Why can't urban and suburban FPs get to do all the procedures the rural FPs do?

[sophiejane]

I am starting this thread because one thread is already fully hijacked and one is in danger.

I think this is a worthy discussion...let it evolve into a discussion on p4, I don't care.

For my part:

I believe that there is no point in FPs trying to compete with specialists. I know that if I personally had the option of seeing my FP for an emergent appendectomy or a general surgeon, both were located the same distance from the hospital, knowing all I know, I would choose the surgeon.

And I'm about as big of a flag-waving FM fan there ever was.

It's a matter of supply and demand. I would not expect to have the same practice in the city that I'd have in the country because it wouldn't make sense to me. Where there are abundant specialists, they should be able to do their thing.

Now, if I live and work in an area where I can do enough scopes and deliveries and colpo to not only keep my skillls up but also to serve an actual need in the are, sign me up.

To try to have this macho-superhuman-full-spectrum-jack-of-all trades, "lie down in the back and I'll cut out your appendix after I do this throat swab" kind of practice in suburban Houston is kind of a fairy tale.

And just to be clear, there ARE programs that will train you well to do all that. That shouldn't even be the argument. Check out Ventura County, JPS, etc. The point is, where are you REALISTICALLY going to do all these sexy procedures when you are done?

You might be able to do some of them in a rural area, or some in a city, but you cannot do it all, all of the time.

---

Members don't see this ad.

 

[wasatch]

What makes you sooo different than an NP or PA then, if you don't actually provide all the above mentioned services?

 

[sophiejane]

What makes you sooo different than an NP or PA then, if you don't actually provide all the above mentioned services?

Kent, brother, where are you?

If you would like to do a search, this particular topic has been discussed on this and quite a few other forums. Not going into that again.

It appears to me that you are saying that a residency-trained FP who does not do ALL the procedures they were trained to do in practice is somehow equal to a PA.

This is so far out in left field I can't even find the words....

Maybe after dinner, and several drinks...

 

[wasatch]

Maybe you just like to sit on your butt all day writing scripts like a NP or PA...fine...you were way overtrained and should have just gone to those schools. It is thinking like yours that has left Family Medicine in the position they are in now.

 

[Miami_med]

At risk of giving away too much information about where I'm coming from, I'll continue the conversation from before. There is an attorney in my family (no he is not me, but he does exist). He graduated from a very high level law school but soon became disenchanted with the high level specialist firms that he associated with and struck out on his own. He took all the business that came through the door. He sold real estate, wrote contracts, did estate planning, went to court, and even got involved in constitutional disputes. He was small for many years, and he often just scraped by. He had a general practice in a downtown suburb in one of the top 10 LARGEST metropolitan areas in the country. The area is loaded with attorneys. It is saturated with specialists. It is so saturated that the lawyers fill afternoon TV with nothing but advertisements looking for work. Yet, his business grew. Why? He took EVERYTHING he could. He became a one stop shop. Sure, he referred out things that were just so far over his head that he couldn't learn them as he went, but they were rare. People would drive by the specialist's offices and come see him, and they would come back again because they were satisfied.

If you think that some aspects of the law that he covered are any less complicated than much of what we do in medicine, you'd be wrong. If you think that most people in law don't eventually specialize, you'd also be wrong. He didn't, and he has recently put together a thriving business. That's how I would like to see FM. Sure, it would be ridiculous to have FM trying to valve replacements or AAA repairs, but there is no reason that a single doctor couldn't handle the everyday things that most families deal with regularly, including intern level surgery. There are surgical PAs doing appys. There is no reason a trained FP couldn't do them. That's just an example, but I'm trying to prove a point.

I really don't know how to make it more clear.

 

[sophiejane]

Maybe you just like to sit on your butt all day writing scripts like a NP or PA...fine...you were way overtrained and should have just gone to those schools. It is thinking like yours that has left Family Medicine in the position they are in now.

Like I said, you should read my previous posts. I intend to do full-spectrum rural FM with surgical obstetrics and colonoscopy, pending the need for these in my area. But I will definitely seek out jobs that allow me to do these, and specifically chose my residency program because it offers excellent training in both.

As an Advisor, I will remind you to remain courteous. There is a difference in what I said and in slinging insults with implied profanity.

Carry on, please.

 

[sophiejane]

If you think that some aspects of the law that he covered are any less complicated than much of what we do in medicine, you'd be wrong. If you think that most people in law don't eventually specialize, you'd also be wrong. He didn't, and he has recently put together a thriving business. That's how I would like to see FM. Sure, it would be ridiculous to have FM trying to valve replacements or AAA repairs, but there is no reason that a single doctor couldn't handle the everyday things that most families deal with regularly, including intern level surgery. There are surgical PAs doing appys. There is no reason a trained FP couldn't do them. That's just an example, but I'm trying to prove a point.

I really don't know how to make it more clear.

