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Trying to convince myself on FP

Discussion in 'Family Medicine' started by WNL, May 7, 2008.

  1. WNL

    WNL

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    Hello all,

    I'm a 3rd year med student, new to the forums although I've been reading threads for quite some time now. I'm at the end of my 3rd year now, trying to pin down my specialty decision. At this point, it's most likely between Family and Med-Peds, althought I wouldn't say I've ruled anything out completely. I have enjoyed most all of my other rotations as well and have also strongly considered OB/Gyn and Surgery while on those rotations. However, I feel that I enjoy spending time talking with patients and working on diagnosis too much to do a surgical specialty, although I do enjoy procedures. Because I have enjoyed just about everything, I feel that Family Med would be a natural choice. However, I have several barriers and concerns that keep me from feeling completely comfortable with that choice. Many of them are discussed elsewhere on the forum but I was hoping to get some individualized feedback from the people here and have some discussion. Also, I'm not trying to be inflammatory with any of these comments, and I'm certainly not trying to be offensive.

    1. Concern about the future of family medicine and primary care.
    I realize that there are abundant arguments backed up by good evidence for the importance of family medicine and primary care in general to the future of medicine in this country. That being said, we seem to be at or approaching an important juncture where the US healthcare system will either allow primary care to continue to dwindle and move towards total specialization, or make substantial changes to reimbursement to favor the growth of primary care. I know what I and presumably everyone here thinks (knows) is the better option. But in politics, what is rational or even evidence-based is not necessarily what ends up happening. I realize that no one has a crystal ball, but this is a source of significant worry to me in deciding between primary care or more specialized residencies.

    2. Uncertainty about the future of family medicine in the context of primary care.
    Assuming primary care survives and thrives in the next several decades, will the field of family medicine remain tenable? Based on my limited experiences thus far, it seems that the family physician performs almost the exact same outpatient work as a general internist, a general pediatrician, and also performs the primary care side of OB/Gyn (including high risk OB and even Cesareans in some cases). I suppose in theory each of these other specialists has slightly more expertise than the family physician, but in reality, I would guess that 90-95% of the problems they treat are identical. As medical knowledge continues to expand at an exponential rate, is it really plausible to keep up in these fields, or will primary care itself be forced to "subspecialize"? It already seems difficult to convince parents to use an FP instead of a pediatrician, or for women to use an FP for their routine OB/Gyn issues. And why should they necessarily? I realize that there is value in continuity of care, but given the fact that so many patients self-refer to specialists, is this continuity really that important to patients? And as far as coordination of care across specialties, is this really something that requires an MD to do, or could this function be provided by mid-levels?

    3. Reimbursement, or "Why make less when you could make more?"
    You can't escape this thought. Even though I wouldn't enjoy being a radiologist nearly as much, I might be able to live with it given the lifestyle that it would buy me. It's the whole work-to-live vs live-to-work issue that I haven't totally sorted out yet. On the other hand, if major changes in reimbursement do occur in the next few years-decades, the income gap between primary care and specialists may get smaller.

    4. Ego.
    There is an unmistakable, although generally unspoken sentiment out there that family medicine is for the bottom tier of medical students. I don't agree with it at all; we obviously need excellent physicians in primary care. But it is present nonetheless. As someone who has the grades and scores to do something more competitive and more lucrative, many would look at me and say "Why on earth would you do primary care?" I know that the answer to this is "because it's the best fit for me," but it's still difficult to have to constantly defend this.

    5. Practice location.
    It seems that family medicine thrives in more rural settings. But is it possible to have a broad and diverse practice, including OB and procedures in an urban setting? I plan on having a family someday and I feel that I would want my kids to have access to a wide variety of opportunities that may only be present in urban settings.

    Those are the concerns that have been on my mind lately. I truly appreciate anyone who took to the time to read this and respond. Thanks.
     
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  3. jetproppilot

    jetproppilot Turboprop Driver
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  4. DocRawk

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    I'm really interested in the responses to this as well. I'm an incoming OMS-1 at TCOM and am entering the rural med program. My intention is to enter an unopposed FM residency and learn to do as much as I possibly can including getting really good at OMM, learning minor cosmetic procedures (hyalin gel injections, botox, microderm abrasion, etc.), OB, upper GI/colonoscopy, and pretty much anything else I can get my head around. I've shadowed a couple of docs with this mentality, and they both do very well. I'd be nice to be sure that it'll still be possible when I get started in seven years.
     
  5. EdibleEgg

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    Most of this has been discussed on other threads, but these same thoughts were going through my head a few years ago, so I'll toss out a few comments.

    The first thing you thing you mention is family vs med peds. At this point in your decision making it probably doesn't matter much. Your rec letters, 4th year electives, etc. don't really differ a lot. If you are willing to trade an extra year of residency for the potential to do an IM or Peds fellowship, then meds peds is the way. If you are interested in OB/GYN/outpatient procedures, then family has the advantage. It's really program dependent, and most end up doing the same things.

