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Discussion in 'Family Medicine' started by zambo, Jul 18, 2006.
Just curious what thing(s) made you decide to do family med instead of internal med?
I knew I wanted to practice in the outpatient setting, and I wanted to see kids, too. I had no desire to specialize.
Note to thread participants: The OP has posted the same question in the IM forum: http://forums.studentdoctor.net/showthread.php?t=301669 . Those of you wishing to read both sides of the issue may be interested in seeing what the IM folks have to say.
How similar would you say are the types of adult cases seen by a FP in the outpatient setting compared to the cases seen by a general IM doctor also in the outpatient setting?
diversity and more office procedures! and there is absolutely no difference in medicine pts in an FP office or IM office. ive worked/rotated in both!
Since the types of adult cases are similar in FM and IM, is it mainly the OB/GYN part of FM that allows for more procedures compared to IM or something else?
Well, I suppose you could say colposcopy (which I don't do myself) is one that most general internists wouldn't do. Aside from that, FM and general IM could potentially do the same sorts of office procedures (lesion removal, joint injection, ingrown toenail avulsion, I&D, wound repair, flexible sigmoidoscopy, exercise stress testing, etc.) This is subject to one's individual practice and preferences, of course.
That is the reason I'm thinking more and more about family practice lately. I'm looking for something that gives me a lot of diversity in practice and something that gives me a good mixture of primary care responsibilities as well as procedural oriented aspects within the office setting.
When I first started medical school, I was pretty dead set on becoming a surgeon. I'm only starting my third year now, so I'm still very unsure of what I really want to do, but family practice is definitely in the picture now. If I had to choose right now, I'd probably choose between family practice and general surgery.
I dont know any internists that do as many office procedures as fp's. Our (fp) training is broad and we get more procedural training in residency. For example we do a month of ortho and sports medicine so I got lots of exposure and training in injections (knees, shoulders, hips, trigger point, etc.) I also did a fair amount of casting and splinting in addition to our 3 ER months. So I feel like Im better trained to splint and cast than my IM counter parts. One of my friends who is an IM resident said they dont any procedures in their academic office. Any little ortho case they refer. FP residents also rotate in surgery and ob/gyn so there are procedures there like I&D's, bx of lumps and bumps, cervical polypectomies, colposcopy, endometrial biopsies, breast cyst aspirations, breast lump core needle biopsies (although most would rather send these to a breast surgeon) , and the list goes on. We are very fortuante to have a procedure clinic at our resident clinic. It is friday afternoons and run by one of our faculty attendings who is a procedure guru and will put a needle into anything. All second and third years rotate through this clinic one month each year. There is a vast array of things that are scheduled and its very busy. Both procedure rooms are running constantly. We get referals from other attendings and PA's in our large academic clinic who dont like to or dont feel comfortable doing certain things. Its a real blast too. So, if you are interested in procedures and decide family medicine is for you, then I suggest applying to residencies that have such a formal procedure training in place. Oh, and we also have procedure didactics and workshops certain times of the year. Hope this helps....
I'm always surprised by how many people narrow their choice down to general surgery and FM.
On a side note, our residency does an amazing job getting us experience in office procedures. I am absolutely ecstatic with my residency choice so far.
would you guys who are in procedure-oriented residency programs mind letting us know what programs you're in?
I didn't really realize this was an especially common final decision. Any others out there thinking of these two?
I am a 3rd year rotating in Uro and I "assisted" (uh, cut sutures) on a vasectomy on Tues and my resident said I should do them in the future b/c they are good money makers. I am all about promoting good family planning... & paying off my loans! Is it a common procedure for FPs?
It is. However, there can be some pitfalls depending on your medmal carrier. One of my partners had to stop doing them because our malpractice insurer insisted on charging him the same rate as a urologist, simply because of that one procedure. By that time, he had performed over 600 procedures, and had never even had any serious complications, much less any suits. There's no way an FP could do enough vasectomies in a year to cover the malpractice insurance costs of a urologic surgeon. Reluctantly, he had to stop doing them. It's possible that he'll do them again if we change insurance carriers, or if our carrier ever pulls its collective head out of its hindquarters.
What made me choose FM over IM?
Quite simply, peds and ob. Really, it just came down to realizing I do want to treat kids and I do want to manage pregnancy and labor. IM doesn't do that.
I'm bumping this thread (rather than start a new one) because I'm in the same boat at the moment.
