 6 months of work.

 

[DocBlin]

You're not creating a primary care track at your program.

Just use your elective time to do outpatient experiences (Rheum, Endo, Outpatient GI and Cards, Ortho can be helpful for learning splinting etc). You can ask if you can do more continuity clinic on your outpatient / elective blocks.

And the honest truth is that you only learn half of what you really need to know in residency, and the other half in your first 6 months of work.

100% correct! In my case I did a 'hands on' PS fellowship in 1980 for 6 months in private practice setting. Than started my own practice and have not stopped since. For my son he finished 1 Prelim GS year, 3 FM residency years. Than started Urgent Care 2 months before end of his FM residency as a 'licensed moonlighter'. At end of residency started fast in UC at 2 locations. Now after 16 months running 1 UC in NYC & planning on opening his own retail FM/Cosmetic Medicine practice. Just added info.

 

[RealHLA11]

100% correct! In my case I did a 'hands on' PS fellowship in 1980 for 6 months in private practice setting. Than started my own practice and have not stopped since. For my son he finished 1 Prelim GS year, 3 FM residency years. Than started Urgent Care 2 months before end of his FM residency as a 'licensed moonlighter'. At end of residency started fast in UC at 2 locations. Now after 16 months running 1 UC in NYC & planning on opening his own retail FM/Cosmetic Medicine practice. Just added info.

Thanks for the helpful response @DocBlin, I appreciate it! I was asking a legitimate question about what goes into creating a primary care track/emphasis, because they don't just arise out of thin air. But your pathway has given me new things to consider.

 

[dozitgetchahi]

Some electives that would be important (i.e., they help cover things that don't get stressed in most IM programs) would include gyn/women's health and derm (rashes, rashes, rashes). Maybe outpatient neuro and psych too.

 

[Crayola227]

try to get office procedures, that's the piece you can't get uptodate to help you when you're an attending outpt clinic

 

[Gastrapathy]

I want to be a fly on the wall.

"Hi Dr PD, I think all this inpatient medicine isn't helping me prepare for an outpatient practice. I'd like to spend my third year doing more clinic"

PD "So you want someone else to do all the hard rotations while you double up on Allergy and Rheum? Sure, sounds fine"

 

[rokshana]

say an ER month not technically required for accreditation/boarding that they program includes, which might be where you're not technically needed (unlike a wards month for example)... maybe could be changed

fyi...an EM month IS required by the ABIM to be able to sit for the IM boards.

 

[mvenus929]

fyi...an EM month IS required by the ABIM to be able to sit for the IM boards.

I'm not sure how it works for IM, but for Peds, programs are held to minimum standards and develop their schedule from there. It's possible that a program schedules an ED month in place of an elective, for instance, and that could potentially be swapped out.

 

[Crayola227]

fyi...an EM month IS required by the ABIM to be able to sit for the IM boards.

some programs work in more than one or whatever is the min number, thanks for making that clear

point is there are some things that are ABIM board required and some that are just program specific that could be changed around... of course the difficulty is really scheduling although often they will say whatever rotation in question is a "critical part of the curriculum" as it may well be

my program has something like 4 months more ICU than is ABIM required (I think, I know it's pretty heavy), obviously that is great inpatient experience... but you could see how that is not so helpful for the primary care bound internist... and aside from coverage issues one might wonder if why not make some of that outpt?

some programs have like a built in research quality control month or independent study time that may not be ABIM required

I guess my point is sit down with the ABIM requirements, your program's schedule, figure out what is not demanded for the program's accreditation or board eligibility, and see what rotations they may not miss you on (like my example of a research or study time, or like we had some inpt cardio consult service that was run by the community practice and frankly did not need you there although everyone loves a note monkey), those rotations would be the ones I would ask a PD "hey can I do more clinic" sometimes they would like to have you more in clinic, there is like the minimum required and our program had a certain amount over that, we had a resident that was looking to cut down on clinic days to get home to a new baby sooner, so the program was looking to cut their clinic days but issue was who would pick up slack, in a scenario like that someone like the OP would might be helpful, so point is, I don't think you step on toes to do this sort of analysis/thinking and approach the PD with an idea of "hey how do we stick me in clinic more" just be prepared for whatever no answer you get

that was really my point

also I think that in the case of some of these newer PC tracks and the need for outpt PCPs I thought some of the programs were getting certain waivers on some of the breakdown of inpt vs outpt rotations to facilitate that training... but I don't know, I'm throwing out leads for this person to look into to try to get more clinic

 

[rokshana]

some programs work in more than one or whatever is the min number, thanks for making that clear

point is there are some things that are ABIM board required and some that are just program specific that could be changed around... of course the difficulty is really scheduling although often they will say whatever rotation in question is a "critical part of the curriculum" as it may well be

my program has something like 4 months more ICU than is ABIM required (I think, I know it's pretty heavy), obviously that is great inpatient experience... but you could see how that is not so helpful for the primary care bound internist... and aside from coverage issues one might wonder if why not make some of that outpt?

some programs have like a built in research quality control month or independent study time that may not be ABIM required