    1. Future of Primary Care- There are tons of opinions on this, but the health care system cannot function without primary care. Family Medicine is not going away. As far as politics goes, I'll agree it's not driven by logic. It's driven by money. Health care is cheapest when it's primary care based. Money talks.

    2. Future of Family Medicine- There has definitely been some change in the way most FP's are practicing. Fewer people are catching babies. We, as a specialty, see fewer kids. I think that was at least partially by choice, but the perception of the speciality has changed. I understand why you would be concerned. However, there is still a huge demand for FP's, specifically because of the diversity of training.

    On another note, most people do "sub-specialize" to some degree once they are in practice. They tailor the way they practice to what they enjoy, what is economically favorable, and what is common.

    Continuity of care is good. A tremendous number of medical errors happen during hand offs. There's a recent thread titled something like, "How do I convince my wife to take our kids to an FP rather than a pediatrician." There are some good responses there.

    3. Reimbursement- This has been beaten to death. The average FP makes a lot less than the average orthopedic surgeon or cardiologist. Just using averages doesn't tell the whole story. If you are not doing something you enjoy, then you are not going to be as productive or happy.

    With that being said, it's practically impossible to pull in a neurosurgeon's salary as an FP. You can make more in other specialities. You can't squeeze blood from a turnip though. If reimbursements really go down, the big money makers will be hit hardest. However, I feel like I make a lot of money, and I love what I do.

    4. Ego- I remeber making rounds with the chief resident on surgery as a third year student. He called the FP's "Family Assassins", the medicine team "Fleas", the OB's "catty, wannabe surgeons with much more estrogen than surgical skill", the pediatricians "diaper changers", and even the ortho surgeons "carpenters", all within the course of one morning's rounds. At least he hated everyone equally. Almost forgot, we made a trip to the ER because the "triage nurses" wanted a patient evaluated that morning as well.

    I did really well on my third year rotations. I think it was mostly because I told nearly every team that I was completely interested in "insert your specialty here." The people who are giving you advice and making these comments are biased (including me). People generally want you to be interested in what they are interested in. Now I don't reccomend that people lie on rotations; now that I have been on the other side, I know it will be obvious. Family medicine was my last rotation, and I really did enjoy every rotation before it (with the exception of surgery), that's one of the reasons I chose family.

    You just can't be phased by negativity. Who cares what people think? Things are different in the real world.

    5. Pracitice location- Rural family med is different than suburban and both are different from urban. The same goes for other specialities. However, you absolutely have the most flexibilty about where you practice as an FP. There are only two residents, out of my graduating class of eight, that are currently delivering. Both live in a city of about half a million people.


    Go out and work with someone in the real world that has a practice you think you would enjoy. Wether that be med/peds, surg, whatever. That will be more valuable than any advice or opinion.

    Cheers
     
  6. chibihamsta

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    Choosing a specialty is difficult as a third year med student, namely because there simply isn't enough exposure to every specialty, and not enough time between doing rotations and having to make the decision on what you want to do for the rest of your career.

    I am glad that I chose FM because
    1. at the end of my intern year now, i can't imagine doing more than three years of residency
    2. i love the challenges and variety of FM
    3. my colleagues in IM/Peds/OB are amazed at how much we FM people know
    4. i can answer questions from family and friends about problems about babies, pregnancy, and general medicine
    5. FM people are nice.

    Family Medicine is a tough specialty to define because there is so much flexibility in what you can do as a FM doc. I love that flexibility and some of the things I plan to do as a FM doc are:
    - work a few days/week at a nursing home
    - do home visits
    - do shifts at a surgical walk-in clinic (minor procedures)
    - open a free clinic abroad
    - work on a cruise ship as the doc on duty and travel the world
    - volunteer 1 day a week at a free clinic

    I will probably not do OB in my practice for practical reasons, but if ever stuck in an elevator or airplane and there is a pregnant woman in labor, I could comfortably deliver her without sweating it. I think that Med/Peds is overkill for someone who wants to do primary care for adults and kids, but that is just my opinion. In my FM residency now, I feel I get so much inpatient experience that I feel somewhat overqualified to do outpt work. I will probably never again have to manage someone in DKA or resuscitate someone in septic shock once I'm done with residency.

    I think it's pretty obvious that FM will always be in demand. There will always be patients for FM docs to see, even if NP's and PA's start running their own clinics. A patient's primary doc (the most important doc) is responsible for so much. There is a lot that goes into health maintenance like BP/blood sugar/chol/weight/substance use control, immunizations, cancer screening etc.