It's the end of 3rd year, and I've spent the past few years feeling certain I wanted to pursue Heme-Onc. I scored well enough on step1 to give me a good shot at IM residencies that would make HemeOnc a realistic option. I've worked on getting LOR's, I've done electives in HemeOnc etc.
But my last IM rotation was at a hospital with an IM residency, I'm a DO student so we don't always get exposure to residents. Anyway, that rotation was pure torture. Partially because the program seems sorta malignant, but partly because I just don't think I care for inpatient medicine all that much.
I've loved my FM and outpatient IM rotations; but have a preference for FM in that regard because the patient population is a little less geriatric, and generally has a little less chronic disease (in my experience so far anyway).
I also loved my OB rotation, and would probably consider that if not for the lifestyle. I didn't mind pediatrics either.
I'm just wondering what I should do. I loved Heme Onc, and I liked the didactic portions of my 1st and 2nd years that death with hematology and oncology. But I hated IM so bad that I worry whether it will be hard to stay motivated well enough to remain competitive for HemeOnc fellowships.
In the meantime, I'm on FM right now, and I'm liking it a lot. I think I can see myself being very nearly as (if not exactly as) happy in Family Med as I would be in Oncology.
Apart from the obvious salary differences, does anyone have any insight into why someone interested in both might pick FM over HemeOnc?
With residency apps coming due I'm in a bit of a panic with respect to my plan going forward.
Thanks in advance!
I had minimal exposure to heme onc. We had a few patients with Sickle cell when I was on Wards, but other than that...
IM was my last rotation of 3rd year, and they were asking for our schedules before that. Peds had been my favorite rotation, and I was pretty sure peds was the direction.
Then I did IM and loved it. Cards was cool, endocrine was like watching paint dry, but what I really loved was the general inpatient medicine.
So, I went back and changed from a Peds directed 4th year schedule to an IM directed schedule thinking I'd be a hospitalist.
THEN I did my AI in wards and realized I missed seeing kiddos, and wondered if I was wrong for not having gone into peds.
Ultimately, family med gave me the mix of everything.
But at the end of my 3rd year IM rotation, I was certain if I went into IM, I would be a generalist. If you have a strong interest in Heme Onc, Med Peds might be a good route in case you get to the end and decide you DO want to do it.
SLC, I think that you know you're probably in an uncommon situation. Heme/Onc vs Family is not something I've heard (ever, maybe, but I only just graduated) anyone decide between.
That being said, don't panic! There are several things you could do this year to figure it out before it comes time to ranking programs.
Probably one of the best things to do is an actual Heme/Onc rotation. As far as I saw in your post you didn't mention a formal clinical rotation. See how you feel about it in actual practice and if you love it enough to overcome how much you disliked IM. (Also remember that programs are different and maybe you can find a program with inpatient you like). I know you probably have a 4th yr sched lined up so it might be difficult to do before apps go out, but I think the goal would be to do it before February when rank happens. You could apply both IM and FM this cycle and then decide which one based on how much you like Heme/Onc. Is it enough to overcome doing an IM residency or can you live with doing FM and never getting a chance at pure Heme/Onc?
I haven't practiced or even done residency yet, so I don't know how much of heme/onc family doctors manage, but I imagine very little. I'm sure they see those patients for other issues, but not ones directly related to their blood disease/cancer.
You could consider Med/Peds like jm192 mentioned above. I....have problems with picking Med/Peds over FM, to be honest, but those are personal feelings. It really depends on what you want to do later in your career. A few caveats with Med Peds: Longer residency, two boards, and should you decide to do fellowship, you may end up having to do two if you decide you want to do Heme/Onc for both children and adults. Also, it's a lot of extra years in residency if you just want to do general practice. For certain things, Med/Peds is a great option. IMO, it's not worth doing unless you have a specific goal in mind (like heme/onc for all ages), bc otherwise ppl usually end up doing general practice or sticking to either IM or Peds. Talk to your advisor/dean/Student Affairs/MedPeds PD (if you have one) to get a better idea of what you would need for ERAS and what rotation you would need before applying. You should still probably try to fit a Heme/Onc rotation in there somewhere.
Sorry I can't help with your actual question of why to pick one over the other. Plus, do you really want some random person's advice on why they picked one over the other? I think the best thing to do is to set yourself up to understand how YOU feel about it. Talk to some attendings in both fields if you can to get a better idea of what they do everyday.