Miami, I understand what you are saying, and in many ways, I'm on your side. I believe in full-spectrum FP with all my heart, but I think it's necessary to be realistic. (I still don't understand how it is that P4 and the concept of a medical home will hold those back who wish to have the sorts of practices that you and I want to have, but that's for another thread). However, we've got to draw the line somewhere.

I'm not saying that FPs can't be trained to do appys--of course they can, and they do. The issue is after they get that training, they enter into a market pretty saturated with general surgeons who, by the way, have been relegated to pretty much ONLY doing appendectomies, gall bladders, I&D's, and exploratory laps due to surgical specializations. By encouraging FPs to get trained to do things like appys, you are not going to suddenly change the market so that it can absorb all those new appy-doers. It's just not going to happen. Talk about turf wars. Try getting into an urban or suburban OR dominated by general surgeons, as an FP. That would be interesting.

Obstetrics and colonoscopy are a different story. One of my favorite rural preceptors did both, successfully. Patients preferred to have him do their scopes because there wasn't a 4 week wait, and they loved the one-stop shopping. They wanted him to deliver their babies because they already took care of grandma, all their cousins, and aunt Billie Jo. But this was a community of 7,000.

I don't know where you are at in your training, but I do know that as I have gone along, I've gained a lot more insight and have become a lot more realisitic about FM.

Best of luck to you--I do hope you find what you are looking for, in FM or elsewhere.

 

[ajce9]

I am starting this thread because one thread is already fully hijacked and one is in danger.

I think this is a worthy discussion...let it evolve into a discussion on p4, I don't care.

For my part:

I believe that there is no point in FPs trying to compete with specialists. I know that if I personally had the option of seeing my FP for an emergent appendectomy or a general surgeon, both were located the same distance from the hospital, knowing all I know, I would choose the surgeon.

And I'm about as big of a flag-waving FM fan there ever was.

It's a matter of supply and demand. I would not expect to have the same practice in the city that I'd have in the country because it wouldn't make sense to me. Where there are abundant specialists, they should be able to do their thing.

Now, if I live and work in an area where I can do enough scopes and deliveries and colpo to not only keep my skillls up but also to serve an actual need in the are, sign me up.

To try to have this macho-superhuman-full-spectrum-jack-of-all trades, "lie down in the back and I'll cut out your appendix after I do this throat swab" kind of practice in suburban Houston is kind of a fairy tale.

And just to be clear, there ARE programs that will train you well to do all that. That shouldn't even be the argument. Check out Ventura County, JPS, etc. The point is, where are you REALISTICALLY going to do all these sexy procedures when you are done?

You might be able to do some of them in a rural area. That's about it.

You seem to be very fixated on the appendix. Last time I checked there were many more procedures available to FPs than just the focous on the right lower abdomen.

colonoscopies, egds, rehab in the office, biopsies, and the list goes on are all office based procedures.

I know you are a first year resident so maybe your overall depth is not yet formed. (I don't mean to say this to put you down).

The fact is that FPs should be able to tailor their practice based on their knowledge and skill, NOT based on what some specialist says.

The average FP sees many patients above 50 that need a screening scope or have reccurent acid reflux that warrants a screening egd. Almost every sport injury or knee injury of 70 years old that has bad knees and muscles that have atrophied over the years could prevent surgery by several years or never have to get surgery if they have proper rehab. Or a possible joint injection.

Many of the same people have AKs that could be removed in your office and not the derm office. why would you want to waiste your patients time like that? Just do it in you office.

Those very same patients may want to enhance their appearance and get botox or dermal fillers. Its the baby boom generation.

The list goes on and the your practice get more interesting because you don't have to do only the top ten FP. HTN, diabetes, etc, etc.

since you can treat 70 % of all derm issues in your office and if you don't know what it is you can biopsy it and then treat it, you are now their number one dermatologist. The other 30% is rare. Ask any dermatologist what their usual bread and butter cases are.

I could go on, but I think you get the point.

 

[deleted87716]

I can only speak from experience.

I have no interest in obstetrics...never did. I used to do flex sigs until insurance companies universally started covering screening colonoscopies. The volume dropped off to the point where it wasn't cost-effective to maintain the equipment, and our skills were deteriorating. I don't miss it, and it didn't really reimburse that well, anyway. I don't do colposcopy, again, because the volume that I'd do in my practice would be fairly inconsequential. Ditto nasopharyngoscopy, vasectomy, etc., although I learned all of these procedures in residency.

I do procedures that I enjoy, that I can do often enough to maintain proficiency, and that I can easily do in the office setting on-the-fly, if needed: laceration repair, joint injection, skin biopsies/lesion removal, ingrown toenail avulsion, I&D, cyst removal, etc.

I don't have any interest in learning colonoscopy, cosmetic dermatology, etc. It's just not my bag, man.

 

[Melanie]

What makes you sooo different than an NP or PA then, if you don't actually provide all the above mentioned services?

So, procedures differentiate PAs/NPs from MDs?? General internists don't really do procedures either...I guess that makes them just like PAs too? What about all of the non-procedure specialties...are they just like PAs? I am really interested in family medicine, because I DON'T want to do very many procedures. That doesn't make me a future PA/NP, not by any means.

