What made you decide internal med instead of family med?

Discussion in 'Internal Medicine and IM Subspecialties' started by zambo, Jul 24, 2006.

  1. zambo

    zambo Member

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    For those of you who don't plan on specializing (no fellowship) after IM residency: what thing(s) made you decide to do internal med instead of family med?
     
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  3. maxpower75

    maxpower75 Junior Member

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    Tough question, there advantages to both IM and FP;
    Most people who choose IM over FP with no desire to specialize do not like dealing with children and OB. Also if someone discovers that they do not like outpatient care, most hospitalist are IM trained.
    In my opinion if you are sure you want to do outpatient care, FP is probably better especially if you plan to work in an underserved area, that way you can see the entire family, if you are not sure if you like inpatient or outpatient, and you are considering some sort of specilization, than IM is the way to go.

    Good Luck
     
  4. glorytaker

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    No kids, no pregnant women, almost no surgery. 'Nuff said.
     
  5. Mumpu

    Mumpu Burninator, MD

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    No kids, no pregnant women, better education with the ability to attend an academic institution for residency without becoming everyone's scutmonkey, higher quality of the average colleague, more challenging cases, better income, opportunity to work as a hospitalist.
     
  6. studentdoc29x

    studentdoc29x Junior Member

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    yep. i agree
     
  7. ekydrd

    ekydrd Senior Member

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    Don't forget about med-peds. We can see an entire family, and while we don't do OB (or surgery for that matter) neither do most FP's who practice primary care in underserved areas, as the cost of malpractice is often inhibitory to such practice. I plan to work in a rural, underserved community as a hospitalist/ER physician/clinician, and feel my med-peds training is perfect.
     
  8. zambo

    zambo Member

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    Since general IM is "adult" medicine, doesn't it also include gynecology for adult women?
     
  9. esposo

    esposo Member

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    A med-peds residency is much harder than a family practice residency. It's one year longer and your lifestyle is pretty harsh considering you don't get the elective months that both IM and Peds residencies get since you are completing core months in the other residency. And for all intents and purposes, you are seeing the same types of patients. The only difference is med/peds affords better training particularly with seeing admitted patients in a hospital setting. But in a private practice outpatient setting, you don't have any real benefit to getting into med-peds. A lot of people do med-peds because they want to make themselves more competitive for fellowship or have the option of practicing emergency medicine. Also, most med-peds residents feel their training is more medicine based and don't feel as comfortable on the pediatrics side because it's almost impossible to become an expert in both fields in 4 years.
     
  10. esposo

    esposo Member

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    No! Gynecology is practiced nearly exclusively by OB/GYN. Some internists will choose to do pap smears but the vast majority don't particularly in today's litigious society. Most internists will just refer that patient to an OB/GYN.
     
  11. esposo

    esposo Member

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    A lot of people have answered your question but I can summarize what they said. A lot of internist would rather avoid seeing women and children so they can focus on adult medicine. Internal medicine is a specialty like pediatrics in which you focus on adult medicine so you are much more specialized than a family practice physician. You can also practice as a hospitalist since internal medicine trains you in a ward setting whereas in family practice, you have very few months set aside in the wards. Then there is the issue of training. Many feel family practice is just an extension of 3rd and 4th year of medical school in that you spend different months focusing on a different field of medicine during your training. Internal medicine offers a more formal albeit grueling lifestyle of training in which your training centers around the wards and taking care of really sick patients that have been admitted. So many physicians like having the ability to take care of really sick patients that need a lot of supervision.

    The advantage of family practice is the lifestyle. You will be much less stressed both mentally and physically as an FP resident versus a medicine. And many people dismiss FP because it is less prestigious when in reality, it's probably a better option if they are going to practice in a clinical outpatient setting. You really don't need the expertise required to see really sick patients in a ward based setting since most of your patients will rarely if ever be that sick. Most internists in private practice settings have hospitalists working for their group so they just refer their really sick patients to them. It's rare that an internist will admit his own patients and tend to them on the wards these days. So for all practicality, internists see the same patients as FP with the exception of women and children. Of course, ideally, you want to have the most knowledge possible to better serve your patients. But realistically, most internists will forget their ward based expertise if they have been in an outpatient setting for years as most of their patients will suffer from the same bread and butter issues that FP patients have. If I knew that I wanted to be done in 3 years and start my own practice or serve patients in a clinical outpatient setting, I would go into FP versus medicine or even med/peds. Why would I go through all that torture if I'm going to practice the same form of medicine and see the same patients.
     