Apologies for the long response. I'm procrastinating...I have pretests to do for my certifications. Blah
Also I totally hated IM inpatient but then ended up LOVING FM inpatient on my AI....so different! I'm pretty sure I want to practice outpatient but inpatient may not end up being as bad as I originally thought after my IM rotation.
This is what I worry about. I hated my inpatient medicine rotation, but I wonder if I might like it more at a better program.
As for hematology-oncology, I have done one formal rotation and it was awesome! I had thought about Cardiology or Nephrology before that, but now if I were going to do an IM fellowship it would have to be HemeOnc all the way.
I wonder if ine of the FM/IM programs would be a good compromise? Maybe those programs (there are only 2 I think) wouldn't be good for fellowship matching?
I think my strategy as of now may be to apply to both IM and FM, but skip the Community IM programs and ones without good track records in HemeOnc matching. Then apply to the FM programs I'm interested in. With the idea that if I don't feel certain I'll match at a good/great IM program that I'm enthusiastic about I'll rank the FM programs highest.
It's the OB, Peds, and Procedures that attract me to FM over Primary Care IM; if I'm not going to be a sub specialist, I'd much rather be a FP than an Internist.
Does that strategy seem legit; or does it sound dangerous?
Also, how competitive is a 227 USMLE1 and 240's USMLE 2 for family medicine as a DO grad?
Your strategy seems pretty reasonable to me if you think you won't make up your mind in the next month or so. Just make sure you can sell yourself to both specialties without sounding fake, and don't apply for both IM and FM at the same institution.
I don't know anything about FM/IM programs since I didn't look into them. No idea if they are competitive or not. I know the EM/FM programs are competitive. Maybe ask around on the combined residency thread? But be careful with that, bc if you interview there then they'll know your whole background thing via studentdoc.
Other DO's will need to take the lead on your last question. I went the allopathic route, but my Step 1 was not so great and I still got plenty of interviews. I have a feeling you'd be fine.
I originally thought I wanted to do IM and do a fellowship in a specific field (I was drawn to GI). Like you, I found that I didn't enjoy inpatient nearly as much as I felt I should in order to become an internist and still be able to enjoy what I was doing. I also felt less enthusiastic about being limited to IM if I did primary care and didn't end up doing a fellowship (which would be a narrower demographic) and found that I enjoy taking care of kids and like the idea of delivering babies, but I don't like either enough to just do one of those things. For me, FP offers a lot of opportunity for flexibility and variety in my career path without having to do a fellowship that would likely lead me to limit my skill-set and scope of practice.
I didn't rotate on heme/onc, but what about it do you like? Do you have a specific interest in the diseases they treat, or is it something about the patient population you like? Within FP, you can likely find a patient population you like working with, whereas you won't likely be able to work with and treat a specific range of diseases.
As for the IM/Peds option, I thought about that a lot too, and ultimately it seemed like FP would be better training if what I mainly want to do is outpatient generalist work (with a primary care focus). Med peds physicians always impress me as very well trained (at least the ones I've met and worked with), but the majority of the residents end up specializing in one or the other.
I also have not heard of someone comparing Heme/onc with family medicine..
They are completely different
-Heme/onc is a specialist - who sees a subgroup of the population and manages a specific scope of diseases. They usually are set as adult or peds. They may further subspecialize into specific heme/onc diseases. It is a area that has constant research/drug development and the field changes every year
-Family medicine in general is the opposite of this. If you are traditional family medicine, you are not bound by ages - "from cradle to the grave". You will often hand off advanced management of disease (including heme/onc) to specialists. The focus of change in family medicine currently is geared towards practice management/PCMH/preventive management
Currently I do peds, adults, OB and procedures (injections, lumps/bumps, and GYN outpt procedures). I would like to add inpatient - but our hospital situation is currently unstable. I feel as if my program trained me well for this.
For me, what I liked about Heme-Onc was a little bit of everything; the patient population was generally very pleasant and for the most part I wasn't seeing a lot of axis II stuff going on there. Similarly to OB, the patients are generally very motivated to do the treatments, and there is something about getting a life threatening diagnosis that in my opinion seems to make people re-prioritize their lives a bit. I didn't have patients getting worked up because we were running behind during clinic, people generally were quite pleasant, and I really felt like they looked up to and respected the input of the oncologist. And believe me, it's not that I need the respect; just that I thought that was one aspect of the patient population that made them enjoyable to work with.