I don't want to turn this into an MD vs. PA thread - we've certainly done that enough, but still, someone has to comment on this.

 

[sophiejane]

You seem to be very fixated on the appendix.

This is in response to another discussion on another thread. I used it as an example of what I consider to be the outer limit of procedures that lie within the scope of FM.

I don't know how many times and in how many ways I have to say it: I am in favor of procedures and want to do as many of them as are needed in my practice, office based or otherwise. My issue is with those who are upset because FPs can't do everything, everywhere, all the time.

It's fine to base your practice on knowledge and skill, but if there is no market for the wares you have to sell, what is the point? The appendectomy example was simply to say that if you really expect you do everything, you better have enough of them to keep your skills current (as Kent suggests as well).

Look, we can argue about this forever and it won't change the reality: if there is no demand for a service in a certain area or if it is already saturated with specialists who are not all busy enough, an FP coming in and offering those services is not going to be very successful.

Supply and demand. It's very simple. If you want to do a lot of procedures you need to go to where the demand is.

 

[deleted87716]

I don't want to turn this into an MD vs. PA thread - we've certainly done that enough, but still, someone has to comment on this.

Actually, it's probably better to ignore it.

 

[deleted87716]

I don't know how many times and in how many ways I have to say it: I am in favor of procedures and want to do as many of them as are needed in my practice, office based or otherwise. My issue is with those who are upset because FPs can't do everything, everywhere, all the time...Supply and demand. It's very simple. If you want to do a lot of procedures you need to go to where the demand is.

Pretty much.

I'm as big a supporter of full-spectrum FM as the next person, even though it's not what I do. I think those who do want to practice OB, see patients in the hospital, perform colonoscopy, etc. should be able to do so.

Don't forget the biggest reason why most of us don't "do it all" anymore...it's exhausting.

 

[ajce9]

I can only speak from experience.

I have no interest in obstetrics...never did. I used to do flex sigs until insurance companies universally started covering screening colonoscopies. The volume dropped off to the point where it wasn't cost-effective to maintain the equipment, and our skills were deteriorating. I don't miss it, and it didn't really reimburse that well, anyway. I don't do colposcopy, again, because the volume that I'd do in my practice would be fairly inconsequential. Ditto nasopharyngoscopy, vasectomy, etc., although I learned all of these procedures in residency.

I do procedures that I enjoy, that I can do often enough to maintain proficiency, and that I can easily do in the office setting on-the-fly, if needed: laceration repair, joint injection, skin biopsies/lesion removal, ingrown toenail avulsion, I&D, cyst removal, etc.

I don't have any interest in learning colonoscopy, cosmetic dermatology, etc. It's just not my bag, man.

AND, you are in the right. You don't want to do something you should not have to do it.

BUT, the point is that you should have the opportunity to learn it and should be allowed to do it when you want.

The physician who does one colonoscopy a year, should not be doing them.
But if he has the opportunity to do many and someone gets in his way, then we have a problem.

And you are right doing it all can be exhaustive.

To me FP was always about picking and choosing how a person wanted to structure their practice.

That is starting to end and that started when certain individuals (we all know who) started to dictate to the FP what they can and can't do and the FPs just sat there and took it.

An FP can tailor his practice. They can market themselves as the dermatologist, gastroenterologist, orthopedist and physiatrist. All of those specialties are taught in an FP residency. You can ask an orthopedist or a physiatrist what their bread and butter cases are and they will say knee, shoulder, elbow, back, etc. The dermatologist will say, acne, acne, acne, cancer, cancer, common rashes, not in that order maybe. And the list goes on.

Is there a family physician on this website that feels they can't do common skin biopsies or common ortho injuries?

You have to market yourself for these procedures and specialize in them. Split your practice into general medicine and one or two specialties that you enjoy. Become the expert in those specilties. Your patients will appreciate it.

Imagine as if you did a sport fellowship and now have to split your practice into general and sports.

 

[deleted6669]

Actually, it's probably better to ignore it.

yup.....

 

[deleted87716]

To me FP was always about picking and choosing how a person wanted to structure their practice.

That is starting to end and that started when certain individuals (we all know who) started to dictate to the FP what they can and can't do and the FPs just sat there and took it.

I guess I'm having a little trouble figuring out who you're mad at, or why. Granted, fewer people want to do full-spectrum FM nowadays, but it's certainly still doable if that's what you want. Depending on where you go, you may face some difficulty obtaining certain privileges, but the AAFP has resources to help with that, if needed: http://www.aafp.org/online/en/home/practicemgt/privileges/assistancepriv.html

An FP can tailor his practice. They can market themselves as the dermatologist, gastroenterologist, orthopedist and physiatrist.

I think that's where you need to tread carefully. You really shouldn't market yourself as a "dermatologist" or any other specialty. You could say something along the lines of, "John Doe, MD, FAAFP, specializing in cosmetic dermatology," but I wouldn't use the word "dermatologist," as it's misleading and potentially fraudulent.