  12. AJM

    AJM SDN Moderator
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    Unfortunately, yes. Although, the gynecology that internists practice is pretty basic -- usually just doing paps and treating vaginoses. Most other gyn issues internists will refer to ob/gyn. The nice thing about gyn in IM is that alot of internists work with NPs who will do the pap smears for them, along with other basic exams to free up time for the internist to do things that they really want to do.
     
  13. jocg27

    jocg27 Senior Member

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    Adult medicine = adult male medicine?
     
  14. PELE#10

    PELE#10 Senior Member

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    I thought FM docs work as hospitalists as well??
     
  15. gutonc

    gutonc No Meat, No Treat
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    No (alhtought a literal interpretation of the parent statement would assume that). IM = medicine for adults and most IM docs either prefer not to do, don't know how to do or completely forget to do routine GYN screening and care for their female patients. HTN, DM, cardiac, GI and pulmonary issues are no problem (regardless of the gender of the patient) but most internists don't even think about going "down there" let alone doing routine breast exams or counseling. All too often that part of the H&P boils down to "when was the last time you saw your OB/GYN? you should make an appointment soon.". It's not something we're routinely trained in. More programs are adding Women's Health tracks or ambulatory rotations (required or optional) in a general OB/GYN setting but those are still the overall exception rather than the rule.

    Another "problem" with this is that many of us (myself included) have our continuity clinics in VA hospitals. Although the patient mix is changing, the overwhelming majority of VA patients are older (Vietnam era and older) men with a varying mix of HTN, DM, CHF, COPD and various other chronic conditions. When 95% of the patients you see are old men, when a younger woman comes into your clinic it can be easy to forget what a big difference that extra X can make.

    BE (now PE)
     
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  17. AJM

    AJM SDN Moderator
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    I disagree that IM physicians are not routinely trained in general Gyn. It is an ABIM requirement for IM residencies to provide training in general Gyn exams and basic Gyn problems, along with other women's health issues. Gyn/women's health topics are featured prominently in the ABIM board exam, so we are clearly required to be familiar with them. At most resident IM clinics, residents routinely perform their own pap smears and breast exams. For residents that have a VA clinic, programs usually require them to also spend time at a women's health clinic in order to satisfy the ABIM training requirements. If you're at a VA clinic, and your program is not providing you with this aspect of training, they likely will be cited on this in their next ABIM program review.

    There tends to be a large difference between male and female internists as to how many gyn exams they tend to do both during and after residency. This is usually because of patient preference to have a female physician performing their pap smear. Most practicing female internists I know do their own pap smears for their patients rather than refer them out. As I had mentioned previously, because paps are slightly more time consuming and require less intellectual effort than regular patient visits, many internists will work with an NP who will do these exams for them. But to say that internists are not trained in this aspect of primary care is inaccurate.
     
  18. signomi

    signomi Amongst the Gravelings

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    This is very true. I worked in an office full of male practitioners who referred all paps to ob-gyn and all gyn acute complaints to the PAs/NPs. I did all my own unless the patients were >300 pounds because we had only one type of speculum. (I'm female.) I think that is why I ended up with a lot of female patients...they liked the convenience. And for the ABIM you must be signed off on 5 breast exams, 5 rectals and 5 pelvics including wet mount.
    On another note I spent a month on adolescent gyn and saw an 8 year old with genital warts. :eek: I could never do FP or peds! I prefer purely adult dysfunction!
    I think IM or MedPeds offer you more opportunity down the road if you change your mind and decide to pursue most fellowships. Some like sports medicine you can do from FP.
     
  19. ramonaquimby

    ramonaquimby I'm a PGY3?! WHAT?!