I also like some of the new cutting edge treatments that are always in the pipeline. Both with respect to hematology and oncology. I think it's incredible what people are doing with stem cells these days, and I'd love to be a part of it. I have an acquaintance with horrible IBD who's looking into trying an allogenic bone marrow transplant to cure or improve his disease. The results from trials so far look fairly promising, and the idea that we can harness and alter someone's immune system to fight off autoimmune disorders or malignancy is incredible to me. This is something I could get involved with as a hematologist/oncologist, but not as a FP.
I did some work in Health Promotion and Health Education during undergrad, and one of the courses I was most drawn to was called "Death and Dying". It was an eye-opener for me to see how embracing death and focusing on improving what life is left, can be the best option. I've been very comfortable with mortality during medical school as a result. I think that's a good thing for an Oncologist. Not that I'm callous about it, but I'm not afraid to talk about it.
But on the flip side, I'd have trouble putting how horrible my experience at the IM residency was into words. I even pitied the residents, none of them seemed that happy, and in talking to them they also came off as pessimistic about the future, about my goals with IM, and about medicine in general. I have not gotten that same vibe from the family medicine people I've interacted with.
I really genuinely do love the work that FP's do as well. On a scale of 1-10, if HemeOnc is a 10 then FP is an 8.5-9. I. Really did love OB, but the schedule just wouldn't work well for me and I like general medicine enough that I don't think OB would keep me going; so I think I'm left to FP in that regard.
I really do wonder about a combined FP/IM residency like the one at EVMS. I have way higher than their minimum board scores; and they have taken a number of DO's in the past. I just wonder of I could realistically expect a shot at HemeOnc from that program or of it's best to do a university IM program if I think I need to be in HemeOnc.
This dilemma is really stressing me out...
I should also add that I am very attracted to the shortened length of training in FM vs HemeOnc, and it's training that I'm not worried about hating like I think I might for the IM portion of HemeOnc. Also, school hasn't been cheap, and I have to admit that my ability to pay off my loans is probably what makes FM tough for me to fully embrace; but I've seen reports on here where FP's are doing well financially so maybe it would be OK?
I just keep finding myself getting excited anytime a cancer patient comes through one of my other rotations, especially in IM and FM where a suspected malignancy is on the differential. I get excited not because I want the patient to have cancer, but more because I just think I find cancer and the ways it presents fascinating.
But I have been very very content on Family Med rotations, and as I said before the people (residents included) seem very enthusiastic about it. The patients seem to love their doc's for the most part. And because I do get a little excited when I suspect malignancy, I'll bet I'd get a lot of satisfaction out of helping make the diagnosis through surveillance or just general H&P; especially when it's early enough to expect a good prognosis.
Initially reading this, I felt you're too attached to heme/onc that FM would leave you desiring something. Unfortunately, the paths are extremely different and don't share common ground beyond med school. Go into FM and then decide you want heme/onc means you'll not be able to secure fellowship unless you restart residency as an IM trainee. On the other hand, if you get into an IM residency and realize you don't want to invest your time into the additional 3 years of training for heme/onc you won't be able to see children or women in regards to women's health.
I wish I had more advice, but my gut reaction was you'd be slightly happier with heme/onc than FM.
You could find a patient population that is motivated to do treatments, but I would say on average the majority of patients seen by FM are not very motivated to follow treatments. I also feel out of all the fields, family medicine gets the least respect and you will be disappointed if this matters to you. When I told people I was going into family medicine I was told it was a "waste" of my intelligence, I was asked "isn't there ANYTHING else you want to do?". I also feel in the general population there is not as much respect "ooh you are JUST a generalist".
I would NOT base my decision on the length of training. I feel that people who do this are forgetting that you practice 30+ years - and the additional training only comes up to less than 10% of your future years!
This statement makes it appear that your core interests lay in heme/onc.
I would normally agree, but I'm an older medical student. I'll be 36 when I finish residency, and that's if I do FM. I also have young children, the oldest of which would be 17 when I finished training if I did Oncology. I don't want her entire childhood to consist of me being completely tied down by pre-med, med-school, and residency. I understand that the initial years of practice won't be a walk in the park, but I think they will be better than now. I'll at least be able to schedule time off then!
I think my family would be a lot happier with Family Medicine than Oncology, even though I know they'd be supportive no matter what I wanted to do.