    Society needs more primary care doctors to keep people from filling the ED's and getting admitted, thus reducing the burden on the system and reducing healthcare costs. The best medicine is prevention. That is why we need more FM docs. I can't think of a specialty better than Family Medicine! (But of course, I'm biased.)
     
  7. secretwave101

    secretwave101 Senior Member
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    I've found that there's much more collegiality once outside the med school environment. As mentioned, EVERYONE thinks their specialty is better than everyone else's. I'm in a community program, so maybe it's saner here, but the specialists NEED us for their referrals. So, they're respectful and we are of them. If you got any of us in a dark corner after a few drinks, we'd each hold forth with disdain about the other, but in general there's is functional mutual respect.

    OB - I'm seeing more and more students coming in wanting to do OB, and then transmorgifying into no-way-in-hell-after-graduation types. (seen in my program, including myself, and some other programs too) NSVD's don't bring much extra money (it's the CS's and hysterectomies that bring the cash), but they do bring a dizzying amount of liability, and a pretty crummy lifestyle. If you can make 150k and work 55 hours a week...or 180 and work 80, you'll see that the pay-off just isn't there. The upshot here is that you can do OB in cities, especially in the west U.S. if you want, but you aren't likely to want to.
     
  8. drwatson

    drwatson Stern. Stern but fair.
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    Just do this. Emphasis on REAL WORLD.

    Once you get into the real world, away from academia, I think Ego becomes much less of a factor. Family just gets a bad rep in academia. Work with a good Family Doc, then decide if it is right for you. The world needs good family docs.
     
  9. oregonbigc

    oregonbigc Resident
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    Having a difficult time deciding whether family medicine is right for you? I had an extremely difficult time with this decision as well. So did a number of students I spoke with at the national convention a week ago.

    The issues I delt with were:
    1) EGO, choosing a less competitive specialty
    2) Liking some other fields
    3) Salary, much less than some specialties


    It turns into an easier decision when you take away the academic mindset of medical school. At least where I went to medical school, which is one of the top university programs in the country in family medicine, there was still a "why would you want to do that attitude in other rotations." Thats all BS. The truth of the matter is that when you are practicing in the community there is not that feeling. Most patients are greatful and almost all specialists are greatful to you for referrals. It is a different happy world on the other side.

    The issue of liking a couple other specialties a lot, intrigued me for a while, but I know myself enough to know that repetitive tasks will bore me within 5 years for sure. Family is the most diverse and eclectic form that medicine has to offer. You may be suprised by the variety of careers FPs pursue. At my residency program many residents go on to ER, urgent care, hospitalist, private practice, OB fellowship, SM fellowship, academic positions. The options are vast for FP trained physicians.

    Salary is a highly considered these days with medical students when choosing a specialty. The bottom line is that medicine will afford you a good living, but no one will become extremely rich unless the practice good business skills. The good news also is that medicare isn't as quick to drop reimbursement for primary care as it is for specialties.

    Ask yourself this question, "If money was not a consideration and all medical specialties paid the same which field would you go into?" It can help to point you in the right direction.

    Good luck and dont forget Family medicine is now the #2 most recruited specialty
     
  10. Aesklepius

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    Personally I think one should not worry about primary care future because the country can't afford to continue down it's path. Well, politics aside......

    Those were all really good questions that I asked myself as well before deciding to go into FP, then I remembered what the director of ICU told me when I was rotating there. He said, do what you enjoy, be good at it and do what is best for your patient and the money will come. I tend to agree with this. You can succeed in just about any field if you are good at it. Just do what made you most happy.
     
  11. Blue Dog

    Blue Dog Fides et ratio.
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  12. WNL

    WNL

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    Thanks so much for everyone's replies. Your comments give me a little more perspective, especially in terms of the real world and life outside academia. I had not even really considered FM until I did my FM rotation with an FP outside the academic setting. It gave me a whole new perspective on the field which is why I started seriously considering it in the first place. It's just a difficult decision, especially at this moment in time given the state of the healthcare system. For every comment here about the necessity of MDs in primary care (with which I agree), you'll hear another doc saying that PAs and NPs are going to run you out of business. So I'll continue to mull it over, at least for a few more weeks! But this forum has been really helpful. Thanks.
     
  13. sophiejane

    sophiejane Exhausted
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    It's funny, reading this, I remember struggling with those same issues, but EGO really stood out for me because I haven't thought of that aspect in so long. All my concerns about that pretty much dissolved as soon as I started residency. Maybe it is because FPs are very well respected in my community, in large part due to the fact that the residents and FP faculty do so much here and care for so many people.

    I kind of remember having issues related to ego, but now it is just a memory. It has absolutely no effect on me in real life, and I am certainly not the lowly non-specialist I thought I'd be seen as. I am seen as what I am, which is the patient's primary care doc, no more and no less, and that is in fact a lot more than I thought it would be.
     

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