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    perfectly stated. :thumbup:
    i'm interested in 'adolescent and women's health'...i could have chose IM or FP. it was a toughy, but in the end, my reasoning was just what you stated, and i haven't looked back since.

    if one wants to become a hospitalist for sure or possibly specialize, go for IM in a heartbeat. if you know you love outpatient mediicince, even if it's adults only you want to see, do FM and use all your electives for adult subspecialities/ward months. you can't lose! :D
     
  20. sophiejane

    sophiejane Exhausted
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    Actually, I beg to differ. You can do as much OBGYN as you want with Family. There are women's health tracks at some FP residencies that give you training in colposcopy, LEEP, etc. Even without that, it's not at all uncommon (particularly for female FPs) to have a large number of Gyn and/or OBGyn patients.
     
  21. sophiejane

    sophiejane Exhausted
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    Pretty much everything in this post except the "no kids, no pregnant women" is without basis in the truth.

    Better education depends on the program. There are plenty of FP programs that rival IM programs in depth of experience caring for sick patients in the hospital. I've seen some pretty abysmal IM programs. Just being IM doesn't make the education superior.

    There's no scutmonkey-ing at unopposed programs, which are pretty much the only programs that people serious about becoming competent FP's are looking at nowadays. The big academic programs where FP is the redheaded stepchild are going the way of the dinosaurs (see Duke FP closing as a recent example). Most opposed academic programs go unfilled or fill with FMGs. The opposite is true with the stronger unopposed programs.

    The most recent numbers put FP at an equal or higher average income than a general internist. The potential to make more money in FP exists because of the breadth of experience and procedures. The bottom line is what you can bill for, and a general internist gets paid exactly the same thing for a routine visit or hospital visit that an FP does.

    FP hospitalists are working happily all over the country and making a fine living.

    Ultimately, it's a question of where you feel most comfortable, and that may not be something you are really sure of until you are into your 4th year.
     
  22. gutonc

    gutonc No Meat, No Treat
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    Totally OT here but what does opposed vs. unopposed mean? Just curious.

    BE (now PE)
     
  23. Blue Dog

    Blue Dog Fides et ratio.
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    An "unopposed" residency is one in which your program is the only residency (or one of only a few) in the facility. The generally leads to a better training experience, as you're not competing with other programs for patients and procedures. When I was in residency, there was just the FM residency, a transitional program, and an OB residency. So, we pretty much did everything.
     
  24. sophiejane

    sophiejane Exhausted
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    For example, the program where I'm doing an IM Sub-I right now is opposed. The senior on the IM on call team is supposed to give every 3rd admission to FP, but it's more like they pick which admissions they don't want and pawn them off to FP at a ratio of 3:1. You can imagine that the FPs don't get the most interesting cases. Good for me on my Sub-I. Would be bad for me if I did FP there.

    Any time you have another residency competing for patients in any department, it's bad for FP, but it seems especially bad if it's IM vs FP.
     
  25. DrMom

    DrMom Official Mom of SDN
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    It is bad if IM (or any other service "sharing" patients) gets to cherry-pick their admissions. At my facility there is a ratio of IM:FM admissions from the ED (can't remember exactly what it is, but something similar to the 3:1 you're seeing), but it is randomly assigned based on the ratio. Neither services get to choose which particular patient goes to which service.
     
  26. sophiejane

    sophiejane Exhausted
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    That seems a lot more fair. I think there are some issues between upper level administration in FM and IM at this program...regardless, it's a huge red flag for me in making decisions about residency.
     
  27. gutonc

    gutonc No Meat, No Treat
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    Thanks, that's kind of what I thought but I wasn't sure. Our FM program (or rather, the FM program at the hospital where I'm in IM) has what seems like a good compromise at least as far as the adult inpatient stuff is concerned. Of the 5 general medicine teams at each hospital, 1 is made up of FM residents/interns. They take call in the normal rotation with the rest of the teams and admit any and all comers on their call days. Patients admitted to their service who don't have PMDs are then referred to the FM service for follow-up after discharge. There's also a FM service for FM patients admitted to the hospital.

    Not sure how it works in the OB or Peds parts of the program. May not be as good.

    One thing I really liked about having FM patients in the MICU last month was that the FM teams were doing social rounds on their patients in the unit, reading the charts every day. This meant that when I had to transfer and sign out patients to the team they knew what had happened during the MICU stay and it made sign out a breeze.