I guess my point is sit down with the ABIM requirements, your program's schedule, figure out what is not demanded for the program's accreditation or board eligibility, and see what rotations they may not miss you on (like my example of a research or study time, or like we had some inpt cardio consult service that was run by the community practice and frankly did not need you there although everyone loves a note monkey), those rotations would be the ones I would ask a PD "hey can I do more clinic" sometimes they would like to have you more in clinic, there is like the minimum required and our program had a certain amount over that, we had a resident that was looking to cut down on clinic days to get home to a new baby sooner, so the program was looking to cut their clinic days but issue was who would pick up slack, in a scenario like that someone like the OP would might be helpful, so point is, I don't think you step on toes to do this sort of analysis/thinking and approach the PD with an idea of "hey how do we stick me in clinic more" just be prepared for whatever no answer you get

that was really my point

also I think that in the case of some of these newer PC tracks and the need for outpt PCPs I thought some of the programs were getting certain waivers on some of the breakdown of inpt vs outpt rotations to facilitate that training... but I don't know, I'm throwing out leads for this person to look into to try to get more clinic

so interestingly enough the guidelines have changed a bit in that they are less defined...

http://www.abim.org/pdf/publications/Policies-and-Procedures-Certification.pdf

previously the ABIM set a certain number of months for EM, Neurology, and ICU (min and max #), now they lump it all together in the 30 month requirements and neurology seemingly is not a requirement now, but a specialty that is allowed to be counted as part of the 30 months...

of an fyi, they have put in a bit about qualifications for ABIM if you are currently in an AOA program that eventually receives ACGME qualifications to be able to sit for the ABIM boards.

 

[Raryn]

so interestingly enough the guidelines have changed a bit in that they are less defined...

http://www.abim.org/pdf/publications/Policies-and-Procedures-Certification.pdf

previously the ABIM set a certain number of months for EM, Neurology, and ICU (min and max #), now they lump it all together in the 30 month requirements and neurology seemingly is not a requirement now, but a specialty that is allowed to be counted as part of the 30 months...

of an fyi, they have put in a bit about qualifications for ABIM if you are currently in an AOA program that eventually receives ACGME qualifications to be able to sit for the ABIM boards.

You're confusing the ABIM requirements for certification with the ACGME RRC requirements for program accreditation.

https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf

An example:

These experiences must include: required critical care rotations (e.g., medical or respiratory intensive care units, cardiac care units) which cannot be fewer than three months and more than six months over the 36 months of training;

 

[Crayola227]

right so this is useful to OP or other readers to know that it's a pretty complex system and very complicated for programs to meet all requirements and get everyone scheduled

it's not like med school where basically you're shadowing and there's a lot more flex to just stick you wherever, in residency you are actually producing work and coverage

so don't expect a PD to be able to do much for you, if you're lucky there's some flex and they'll try

really your best bet is to get some idea that you want to be an outpt internist (and I'll smack someone if they say "well then why not just do family SMH family med [not the practitioners just a lot of other things] because I truly believe the outpt internist is a slightly different beast than the FM'er and the training background certainly is much much different) figure it out and do your homework and make it a point to go to apply interview rank match to a program that can help you meet those goals

a lot of community programs I went to seemed almost relieved to have interviewees that didn't want fellowship because obviously that takes pressure off of them to help you with that, and then you won't be a risk for contributing to an unmatched fellowship rate stat that is part of their rep, and I'm sure they feel it makes them feel they can compete better for your affections compared to a uni program that is usually better for the fellowship bound

depends on the program but for the most part do not be afraid to let programs know you are not interested in fellowship, there is a lot of respect for the person who just wants to be a general internist outpt or inpt, just be ready with a thoughtful answer as to why that doesn't make you sound unambitious or a slacker "my ovaries are getting too old" "I just want to be done with training" "prepping for fellowship? forget it I don't want to do research I want to sleep"

try: "I really enjoy all aspects of medicine and really like the idea of coordinating all of a patient's care as opposed to focusing on an organ system." "I like the idea of being able to do either inpt or outpt medicine as I am not fully decided on that." "While I am interested in working outpt, I was not drawn to family medicine because it is so difficult to work inpt if that is ultimately the direction I want to go in, internal medicine training prepares one for more complex patients and diagnostic skills which can translate to both inpt and outpt in a way that Fam Med does not, and frankly, I have no interest in peds or obstetrics."

TLDR
program requirements are complex
changing the program for you snowflake likely VERY difficult but not impossible so you could ask I guess
if it's not too late my advice is figure out if you want good outpt experience and look for program set up to help you with that
you can let programs know you want to be a general internist and/or to be outpt, just be prepared to answer "why not FM then?"
otherwise most community programs have no issue with you expressing interest in being a general internist I did not feel any stigma at most programs in fact it seemed desirable

 

[rokshana]

You're confusing the ABIM requirements for certification with the ACGME RRC requirements for program accreditation.

https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/140_internal_medicine_07012013.pdf

An example:

These experiences must include: required critical care rotations (e.g., medical or respiratory intensive care units, cardiac care units) which cannot be fewer than three months and more than six months over the 36 months of training;

you are RIGHT! thanks!!

and that was the exact example was looking to find...🙄