Training required to be a PCP

[PCPDoc983]

This thread is not in any way meant to sound condescending, more for my general knowledge.

If PAs and NPs are providing seemingly good primary care to a broad spectrum of ages, with just 2 years of grad school and NO post-graduate training, then why are Primary Care tracks even in place for IM residencies? The whole concept of "IM residencies are leaving graduates unprepared to do primary care" is completely bogus then...because clearly ANY practitioner can provide primary care, even with subpar training, right?

Why even have that emphasis? even a categorical resident with 1 clinic day/week and mostly inpatient training will trump the training of an NP/PA and will provide better primary care. So, why even have these tracks, when any resident can fullfill that duty...if anything all the track does is limit you, IMHO.

---

Members don't see this ad.

 

[Blackcomb]

This thread is not in any way meant to sound condescending, more for my general knowledge.

If PAs and NPs are providing seemingly good primary care to a broad spectrum of ages, with just 2 years of grad school and NO post-graduate training, then why are Primary Care tracks even in place for IM residencies? The whole concept of "IM residencies are leaving graduates unprepared to do primary care" is completely bogus then...because clearly ANY practitioner can provide primary care, even with subpar training, right?

Why even have that emphasis? even a categorical resident with 1 clinic day/week and mostly inpatient training will trump the training of an NP/PA and will provide better primary care. So, why even have these tracks, when any resident can fullfill that duty...if anything all the track does is limit you, IMHO.

You just gave the argument for why PAs and NPs do not provide "good" primary care (as a whole). I consider outpatient internal medicine one of the hardest professions to do "well"; primary care is not that hard to manage if you only manage HTN/DM and refer away everything else. "Good" internists who can spot difficult-to-discern diseases and have sound clinical judgement are few and far in between...

Now before everything jumps me, I think there are some fine NP's and PA's who have accumulated enough experience to become proficient providers for 80% of patient visits... However, there is a lack of clinical standarization and evaluation methods in NP training (I'm not as sure about PA training). NP's can state they did "6 months at an outpatient office" without providing rigorous evaluations/milestone-based achievements that we have to undergo during medschool/residency. I think this lack of standarization does them a disservice in the end...

After 3 years of residency and a outpatient-clinic-heavy chief year, I still think I am far far away from becoming an "excellent" PCP...

 

[Rheumination]

This thread is not in any way meant to sound condescending, more for my general knowledge.

If PAs and NPs are providing seemingly good primary care to a broad spectrum of ages, with just 2 years of grad school and NO post-graduate training, then why are Primary Care tracks even in place for IM residencies? The whole concept of "IM residencies are leaving graduates unprepared to do primary care" is completely bogus then...because clearly ANY practitioner can provide primary care, even with subpar training, right?

Why even have that emphasis? even a categorical resident with 1 clinic day/week and mostly inpatient training will trump the training of an NP/PA and will provide better primary care. So, why even have these tracks, when any resident can fullfill that duty...if anything all the track does is limit you, IMHO.

I think you do not have enough respect for primary care! It is hard! It encompasses everything and you have a short time with patients in the clinic (though a long time long term). On the inpatient side, only something big an important buys you an admission and it's easy to get comfortable with those admits, many of which are repetitive (CHF exac, PNA, chest pain r/o, etc). On the outpatient side, anything goes and it is tough being a primary care doctor.

Yes, many people could provide subpar care. You are comparing a categorical resident to an NP but the question you are asking is primary care resident vs categorical resident and the reason for it. I think my primary care colleagues are definitely ahead of me in treatment of the primary care patient but I also believe that it takes years to become comfortable in the outpatient setting. It is definitely for people who are destined to primary care, it is not destined for people who really want to do some other training and would feel "limited".

 

[infarct]

This thread is not in any way meant to sound condescending, more for my general knowledge.

If PAs and NPs are providing seemingly good primary care to a broad spectrum of ages, with just 2 years of grad school and NO post-graduate training, then why are Primary Care tracks even in place for IM residencies? The whole concept of "IM residencies are leaving graduates unprepared to do primary care" is completely bogus then...because clearly ANY practitioner can provide primary care, even with subpar training, right?