    BE (now PE)
     
  28. ekydrd

    ekydrd Senior Member

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    Yeah, and that's why I have to have the pelvic and Pap smear completed BEFORE I refer my pt's to OB/GYN... because I'm "just" an internist.
     
  29. sophiejane

    sophiejane Exhausted
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    Not doing a pelvic/pap before referring a patient to Gyn is like not doing an EKG before referring to cards. There's absolutely no reason why IM can't do basic preventive medicine for women as well as men.

    It's like the old rule about DREs: the only reason not to do a pelvic is if she doesn't have a vagina or you don't have a hand.
     
  30. DrRobert

    DrRobert Day or Night

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    I've never met an internist who does not do paps when indicated. For certain presentations of abd pain, a pap is part of the standard of care. Shipping that patient to an OBGYN without doing the pap is poor form.
     
  31. RuralMedicine

    RuralMedicine Senior Member
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    I'd argue that a speculum and bimanual exam would be more valuable in your workup of abdominal/pelvic pain than a pap smear. Pap utility is to identify cervical dysplasia/ cervical cancer (more likely to present with dyspareunia and post-coital bleeding) than abdominal pain.

    On the original topic I think you can do decent women's health as an internist if you seek it out as a resident. Honestly it wasn't particularly something I was really invested in doing when I started practice. Sure I'm comfortable with paps/ pelvics and I did a fair amount of colpo and endometrial biopsy as a resident but I never thought I'd do either after. (Honestly if I practiced in an area with a gynecologist I wouldn't be doing it either. I'm only considering doing more colpo now because there is a need).
     
  32. novacek88

    novacek88 Senior Member

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    Where do you live? I have never met an internist who doesn't refer his patients to OB/GYN for womens health issues. If you live in a large metropolitan city, it's rare that a female patient doesn't already see an OB/GYN. I don't know any internists in my area that perform a pap and pelvic. And to be honest, I think it's in the patient's best interest that you refer them to an OB/GYN. I think that's better than trying to be greedy and charge for an additional procedure that you rarely perform.
     
  33. novacek88

    novacek88 Senior Member

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    Of course, and there is no reason why I can't perform a skin biopsy either. But again, it comes back to what's in the patient's best interests, not what's in the physician's best interests. Should I perform the biopsy or should I refer the patient to a dermatologist who has more experience and skill in performing them. I have no hesitation referring female patients to OB/GYN for womens health issues because that is their area of expertise and the patient would benefit the most from being in their care. Furthermore, you act like pap smears are an uncomplicated procedure. False positives and negatives are common in regards to these procedures. An OB/GYN is better adept at handling any possible complication when interpreting the results of a pap smear.
     
  34. Blue Dog

    Blue Dog Fides et ratio.
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    Well, they are...to those who perform them regularly. So are skin biopsies. ;)

    If you're not comfortable performing them, of course, you should refer. This stuff is bread and butter in FP, though. I do Paps and skin biopsies every single day. Of course, I'm also prepared to handle the follow-up.
     
  35. novacek88

    novacek88 Senior Member

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    This is pure rubbish. IM is trained on ward based medicine. I challenge you to compare any FP schedule with any IM schedule and you will see the disparity in the number of ward months, ICU months etc. This is like saying that some Family Practice programs rival General Surgery programs in regards to surgical training depth. On the flipside, as DO's, we are both aware of the many osteopathic FP programs that are basically fulfilled out of someone's private practice. A lot of these programs have difficulty filling and their training is very very loose. There are many FP programs that have ridiculously easy call schedules too. St. Josephs hospital in Houston offers a Q8 schedule to its interns. The overwhelming majority of FP residencies are not unopposed programs. The majority offer very weak inpatient training.

    Uh could you provide these so-called "recent numbers" because all of the factual evidence I have read says otherwise. Here is one off the web that shows General Internists earning more than FP

    http://www.allied-physicians.com/salary_surveys/physician-salaries.htm

    Uh...no Most FP in big cities drop OB from their practice because they don't have enough OB related patients to justify the higher malpractice premiums. It's rare that you will see FP in major metropolitan cities practicing OBGYN because it's not feasible. Making blanket statements like "You can do as much OBGYN as you want with Family" is completely assinine. It depends on where you choose to practice.