 

[Miami_med]

My point has been that FM could recruit more people to do FM if they promoted the specialty as a way to have control over a practice customized to the liking of the physician. P4 doesn't sell FM well to those that aren't looking for a limited primary care practice, and those that are will pretty much already choose FM. Look, as a student, I was originally not all that interested in FM. During my MS1 year, I picked up an interest. I receive the AAFP journal. It's probably my favorite journal, and it is the single most practical thing that I get when it comes to what every doctor should know. However, I have become disillusioned with where FM is going, and this comes from reading the specialty journal. This is why I will probably not go into the specialty.

Please don't misunderstand me. You will never find a bigger realist than me. The examples of what you wouldn't get away with in the city are things that stand for themselves. That's the point. Rather than focusing energy on the medical home, the AAFP needs to move its efforts to protecting FM practice rights, or soon all FM will be in the cities is a rigidly structured "medical home" primary care practice with little flexibility and declining income. That isn't what I want. I've always tended to view FM, EM, and Surgery as the most practical of all specialties, and I'm fond of all of them. I'd love to see them do well. The one in the middle really seems like the only one that is doing a reasonable job trying to protect itself, and It's no coincidence that it's the fastest growing specialty in the country.

If FM even published surveys of average income of FULL SCOPE practicioners and could provide some assurance that you could be a full scope practicioner after training, I think that the salary issue would take care of itself. The practicioner could mold his practice to be flexible with where the money was. It'd become the most safe specialty in medicine, rather than one of the more threatened.

Best of luck to all of you.

 

[deleted87716]

Rather than focusing energy on the medical home, the AAFP needs to move its efforts to protecting FM practice rights

Actually, that's all going on simultaneously. There are many advocates within the AAFP for the preservation of full-spectrum FM, and you'll find resources here: http://www.aafp.org/online/en/home/policy/state/issues/scope/fpscope.html.

Could more be done? Always.

 

[Miami_med]

Actually, that's all going on simultaneously. There are many advocates within the AAFP for the preservation of full-spectrum FM, and you'll find resources here: http://www.aafp.org/online/en/home/policy/state/issues/scope/fpscope.html.

Could more be done? Always.

Interesting link Kent, I bookmarked it for future reading.

 

[Tn Family MD]

I recommend seeing my post in the other thread in reference to practicing in more urban areas with a procedure heavy type of practice. As I state there, it can be done and is being done currently by some FM docs.

I truly abhor this victim mentality that some FM docs have, thinking they just can't have what they want in a practice. It's just not true. There are good examples of this out there. You just have to look.

 

[sophiejane]

I truly abhor this victim mentality that some FM docs have, thinking they just can't have what they want in a practice. It's just not true. There are good examples of this out there. You just have to look.

Well said.

I've said that before--what you hear/read in medical school, in the media, from other people about FM sometimes (often) has very little in common with what you find when you get out there and experience it.

 

[sophiejane]

Reading through some other posts on this matter that have sprung up on other threads, I realized that whenever I write "rural", in my mind, it's synonymous with "underserved." I realized that I'm not including the underserved populations in urban areas, of which there are many. SO I apologize.

I do think that much of what I have said about rural medicine in this thread can apply to underserved urban populations with regard to procedures.

What I disagree with is the mentality that an FP should be able to set up shop in a more affluent suburban or urban neighborhood and expect to start doing c-sections, scopes, etc. But obviously there are some who feel this can be done (see post below). If you want it, try it. We don't all have to agree on the best way to practice FM. It's too big, too varied, too many possibilities for us all to agree--that's why I love this field.

So, it goes back to "Where is the need?" I think that's why FPs are so perfectly suited for mission and relief work. We really can do a little of everything. But to do these procedures just to do them, because it's fun or sexy or whatever, is what I have a hard time with. Bring your services where people need them, set up shop, TAKE MEDICAID, learn Spanish, and go to town with your full-spectrum FP.

I'll be doing the same about 60 miles out of town. Take a left at the second cornfield.

 

[sophiejane]

ajce9:

Wouldn't it be nice if you could do all of those things in a non-rural setting? If you could open your practice and just see and treat patients the way you were trained?

TnFamilyMD:

Ya know, I am not totally convinced that you can't do this. If you have read my other recent posts, I have referenced the Medicos para la Familia Fellowships. These are located in urban areas (at least what I call urban -- Nashville, TN and Memphis, TN). They each provide training in c-section, D&C, c-scope, EGD, even spinal epidural anesthesia and other advanced procedures. These are FM docs that set these up as clinics in which to train other FM docs in these procedures, and obviously in order to train others you have to have the volume. I readily admit that these programs are set up to serve the underserved, but it is my feeling that the underserved exist in all cities as well as all rural areas and represent upper as well as middle and even lower class people. Obviously not all people feel this way, but I do not feel constrained geographically because of my choice of FM and my intention to do procedure rich FM. The bottom line is that nobody can tell you how to run yoru practice. Customers (patient in this case) vote with their wallets and their feet. If you provide a set of services that are needed or necessary or even just wanted and you are pleasurable to work with, people will come to you for your services. Listen, I highly doubt that most patients even know the real difference in training between FM and other specialties such as IM or GI or even Ob/Gyn. All they know is that Dr. X provides service Y and that Dr. X is a nice guy and easy to work with.

