What makes FM residency challenging?

[DrMDAware]

To preface, I am writing this since my partner is going into FM and starting intern year next year. I am in IM and wanted to try and understand what she'll be going through next year so I could better understand and empathize with her.

And for the record I think primary care has a huge impact and I am grateful for those who do it well.

To me, it would be very challenging to be able to handle peds to adults to pregnant adults to the elderly. That is a ton of pathology! And especially to do this all in 15 minutes at a time. I remember from med school how FM would have to cover OB, GS, and IM (inpatient services) in addition to their outpatient clinic.

For those who are in FM, what things make it challenging that an outsider like me doesn't see?

I 'get' the following:
- Surgery: no sleep, super long hours, attendings who belittle
- Rads: tons of reading at home, every one wants it read right now
- EM: juggling a drug seeker, running a code, having sleep/wake cycle flipped around constantly, writing a note 10 hours after you saw a patient
- IM: notes, discharge summaries, labs to follow up on, consults to place, pages to answer, long call, no sleep

Please help me to understand.

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[JustPlainBill]

Well, think of it this way....you are expected to be at level of the residents of the service you are on time in grade wise....for example....say peds is your last rotation of first year...you are expected to perform as a peds intern at the end of their first year.....if your icu rotation is in 2nd year, you are expected to perform as a 2nd year im resident.....and still function well in your weekly clinic no matter what rotation you are on.....

Jack of all trades, competent in all, most looked down upon specialty that's being threatened to be replaced by someone with 700 "clinical hours".....

 

[AFMD]

At some Family Medicine residencies the scope is hard to get used to. During a night shift you could run a code, send someone to the ICU, manage sick floor adult/peds/OB patients, admit complicated adult/peds/OB patients, take a million answering service calls, triage a million OB patients, manage labor, deliver a baby, manage a postpartum hemorrhage, fly sick kids or OB patients in bad shape to the city (I guess you'd deal with these differently if you were in a bigger place) etc. etc. During ER rotations, or if you moonlight in the ER, you do ER shifts. You could do ICU shifts (on our ICU rotations we have a lot of supervision, so not very stressful). Not to mention clinic multiple days a week. It's a lot of stuff. The hardest part for me is never knowing when one of your OB patients will deliver. It's not all the time, but it's hard to sleep well when you can get a call anytime and have to come in. Sometimes I think about what it would be like to do IM, just adult clinic/hospital. It has to have it's own challenges though.

 

[smq123]

To preface, I am writing this since my partner is going into FM and starting intern year next year. I am in IM and wanted to try and understand what she'll be going through next year so I could better understand and empathize with her.

And for the record I think primary care has a huge impact and I am grateful for those who do it well.

To me, it would be very challenging to be able to handle peds to adults to pregnant adults to the elderly. That is a ton of pathology! And especially to do this all in 15 minutes at a time. I remember from med school how FM would have to cover OB, GS, and IM (inpatient services) in addition to their outpatient clinic.

For those who are in FM, what things make it challenging that an outsider like me doesn't see?

I 'get' the following:
- Surgery: no sleep, super long hours, attendings who belittle
- Rads: tons of reading at home, every one wants it read right now
- EM: juggling a drug seeker, running a code, having sleep/wake cycle flipped around constantly, writing a note 10 hours after you saw a patient
- IM: notes, discharge summaries, labs to follow up on, consults to place, pages to answer, long call, no sleep

Please help me to understand.

1. It depends on the program. Yes, there is a stereotype of FM residencies being nurturing, kind, compassionate places. Not all are, just like not all surgery residencies are malignant. Some are great, some are not. This is, of course, no different from any specialty.

2. Outpatient clinic carries its own challenges. Some programs expect you to function like a private practice attending - keeping up with all your messages, tasks, and labs (even if you are in the hospital at the same time).

3. Constantly being off-service sucks sometimes. I remember my OB/gyn rotation as an intern - I didn't have a name that month, I was just constantly referred to as "the FP intern."

4. The hardest thing about primary care, in general, is that there are a ton of gray areas. Sometimes more than in other specialties.

In the hospital, you can order a bunch of tests, and feel reasonably assured that they will be carried out in the next 24 hours. In outpatient primary care, you have no such assurance. The insurance could deny the test. Maybe the only outpatient facility that does that test is 45 miles away and they can't get transportation there or can't get a babysitter to watch the kids. The patient could decide that the co-pay is too much. Maybe the patient misunderstood your instructions but was too embarrassed to say so.

A lot of subspecialties have far fewer gray areas - for example, by the time the oncologist sees the patient, the diagnosis has already been made and now it is just a question of the appropriate treatment. In primary care, almost NOTHING comes to us "solved." Even patients who are dispo'ed from the ER often do not have a diagnosis, they have just been told to go home because there is no immediate emergency (which is reasonable, even if the patients don't always see it that way!)