Why even have that emphasis? even a categorical resident with 1 clinic day/week and mostly inpatient training will trump the training of an NP/PA and will provide better primary care. So, why even have these tracks, when any resident can fullfill that duty...if anything all the track does is limit you, IMHO.

dude one of the biggest reasons i want to specialize is that primary care is so damn hard.

 

[machomed]

dude one of the biggest reasons i want to specialize is that primary care is so damn hard.

Mid-level providers like NPs are VERY good at chronic disease management, and carrying out routine health maintenance. That is completely within the scope of their license and they should eventually take over most of that care. They are probably better at it, and deliver the care at a lower price.

However, mid-level providers do not have the core training required to be good diagnosticians. This is where PCPs are needed. And the work is extremely difficult.

In the primary care model of the future, every provider is working at the top of their license, and working in a team. In this model, the PCP also takes on the role as team manager and quality improvement coordinator. We need PCPs trained to be leaders of interprofessional teams, to have a good understanding of the application of evidence based medicine and best practices for management of clinical microsystems. THIS is why we should have primary care tracks. This kind of training is currently absent from the average categorical residency, but is crucial to training the PCP of the future. At the best primary care track programs, they are working towards training PCPs to fill this niche.

One last thing, to my future interventionalist friends who ask, "aren't you worried about the future of primary care?" In an era in which we are moving towards pay for performance and accountable care, I would be more concerned about training to be a proceduralist in some specialties with interventions of questionable value (jamming stents into stable angina patients, performing Mohs on every corner of skin on the body, etc). Primary care's future is bright.

 

[dozitgetchahi]

Mid-level providers like NPs are VERY good at chronic disease management, and carrying out routine health maintenance. That is completely within the scope of their license and they should eventually take over most of that care. They are probably better at it, and deliver the care at a lower price.

However, mid-level providers do not have the core training required to be good diagnosticians. This is where PCPs are needed. And the work is extremely difficult.

In the primary care model of the future, every provider is working at the top of their license, and working in a team. In this model, the PCP also takes on the role as team manager and quality improvement coordinator. We need PCPs trained to be leaders of interprofessional teams, to have a good understanding of the application of evidence based medicine and best practices for management of clinical microsystems. THIS is why we should have primary care tracks. This kind of training is currently absent from the average categorical residency, but is crucial to training the PCP of the future. At the best primary care track programs, they are working towards training PCPs to fill this niche.

One last thing, to my future interventionalist friends who ask, "aren't you worried about the future of primary care?" In an era in which we are moving towards pay for performance and accountable care, I would be more concerned about training to be a proceduralist in some specialties with interventions of questionable value (jamming stents into stable angina patients, performing Mohs on every corner of skin on the body, etc). Primary care's future is bright.

Sounds like somebody really drank the 'patient centered medical home' (or whatever it's called this week) kool-aid.

I don't feel that midlevels as a group (especially NPs) do anything particularly well, no matter how much bogus research they generate claiming that they do things as well or better than physicians. Furthermore, general internal med is a damn tricky specialty. It's easy to do a lousy job of it, and much, much harder to do it truly well. The spectrum of talent between the zenith and nadir of PCPs is probably the broadest in all of medicine - and I'm just talking about the docs. Throwing a bunch of undercredentialed midlevels into the situation isn't going to make anything better.

 

[obiwan]

agreed that as my residency training comes to a close, i am no where the level of an outpatient physician where I would be providing patients what i consider an good outpatient medicine

 

[Textbookversion]

This thread is not in any way meant to sound condescending, more for my general knowledge.

If PAs and NPs are providing seemingly good primary care to a broad spectrum of ages, with just 2 years of grad school and NO post-graduate training, then why are Primary Care tracks even in place for IM residencies? The whole concept of "IM residencies are leaving graduates unprepared to do primary care" is completely bogus then...because clearly ANY practitioner can provide primary care, even with subpar training, right?

Why even have that emphasis? even a categorical resident with 1 clinic day/week and mostly inpatient training will trump the training of an NP/PA and will provide better primary care. So, why even have these tracks, when any resident can fullfill that duty...if anything all the track does is limit you, IMHO.

Do you feel ready to practice as a primary care doc after your third year? Because a graduating PA knows half as much as you do starting your fourth year. I'm firmly comfortable with the fact that I'll need 3 years of residency before I can practice independently. The PA's and NP's acting basically independently have to live with themselves. It's not for me.