Here is a little experiment for you to try. Get out your phone book and call some local physicians and ask about some of these services. Call some GI docs and see when their next available appointment is and when you can schedule a colonoscopy The two more urban areas I have lived in had waits to see specialists that numbered in the months. If there was an FM doc that was out there offering c-scopes and you could get one next week versus three months from now, how many consumers (again patients in this case) would just go ahead and have the FM doc do their c-scope? I know I would personally just go ahead and have the FM doc do it. And I ain't the regular lay person, I'm a doc myself.

Maybe I am an idealist, but I just don't see that we are all that limited geographically. That being said, I intend to practice in a more rural area, but that is because I despise city traffic, the anonymity of being one of a half million residents in my city, and lots of other crap that goes along with city life.

I'm sure there are tons of people that are gonna hafta jump in and tell me how stupid I am. But, the bottom line is it is being done and FM docs have been and continue to be successful with these types of practices in more urban areas. You will have more work to do to be successful in that you will have to market yourself more aggressively, target populations that are more underserved (and this may mean learning to speak Spanish for instance), or other ways to get your name out there. But it can be done and is being done. And that is the bottom line.

 

[Frijolero]

Reading through some other posts on this matter that have sprung up on other threads, I realized that whenever I write "rural", in my mind, it's synonymous with "underserved." I realized that I'm not including the underserved populations in urban areas, of which there are many. SO I apologize.

I do think that much of what I have said about rural medicine in this thread can apply to underserved urban populations with regard to procedures.

What I disagree with is the mentality that an FP should be able to set up shop in a more affluent suburban or urban neighborhood and expect to start doing c-sections, scopes, etc. But obviously there are some who feel this can be done (see post below). If you want it, try it. We don't all have to agree on the best way to practice FM. It's too big, too varied, too many possibilities for us all to agree--that's why I love this field.

So, it goes back to "Where is the need?" I think that's why FPs are so perfectly suited for mission and relief work. We really can do a little of everything. But to do these procedures just to do them, because it's fun or sexy or whatever, is what I have a hard time with. Bring your services where people need them, set up shop, TAKE MEDICAID, learn Spanish, and go to town with your full-spectrum FP.

I'll be doing the same about 60 miles out of town. Take a left at the second cornfield.

I admire your commitment to the underserved/rural population, I have a strong interest there as well. But to say that anyone who wants a full-scope practice needs to choose that kind of population puts too great a limit on FM, IMO. With regards to what FM "should" be able to do: they should be able to do whatever they can safely do wherever the market will bear it. Where we differ, though, is that you don't believe FP's can be procedure-competitive in an urban atmosphere.

At the risk of being repetitive, I think you're not giving enough weight to the convenience factors at play when we're talking about minor procedures that could either be referred out or just done by the FP herself. What's more, I don't see anything wrong with an FP who wants to do a certain procedure just because it's "sexy". We're allowed to have a little fun too, ya know. Is their room in your "something for everyone" FM philosophy to include those who'd like a procedure-heavy practice in an urban environment? I hope so.

 

[sophiejane]

Is their room in your "something for everyone" FM philosophy to include those who'd like a procedure-heavy practice in an urban environment? I hope so.

Of course. I'm just skeptical that it can work outside of the underserved/community medicine model. Go on out there and make a believer of me--I'd love to be proven wrong on this, I just don't think it's likely, that's all...

 

[wasatch]

Sophiejane....thus far your comments have been completely useless...we don't really care what you are doing personally...not an issue about YOU!

The issue is the restricted access to do procedures that has been forced upon the practice of FM in the last 20 years.

This is NOT an issue of rural vs. urban or underserved vs affluent.

 

[Melanie]

So, I've been following this thread, and I have a question for all of the practicing FPs out there. The FPs that I've worked with haven't really shown a strong desire to do procedures, and several of them have outright said that they prefer to minimize procedures in their office. Do you guys think that this is how the majority of practicing FPs feel? Or, are there lots of practicing FPs out there who get up every morning and go to work bitter because they are unable to do procedures? (I guess another question would be how many of those practicing are frustrated by their lack of reimbursement and for that reason would like to do procedures to increase revenue - that, however, doesn't really seem to be what this discussion here is about and is really a whole different issue.) I was just under the impression that most docs didn't spend time stressing over the number of procedures that they do/can do in the community. Any input would be appreciated. Thanks!

 

[Melanie]

Sophiejane....thus far your comments have been completely useless...we don't really care what you are doing personally...not an issue about YOU!

The issue is the restricted access to do procedures that has been forced upon the practice of FM in the last 20 years.