The more and more I talk with people about it, and the more and more I think about it myself, I just get a gut feeling that FM is a better option for me. I am really attached to Oncology, but I think that may be because I've spent the past year and a half convincing myself that was the way I was going. Whenever I think about doing Internal Medicine residency, and even Oncology fellowship for that matter (during the past few weeks) I get a very uneasy feeling. Not so with Family Medicine.
I think perhaps I'll just use my interest in Cancer, and combine it with my background in health promotion as a FP to really try and get my patients to get their health maintenance screenings done. I'll make it my goal to catch cancer in its early stages among my patients.
I think some of the most difficult and necessary aspects of cancer care are in primary care, long term.
Another option would be Med/Peds - you would only lose the OB aspect, plus still be able to specialize (if you want) or go immediately into an outpt/inpt practice with kids/adults
I think the OB aspect is one of the most appealing parts of Family Med for me.
OB or women's health in general? The majority of locations you'll live in the US won't have FM trained docs doing deliveries. You'll either have to do academics or live in a very rural location.
The place I'm rotating at is neither academic or rural, but the FP's do a handful of deliveries each month. It is a multi-specialty group and they are backed up by OB's which makes things better risk-wise (or so they say). Since the OB's are in their group, they are more inclined to help out when needed.
One of my FM colleagues says "If your doctor is IM-trained, you'll die with perfect labs. If your doctor is FM-trained, you'll die with grace, and dignity, and with someone holding your hand."
This is probably a gross over-generalization, but I think it sums up why I'd rather do FM than heme/onc. I liked that heme/onc didn't focus on any one body system (not JUST the GI tract or JUST the heart or JUST the lungs or JUST the kidneys, etc.), and if I had to pick an IM subspecialty, I'd probably have picked heme/onc or ID.
But my experiences with heme/onc during residency and med school just completely turned me off the field. They treated patients without a single thought to the big picture. Even during my med school rotations, I never had any idea where the goal posts were, or if there even WERE goal posts. "We're going to continue chemo"....until? Until her intestines fall out? Until her eyeballs pop? Until Armageddon? And even when I dared to ask, no one could tell me.
It wasn't any different when I was a resident (at a different hospital, with different oncologists who had trained elsewhere). They were scheduling patients to try new chemo regimens a week before the patient died. It was an attitude and a philosophy that I just didn't like very much.
This is probably not true of all heme/onc fellowships or all oncologists. But that was why I don't regret not doing it. Your experience on your rotation may have been very different....
I would say this is pretty common. I once read that the biggest optimist is very close to you, its your local oncologist. I suppose you need to be this way to maintain your sanity, just as some people use offensive humor to cope.
In my experience, we would often get end stage cancer patients who were treated by large cancer centers or private oncologists with "curative" treatment up until the last week of their life. I do not think specialists - and oncologists specifically, are to onboard with end of life care.
Why is the lid nailed onto a coffin? To prevent the oncologist from running one last round of chemo.
My experience was a little different, but I can definitely see what you mean. There were plenty of patients who wouldn't give up on trying to fight their cancer, trying treatment after futile treatment. I was a little disheartened to see the Oncologist acquiesce. I understand the desire to give people in this situation what they want, but I felt that some frank discussions on what was really going on, as well as ways to maximize the livability of the time the patient had left would have been invaluable. It's something I'd hoped to do differently.
One provider was particularly good, after a patient with a myelodysplastic sydrome converted to acute leukemia during the course of 2-3 days (we literally watched his blast count quadruple every 24 hours), he sat down with the patient (who he had known for years by then) and told him "we've always been honest with eachother, and I need to tell you what is happening here and what your options are". The patient wouldn't decide for himself what to do, he wanted the doctor to tell him what he should do. After a long discussion, and an evening at home with his family, the patient decided to spend his last little bit of time with his wife and son at his son's home (which is what the Oncologist thought was best, but couldn't tell the patient to do). He died two days later.
Again, I can see your point. Though I'm not sure I'd need to be the eternal optimist to remain sane in Oncology; but I have some education and interest in end of life issues which many other people may not have going in.
I've wondered if perhaps a Palliative Care fellowship a few years out of FM could scratch that itch should I decide I needed more work with Oncology patients. I spent time in Palliative Care as part of my Oncology rotation, and I really really loved what they do as well.
Sadly, based on what I've seen, the end point was when the client or parent/child yelled "uncle."