 

[mercaptovizadeh]

The issue I'm seeing with primary care is that a lot of them just outsource any slight problem to the specialist. I've seen so many pediatric endocrine patients who could be managed by their PCPs for their type 2 diabetes or their hypothyroidism. It's not that hard to order TFTs and antibodies and then follow-up on them every 6 months!

By all means, procedural work such as colonoscopies, dialysis management, and caths must be done by specialists. But there is a wealth of patients with presentations that fall into the more cognitive specialties that could and should be handled by their PCP, and instead they are being referred out.

 

[ihearttriangles]

I find it interesting that many residents seem to feel under prepared to practice outpatient medicine. Do you guys think this was due to a particular weakness in your program or is something inherent in most internal medicine training programs? Also, I'm curious to know if any practicing PCPs can comment on how a family medicine residency might compare in terms of actually preparing you for outpatient medicine. It seems like they get some stuff that might not be so useful (obstetrics/nicu) but seems like they also do some rotations in optho/derm/sports med that might be super helpful. Thanks.

 

[dragonfly99]

I find it interesting that many residents seem to feel under prepared to practice outpatient medicine. Do you guys think this was due to a particular weakness in your program or is something inherent in most internal medicine training programs? Also, I'm curious to know if any practicing PCPs can comment on how a family medicine residency might compare in terms of actually preparing you for outpatient medicine. It seems like they get some stuff that might not be so useful (obstetrics/nicu) but seems like they also do some rotations in optho/derm/sports med that might be super helpful. Thanks. }

In my opinion, family med is better prepared to deal with sports med type and birth control OB/gyn type of problems. they are less well prepared than medicine residents to deal with chronic diseases of the middle aged and elderly, such as HTN, diabetes, CAD, COPD, etc. FP also tends to be better trained perhaps in the psychosocial stuff like family dynamics, etc. And for things like minor procedures like ingrown toenails, etc. I'm not making a job of that stuff - it's actually important to patients since they feel like their doctor can "do stuff" for them. But I get quite a few referrals from fp's where they haven't controlled the diabetes and HTN (happens with internists too...they just all have too much stuff to do). IM tends to be better trained to deal with elderly patients and their polypharmacy, and with sick hospital patients. But all this will vary with the individual and the training program they graduated from...

 

[group_theory]

I find it interesting that many residents seem to feel under prepared to practice outpatient medicine. Do you guys think this was due to a particular weakness in your program or is something inherent in most internal medicine training programs? Also, I'm curious to know if any practicing PCPs can comment on how a family medicine residency might compare in terms of actually preparing you for outpatient medicine. It seems like they get some stuff that might not be so useful (obstetrics/nicu) but seems like they also do some rotations in optho/derm/sports med that might be super helpful. Thanks.

I don't think it's a particular program weakness. It's more of a realization that good primary care medicine is hard. You never know what will walk through that door - if that young adult with a cough is just a virus, asthma, or lymphoma. And chronic management of disease is not one disease - it's multiple diseases simultaneously. It is managing your diabetic patient with history of MI and now with ischemic cardiomyopathy who continues to smoke. It's deciding on the spot if you need to work this up immediately, or if you can send the patient home with labs/imaging and close follow-up. It's making sure that your patient whom you want to repeat labs in 3 months (to make sure it returns to normal) actually gets the lab done in 3 months.

It's the fact that we know more that we realize how hard it is. Off the top of your head, what's the differential for someone who is short of breath who comes into your clinic. It's a broad list, from benign to very serious - and you have to short that out in a 15 minute acute visit. And the thought of missing something serious weighs heavily on everyone. Plus we all know that diseases don't read textbooks. Diseases don't read textbooks and common diseases often present atypically. It's the years of training (and education) that allows a good doctor to recognize the atypical presentation of a common disease. Ignorance is bliss. If you don't realize what you might miss, you will have a false sense of confidence. That's why I think a lot of us think primary care is hard - we realize that's out there, what can happen, and what's at stake.

I believe our family medicine colleagues have an advantage over us when it comes to outpatient medicine. They spend a lot of their training in an outpatient setting. Even when they have "inpatient medicine ward", they still have clinic obligations (with increase clinic time when they are a PGY2 and PGY3). The amount of time they spend in clinic far outnumbers the time Internal Medicine residents spend in clinic.