This is NOT an issue of rural vs. urban or underserved vs affluent.

Okay, but can't we argue that family medicine in general has been scaled back over the years? I know that in my area (city, not rural) 5 years ago family practitioners were still admitting their patients to the hospital. That has since changed, and the FPs are much happier. The ones that I've spoken with are glad that they can have more regular working hours and don't have to spend as much time in the hospital. Scaling back FP perhaps in some ways only reflects the preferences of the majority of people who are out there practicing family medicine. If a majority of physicians don't really care about doing procedures or admitting or whatever, then they are certainly not going to go out and try to "fight" for their right to do so. I guess I just have to sort of question whether this type of "scaling back" has been "forced" on family practice, or if FPs are actually okay with it.

And, as a side note, many medical students who are going into primary care are now doing it, because they don't have to practice "full scope" family medicine. I really have to question whether the majority of this generation really cares about not being able to do procedures, etc. I think many accept that as a reality and choose family medicine based on that reallity.

 

[sophiejane]

Sophiejane....thus far your comments have been completely useless...we don't really care what you are doing personally...

As your friendly neighborhood Advisor, I will remind you and everyone else to please keep the comments to the topic, and refrain from personal insults.

Those of you who have received warnings from Moderators in particular should keep this in mind.

 

[deleted87716]

So, I've been following this thread, and I have a question for all of the practicing FPs out there.

I might be the only one here. Anyone else, feel free to jump in.

The FPs that I've worked with haven't really shown a strong desire to do procedures, and several of them have outright said that they prefer to minimize procedures in their office. Do you guys think that this is how the majority of practicing FPs feel?

Absolutely. Look at the statistics for colonoscopy, OB, etc. on the AAFP web site (link is stickied at the top of this forum). The percentage of FPs doing most of these procedures is in the single digits, and roughly 80% of the time, the reason given for not doing them is "not desired."

I guess another question would be how many of those practicing are frustrated by their lack of reimbursement and for that reason would like to do procedures to increase revenue

Procedures don't automatically increase revenue. The reimbursement for colonoscopy, for example, is steadily declining, and the only way the GI folks are making it work is through volume. Most FPs could probably make more money by doing derm procedures rather than colonoscopies.

Many of the FPs who are still doing hospital medicine are actually losing money doing it, but they keep doing it because they either enjoy it, or they feel that they can't give it up. You can nearly always make more money in your office than you can in the hospital.

 

[8744]

Don't worry. P4 is going to solve all of your problems. Didn't you get the memo?

 

[deleted87716]

Don't worry. P4 is going to solve all of your problems. Didn't you get the memo?

What happened to that part about you not caring?

 

[8744]

What happened to that part about you not caring?

I don't care. But, like most people, I can't help slowing down to rubber-neck while passing bad accident.

 

[ajce9]

I guess I'm having a little trouble figuring out who you're mad at, or why. Granted, fewer people want to do full-spectrum FM nowadays, but it's certainly still doable if that's what you want. Depending on where you go, you may face some difficulty obtaining certain privileges, but the AAFP has resources to help with that, if needed: http://www.aafp.org/online/en/home/practicemgt/privileges/assistancepriv.html



I think that's where you need to tread carefully. You really shouldn't market yourself as a "dermatologist" or any other specialty. You could say something along the lines of, "John Doe, MD, FAAFP, specializing in cosmetic dermatology," but I wouldn't use the word "dermatologist," as it's misleading and potentially fraudulent.

You took that too literally. Marketing yourself for sub-specialty care. That what I meant.

People need to know what Family physicians do. What can they see.

It's important to move away from the phrase "He is just an FP" to My FP can treat most anything. Because he can.

Oh, I'm not mad. A little animated but not mad.

 

[ajce9]

So, I've been following this thread, and I have a question for all of the practicing FPs out there. The FPs that I've worked with haven't really shown a strong desire to do procedures, and several of them have outright said that they prefer to minimize procedures in their office. Do you guys think that this is how the majority of practicing FPs feel? Or, are there lots of practicing FPs out there who get up every morning and go to work bitter because they are unable to do procedures? (I guess another question would be how many of those practicing are frustrated by their lack of reimbursement and for that reason would like to do procedures to increase revenue - that, however, doesn't really seem to be what this discussion here is about and is really a whole different issue.) I was just under the impression that most docs didn't spend time stressing over the number of procedures that they do/can do in the community. Any input would be appreciated. Thanks!

I'm a practicing FP and I have not moved away from procedures. In fact in my residency we made a point of learning procedures. As many as we could.

The FP procedures have been scaled back because over time FP have allowed the specialist to dictate what they do. Now, they rely on the specialist to teach them many procedures. I believe in the past the FP program attendings did the teaching.

Even the aafp said it. If you can't just do outpatient medicine as an FP. you need to broaden the scope.

 

[ajce9]

Don't worry. P4 is going to solve all of your problems. Didn't you get the memo?

Pot calling the kettle black.

You are in ER. Wait till they come knocking a little harder on your door.