5. Your partner will have to know a lot about things that he/she may not even think that they need to know. I have so many patients who come to me who saw the specialist and say, "But I don't understand what the specialist told me and they didn't leave time for questions. Can you explain it to me?" So I've had to explain radiation cystitis to them. Or I've had to explain how a knee replacement works, or why their hip hurts even though the surgeon operated on their ankle. Or I've had to explain that their CHF is probably a side effect of their adriamycin and I don't think that that is fixable. Or why their symptoms are due to a leaky heart valve. Or the significance of the polyp that was removed from their colon.

 

[JonMonkey]

As someone who just finished their FM residency I agree with all of the above. Your partner is going to have to learn a lot about a lot of things maybe not to the extent that an IM, peds, OB or surgeon has to but they definitely have to know as much as the other specialty resident counterparts. The logistics of doing all this away from one site or another compounds the situation especially when considering various EMRs, access to resources, travel, etc. The biggest thing for you I guess would be to realize this and provide support along the way. Don't assume like may others that FM is easy or not as difficult, which it sounds like you do. Share resources along the way that you found helpful.

 

[JustPlainBill]

I just thought of something -- just for s***s and giggles, if you've got a friend who's an FM attending and up for shadowing -- see if you can shadow them -- then ask if they can do (they'll know which patients they can pull this off without exciting them too much) an FM attending stream-of-consciousness with respect to the considerations that fire through their head as they're seeing a patient --- I typically verbalize this when I get a patient who's Dr. Google and confusing a Google Search with my medical degree -- they tend to ask me to shut it off after I get through the top three kill-you-in-either-2days-or-very-slowly-and-painfully diagnoses that I've ruled out....works well....

Anyway, gotta go....

 

[FrustratedFamDoc]

To preface, I am writing this since my partner is going into FM and starting intern year next year. I am in IM and wanted to try and understand what she'll be going through next year so I could better understand and empathize with her.

And for the record I think primary care has a huge impact and I am grateful for those who do it well.

To me, it would be very challenging to be able to handle peds to adults to pregnant adults to the elderly. That is a ton of pathology! And especially to do this all in 15 minutes at a time. I remember from med school how FM would have to cover OB, GS, and IM (inpatient services) in addition to their outpatient clinic.

For those who are in FM, what things make it challenging that an outsider like me doesn't see?

I 'get' the following:
- Surgery: no sleep, super long hours, attendings who belittle
- Rads: tons of reading at home, every one wants it read right now
- EM: juggling a drug seeker, running a code, having sleep/wake cycle flipped around constantly, writing a note 10 hours after you saw a patient
- IM: notes, discharge summaries, labs to follow up on, consults to place, pages to answer, long call, no sleep

Please help me to understand.

I'm really not getting defensive, but how can you list 3-4 things that you think are challenging about FM but then 3 lines later ask "what things make it challenging that an outsider like me doesn't see?"

You've sort of already answered your question.

Here's what makes it a challenge for me. There is no cop out for basically anything your patient brings you. Even on things you're planning on turfing, the expectation is that you at least do somewhat of a workup before sending on to a specialist. Your morbidly obese, horribly controlled diabetic, chainsmoking patient comes in for a f/u on their 4th SSRI (you know, 'allergies' to the last 3) in the last 6 months with a BP 185/110 and chest pain but they really just want to talk about their back pain and how nothing seems to be helping their nerves here lately.

Cards guy would get BP right, ekg, stress test and maybe smoking cessation and "you should talk to your family doc about your pain/nerves."
Pulm: PFT, stop smoking, and here's your Steroid/LABA
Pain doc would keep writing narcs as long as insurance and UDS comes back right (not all, but most, unfortunately)
Psych may or may not consider mood stabilizer

You're expected to be in and out of that room in 20 minutes (to appease your corp med overloards) with what will likely be a 4-6 week f/u so you can go over the same stuff again, if you're lucky.

Now of course this isn't all of primary care/family medicine, but it still represents quite a bit of it.

 

[letsdoit]

Just imagine running up to the OB floor in the middle of your outpatient clinic because you got word that your continuity delivery just went into labor. LOL! There were times when I felt like I wasn't smart enough for the breadth of knowledge. I still do, even after residency LOL☺️! But then again, I know docs who practice cradle to grave medicine and never ceases to amaze me how they can do so in today's day and age.

 

[DocWeeaboo]

Amen to all of this.
I never realized how much I needed results and fixes and gratification of a job well done until I experienced the utter absence of these as a family medicine intern.
Surgeons get to close; specialists get to escalate the protocol and say "see your PCP" for everything not on the protocol; OB's job is done once the baby's out. All these specialties have an end point, "you don't need to see me anymore", a minute of success.
As a family medicine doc, it's never ending. Patient can come up with complaint after complaint, and guess what each one of those is your problem! You never get to say, "you're healed!" or "not my problem". I don't get the satisfaction of closing the chapter. Turns out that's important to me.
Now I have to find a way to grind through the rest of intern year and 2 more years of residency so I can pay off my loans and retire to urgent care at age 30.