 

[wyme84]

It's IM residency in general...very inpatient heavy. Some programs are trying to create a better balance. Its a difficult issue.

I find it interesting that many residents seem to feel under prepared to practice outpatient medicine. Do you guys think this was due to a particular weakness in your program or is something inherent in most internal medicine training programs? Also, I'm curious to know if any practicing PCPs can comment on how a family medicine residency might compare in terms of actually preparing you for outpatient medicine. It seems like they get some stuff that might not be so useful (obstetrics/nicu) but seems like they also do some rotations in optho/derm/sports med that might be super helpful. Thanks.

 

[Trogghunter]

What are the 'best' PC programs? Not according to usnews.

 

[smq123]

I find it interesting that many residents seem to feel under prepared to practice outpatient medicine. Do you guys think this was due to a particular weakness in your program or is something inherent in most internal medicine training programs? Also, I'm curious to know if any practicing PCPs can comment on how a family medicine residency might compare in terms of actually preparing you for outpatient medicine. It seems like they get some stuff that might not be so useful (obstetrics/nicu) but seems like they also do some rotations in optho/derm/sports med that might be super helpful. Thanks.

I find it interesting that many residents seem to feel under prepared to practice outpatient medicine. Do you guys think this was due to a particular weakness in your program or is something inherent in most internal medicine training programs? Also, I'm curious to know if any practicing PCPs can comment on how a family medicine residency might compare in terms of actually preparing you for outpatient medicine. It seems like they get some stuff that might not be so useful (obstetrics/nicu) but seems like they also do some rotations in optho/derm/sports med that might be super helpful. Thanks.

FM residencies often have a lot of outpatient clinic. As a 2nd and 3rd year, I had 2 full days a week, and saw about 14-16 patients a day, generally. That's very similar to what I do now as an attending (except it's 5 days a week, 18-21 patients). Many of my IM colleagues only ever did a half day a week.

FM residencies are required to teach residents about billing and coding. My sister, who is a pulmonologist, did not know how to effectively bill until she was an attending; I had to learn this as an intern.

FM residencies frequently have a large procedural component. As a resident, we did colposcopies, IUD insertions, joint injections, and skin biopsies. I do skin biopsies fairly frequently now - my patients have a hard time getting in to derm. My colleagues who did IM residencies have said that they will be referring their patients to me for these types of procedures, because they didn't learn how to do these during their residency time.

Because we do so much clinic as residents, I definitely have a lot more comfort with psych issues than some of the people who came out of IM residencies. As a PCP, about 30% of your patients will come in for psych related things; you should have a good handle on that. Not just depression and anxiety, but also PTSD, panic disorders, ADHD (pediatric ADHD kids sometimes grow up to be adult ADHD patients), schizophrenia, etc.

they are less well prepared than medicine residents to deal with chronic diseases of the middle aged and elderly, such as HTN, diabetes, CAD, COPD, etc.

I disagree with this as a blanket statement, although there are certainly a lot of lazy FM doctors (as well as internists) who don't want to take the time to manage difficult patients. Or who get overwhelmed. Like you said, depends on the program. We have a couple of IM trained PCPs who work with us who keep insisting on using beta blockers as first line drugs on all of their newly dx'ed hypertensives....

 

[sluggs]

To be a good PCP, you had better know some: Derm, ENT, Rheum, Endocrine, Psych; in addition to the big inpatient stuff. You had better have top-notch exam skills, work very quickly, and remeber everything you have to follow up in 2 weeks to 6 months. It is hard as hell. and many of the skills just aren't taught. You get minimal reimbursement, and not nearly enough respect. You also can really help people. The field is tough, demanding, and underrated and undertaught!

 

[acesup123]

Do you work in a rural area? I was under the impression that in urban areas family practice don't do much procedures because of all the specialists.

 

[smq123]

Do you work in a rural area? I was under the impression that in urban areas family practice don't do much procedures because of all the specialists.

I work in an underserved urban area. Almost all of my patients are uninsured or underinsured. So it's kind of like working in a rural area.

Even if you have specialists around you, it doesn't mean that your patients have financial access to them. And just because the specialists are there doesn't mean that you automatically HAVE to refer your patient out. That's part of the challenge of being a good PCP - knowing when to refer and when not to.