 

[Frijolero]

I might be the only one here. Anyone else, feel free to jump in.



Absolutely. Look at the statistics for colonoscopy, OB, etc. on the AAFP web site (link is stickied at the top of this forum). The percentage of FPs doing most of these procedures is in the single digits, and roughly 80% of the time, the reason given for not doing them is "not desired."



Procedures don't automatically increase revenue. The reimbursement for colonoscopy, for example, is steadily declining, and the only way the GI folks are making it work is through volume. Most FPs could probably make more money by doing derm procedures rather than colonoscopies.

Many of the FPs who are still doing hospital medicine are actually losing money doing it, but they keep doing it because they either enjoy it, or they feel that they can't give it up. You can nearly always make more money in your office than you can in the hospital.

If FM gets to the point where nobody is doing hospital work or procedures then I'm out, seriously. Currently, it's the docs themselves doing the choosing. If the general consensus is that it will get to the point where hospitals start denying FPs privileges and insurance companies won't reimburse FPs doing minor procedures then I need to seriously reconsider my specialty choice. Anyone?

 

[Tn Family MD]

The FP procedures have been scaled back because over time FP have allowed the specialist to dictate what they do. Now, they rely on the specialist to teach them many procedures. I believe in the past the FP program attendings did the teaching.

.

This is a very valid and salient point. In fact, many believe this same way. I think in Dr Rodney's words, we have neutered ourself as a specialty when our attendings can no longer teach procedures. We have sterilized FM as a viable specialty.

I feel the same exact way.

 

[Tn Family MD]

If FM gets to the point where nobody is doing hospital work or procedures then I'm out, seriously. Currently, it's the docs themselves doing the choosing. If the general consensus is that it will get to the point where hospitals start denying FPs privileges and insurance companies won't reimburse FPs doing minor procedures then I need to seriously reconsider my specialty choice. Anyone?

I'll be right behind you. Last one out don't forget to turn out the lights.

Seriously, there is nothing satisfying about the prospect of practicing a 9 to 5 limited generalist model practice, at least not to me. If that became my life, I would go back and retrain in another specialty without a second thought.


I think the point of this mess is that there are basically two types of people practicing FM these days. There are one type who firmly believe in the limited generalist model. They want regular 9 to 5 hours, no call, and they need to feel very comfortable in their routine stuff that they do. This type represents maybe 50% or so of the residents in my current program. The other type is the true generalist, yearning to do a range of simple procedures, provide high level care to all people regardless of age, sex, or gender and don't necessarily need that regular 9 to 5 day and may even enjoy a late night in the hospital helping someone through a tough time or a difficult delivery. Those are the people like me, sophie, ajce9 and many others on here. One could make an argument that there is a third type that likes the 9 to 5 but still does one or maybe even a few simple procedures. I don't think this represents a new type but rather a hybrid of the first two types that is yet to fully declare itself one way or the other.

Therein lies the reason for my belief that FM is at a crisis time and needs a vastly new direction. That new direction I recommend is splitting the specialty into two different sub-specialties. Let one remain as the three year residency and let that one drop OB training, increase its sub-specialty exposure during residency, focus more on out-patient training and that one can become the limited generalist that so many people seem to like. I would call this specialty Family Medicine - Clinical. The other could be extended to four or even five years of residency. You would be required to provide training in colonoscopy, EGD, and endoscopic procedures of all ranges, be required to teach c-sections to residents, have the option of picking up training in appy's and chole's, be more hospital and surgical oriented in the training and less out-patient. This new specialty could be called Family Medicine - Surgical. I think this would allow those that are more interested in procedure heavy full spectrum FM to get the training they so richly deserve without having to fight tooth and nail for it while still allowing those more interested in purely out-patient clinical work to have their own niche as well. A win-win situation for both parties. Of course, I am a lowly resident and so my ideas can't possibly be valid, can they?

 

[Miami_med]

Therein lies the reason for my belief that FM is at a crisis time and needs a vastly new direction. That new direction I recommend is splitting the specialty into two different sub-specialties. Let one remain as the three year residency and let that one drop OB training, increase its sub-specialty exposure during residency, focus more on out-patient training and that one can become the limited generalist that so many people seem to like. I would call this specialty Family Medicine - Clinical. The other could be extended to four or even five years of residency. You would be required to provide training in colonoscopy, EGD, and endoscopic procedures of all ranges, be required to teach c-sections to residents, have the option of picking up training in appy's and chole's, be more hospital and surgical oriented in the training and less out-patient. This new specialty could be called Family Medicine - Surgical. I think this would allow those that are more interested in procedure heavy full spectrum FM to get the training they so richly deserve without having to fight tooth and nail for it while still allowing those more interested in purely out-patient clinical work to have their own niche as well. A win-win situation for both parties. Of course, I am a lowly resident and so my ideas can't possibly be valid, can they?