    Where??? Again, evidence would be nice. Show me an FP hospitalist working in NYC, SF, downtown Chicago and Boston? No reputable hospital in one of the 4 largest cities in the United States would consider hiring an FP as a hospitalist.
     
  36. novacek88

    novacek88 Senior Member

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    Kent

    My apologies but I was disturbed by Sophie's tone and loose presentation of the facts.
     
  37. Blue Dog

    Blue Dog Fides et ratio.
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    Well, I deleted my post right after you quoted it, apparently. I don't want to see this thread turn into a pissing contest. I've read the thread, and I think you're overreacting. Take a few deep breaths and think about why anything she has posted bothers you in the first place.
     
  38. novacek88

    novacek88 Senior Member

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    While I may have overreacted, it is irresponsible for someone to hyperbolize and embellish the truth to prove a point. I think you are naturally biased because you are in FP but to an internist such as myself, an FP implying that their training is on par with ours in regards to ward based medicine is pure bunk.
     
  39. Blue Dog

    Blue Dog Fides et ratio.
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    I don't think anyone is disputing the fact that internal medicine residents do more inpatient months than family medicine residents. However, that doesn't necessarily mean that a well-trained family physician isn't going to be equally capable of caring for hospitalized patients. Training is as much about quality as it is quantity.
     
  40. novacek88

    novacek88 Senior Member

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    I'm sorry but that would be like suggesting an FP could become as skilled at reading films as a radiologist if they had quality training regardless if they spent significantly less time looking at films; that's the jist of your argument. The volume aka "quantity" is what makes you successful as an internist. It doesn't matter how well someone teaches you something, you don't become adept at it unless you spend time doing it. An internist has devoted more time to training in inpatient care so it shouldn't suprise anyone why they are better equipped to deal with hospitalized patients. It's not a difficult concept to understand. No one is arguing that family practice physicians are incapable of properly caring for hospitalized patients. But to suggest their ability to care for them is on par with that of an internist is silly.
     
  41. Blue Dog

    Blue Dog Fides et ratio.
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    I think we're all in agreement on that.

    I'm not going to turn your "quantity" argument around and suggest that FM can take better care of outpatients because we spend more time doing that in residency compared to IM, because that would be wrong. I don't really think one can accurately make blanket statements that apply to inpatients, either, based solely on whether one trained in IM or FM. There are too many individual variables.
     
  42. jocg27

    jocg27 Senior Member

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    Not to be a pain or anything, but just a random, basically irrelevant point...Those aren't the four largest cities in the US. SF and Boston are not even close, really.

    Have a nice day :)
     
  43. sophiejane

    sophiejane Exhausted
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    I think there is some miscommunication here in that when we refer to an FP hospitalist, my understanding was that most people assume that they have done a hospitalist fellowship. So, that's an extra 12 months of inpatient medicine. I think that would catch them up just fine with their IM hospitalist colleagues if they had any deficits going in.

    I would be surprised if there are many FPs who apply for hospitalist jobs without that extra year, but this is conjecture on my part.
     
  44. sophiejane

    sophiejane Exhausted
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  45. sophiejane

    sophiejane Exhausted
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    If you read my post, you'll see I never made such a broad statement. I said that SOME FP programs rival (meaning are comparable to) IM training.

    I'm not saying FP=IM. As Kent said, FPs have more outpatient training than IM. And I don't disagree that most opposed programs don't give FP residents enough time on the wards.
     
  46. sophiejane

    sophiejane Exhausted
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    FP (with OB) $182,000 $204,000 $241,000
    FP (w/o OB) $161,000 $135,000 $239,000
    FP - Sports Medicine $ 152,000 $208,000 $363,000
    FP - Urgent Care $ 128,000 $198,000 $299,000
    Internal Medicine $154,000 $176,000 $238,000
    IM (Hospitalist) $161,000 $172,000 $245,000

    This was cut and pasted directly from the link you provided.

    How did you get the impression that IM makes more than FP?

    A hospitalist may make on average a few thousand dollars a year more than FP w/o OB, but other than that, after three years, it's pretty obvious that there are more opportunities to make more money as an FP than as a general internist.
     
  47. sophiejane

    sophiejane Exhausted
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    Here's a link to a job board on the Society of Hospital Medicine website. It appears that there are hospitals in the Bay area, Sacramento, Denver, Houston, Dallas, San Antonio, and Detroit seeking FP boarded hospitalists.

    Are those in your required "4 largest cities?" I'm not sure. I don't know what those cities are. Do they fit your description of reputable? Again, you'd have to elaborate on that. Furthermore, most hospitalists do not work in the top hospitals in the largest cities, simply due to the law of supply and demand.

    http://careercenter.hospitalmedicine.org/search/results/?job_category=6794&ss=0&sec=browse

    ps: just found out (I'm learning so much from this discussion!) NYC #1, Chicago #3, SF #13, Boston #24

    http://www.infoplease.com/ipa/A0763098.html
     
  48. novacek88

    novacek88 Senior Member

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    If you look at the data The FP w/o OB earn less than general internists after 3 years, about 37,000 dollars less: 172,000 vs. 135,000 for FP. The majority of FP do not practice OB and an increasing number are dropping OB from it's practice due to increased malpractice premiums. It would be foolish to compare FP w/OB to General Internists since the majority of FP do not practice OB.

    FP -Sports Medicine is not a fair comparison because many of those FP pursue fellowships so you might as well compare them to Allergists or Cardiologist. Furthermore, Sports Medicine and Urgent Care medicine are also practiced by internists. Just because the salary survery doesn't show "IM- Urgent Care" and "IM-Sports Medicine", don't assume the field is limited to FP.

    Here are 6 more links in which IM is reported to earn a higher avg salary than FP. The first link even states IM earning more than FP w/OB, go figure. Likewise, why don't you provide 6 links in which FP is reported to earn more than IM. Thanks

    http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm

    http://www.physicianssearch.com/physician/salary2.html

    http://jacksonandharris.com/physicians/salarytool.aspx

    http://www.faqfarm.com/Q/What_are_the_highest_paying_jobs

    http://www.deltamedcon.com/MHC/MHC2.asp

    http://www.acinet.org/acinet/oview5.asp?next=oview5&Level=Overall&optstatus=&jobfam=&id=1%2C&nodeid=7&soccode=&stfips=00&x=37&y=10
     
  49. novacek88

    novacek88 Senior Member

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    The 4 largest cities in the United States are NY, LA, Chicago and Houston. Please show me an ad that from a hospital located in one of these cities that requests the services of an FP Internists. More importantly show me a profile of an FP internists practicing in a hospital in one of these cities. I don't want to read about some shady recruiter site advertising for an FP internist. Please locate one that actually functions in this role at a major hospital.
     
  50. novacek88

    novacek88 Senior Member

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    Not to rub it in....but okay to rub it in just a little. :)

    http://www.merritthawkins.com/pdf/2005_Modern_Healthcare_Physician_Compensation_Review.pdf

    Below are 7 companies that compile salary information

    Internal Medicine/ Family Practice
    AMGA 180,800 / 177,900
    MGMA 175,935/ 173,500
    Sullivan 167,270/ 166,631
    Merritt 161,000/ 165,135
    Hay 179,900/ 164,708
    HHCS 168,066/ 156,791
    Warren 163,250/ 150,000
    (range: 163,250-180,000)/ (range: 150,000 - 177,900)

    Merritt was the only company in the above 7 that stated FP earned more than IM on average. In some surveys, the difference was fairly significant.

    Would you like more examples or are 7 resources enough? I'm sure I could provide more if you wish.

    Anyway, I made my case. There is nothing more left to say. You can try to argue than a "FP with urgent care training still earns more than a general internist" and I can show you a cardiologist that is earning a 7 figure salary. In general, Internists earn more than FP. I'm sure there areas of the country in which FP earns more but ON AVERAGE, an internist earns more. You may have the last word because this discussion is closed. I'm out
     
  51. skypilot

    skypilot 2K Member

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    Yeah, I would like the dollars per hour worked. That is the most important one. A doc can always make a few more dollars by putting in more hours. Maybe the IM docs shown were working 70 hours a week.
     
  52. novacek88

    novacek88 Senior Member

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