I don't think more residency is necessary. They should simply increase the number of post-residency workshops in different procedures and promote the usage of these workshops. They should then fight to get FPs access to hospitals or rights with insurance companies in order to utilize these procedures. Perhaps there could be two different approaches within residency, but the extra years will kill it. There's no reason a person couldn't learn full scope FM in 3 years. Will they know everything, of course not. They still won't after 5 years. The point would be to get comfortable doing new things, so that they can always adapt. The money procedures of today aren't going to be the the money procedures of tomorrow anyway.

 

[deleted87716]

If FM gets to the point where nobody is doing hospital work or procedures then I'm out, seriously. Currently, it's the docs themselves doing the choosing. If the general consensus is that it will get to the point where hospitals start denying FPs privileges and insurance companies won't reimburse FPs doing minor procedures then I need to seriously reconsider my specialty choice. Anyone?

The only real turf issues you might face are obtaining privileges for obstetrics, emergency medicine, and maybe colonoscopy, but this is strictly regional. If you go someplace where there are already FPs doing these things, you'll likely encounter less resistance. Hospital privileges usually aren't much of a problem. Once you have privileges, reimbursement from third-party payers shouldn't be much of an issue, either. Malpractice coverage can be a sticking point, of course, but again, this is regional. If you have to pay more for insurance coverage for something than you'll earn doing it, you won't make any money from it.

 

[8744]

Pot calling the kettle black.

You are in ER. Wait till they come knocking a little harder on your door.

The bureaucratization of medicine and the medicalization of life should be of concern to every doctor. Didn't you get that memo?

I'm sure KentW can fill you in on "P4P."

 

[ajce9]

I'll be right behind you. Last one out don't forget to turn out the lights.

Seriously, there is nothing satisfying about the prospect of practicing a 9 to 5 limited generalist model practice, at least not to me. If that became my life, I would go back and retrain in another specialty without a second thought.


I think the point of this mess is that there are basically two types of people practicing FM these days. There are one type who firmly believe in the limited generalist model. They want regular 9 to 5 hours, no call, and they need to feel very comfortable in their routine stuff that they do. This type represents maybe 50% or so of the residents in my current program. The other type is the true generalist, yearning to do a range of simple procedures, provide high level care to all people regardless of age, sex, or gender and don't necessarily need that regular 9 to 5 day and may even enjoy a late night in the hospital helping someone through a tough time or a difficult delivery. Those are the people like me, sophie, ajce9 and many others on here. One could make an argument that there is a third type that likes the 9 to 5 but still does one or maybe even a few simple procedures. I don't think this represents a new type but rather a hybrid of the first two types that is yet to fully declare itself one way or the other.

Therein lies the reason for my belief that FM is at a crisis time and needs a vastly new direction. That new direction I recommend is splitting the specialty into two different sub-specialties. Let one remain as the three year residency and let that one drop OB training, increase its sub-specialty exposure during residency, focus more on out-patient training and that one can become the limited generalist that so many people seem to like. I would call this specialty Family Medicine - Clinical. The other could be extended to four or even five years of residency. You would be required to provide training in colonoscopy, EGD, and endoscopic procedures of all ranges, be required to teach c-sections to residents, have the option of picking up training in appy's and chole's, be more hospital and surgical oriented in the training and less out-patient. This new specialty could be called Family Medicine - Surgical. I think this would allow those that are more interested in procedure heavy full spectrum FM to get the training they so richly deserve without having to fight tooth and nail for it while still allowing those more interested in purely out-patient clinical work to have their own niche as well. A win-win situation for both parties. Of course, I am a lowly resident and so my ideas can't possibly be valid, can they?

I agree. this would insure that the residents would get the training the wanted and needed.

Another route would be to create better fellowships for FP.

Fellowships that matter, ones that have real life value.

I looked at the fellowship programs on the aafp site. did you know there is a fellowship in informatics? what the H***?

How about a fellowship to do strickly office based procedures. Pick 10 top procedures an start in intensive training program for them.

How about a derm fellowship.
A pure office ortho fellowship. Not sports med. but just office ortho.
Or just combine the two with a few others.

Dr. Phenninger wrote the book on primary care office procedures. He also has a center that does nothing but procedures.

I'm not suggesting we all go out and do the same. But, we could learn a thing or two from his practice model.

I'm just the kind of guy that when I see something I can fix, I want to fix it. I don't want to wait or send the patient out someplace. He is right in front of me. I'm the guy he came to get help from.

If I can't do it. I tell him.

 

[Tn Family MD]

How about a fellowship to do strictly office based procedures. Pick 10 top procedures an start in intensive training program for them.



Dr. Phenninger wrote the book on primary care office procedures. He also has a center that does nothing but procedures.

I'm not suggesting we all go out and do the same. But, we could learn a thing or two from his practice model.

I'm just the kind of guy that when I see something I can fix, I want to fix it. I don't want to wait or send the patient out someplace. He is right in front of me. I'm the guy he came to get help from.

The fellowship for office procedures already exists and I have mentioned it several times. Check out some of my other posts in regards to the Medicos fellowships and find the link there. It sounds like something you'd be really interested in.

I am signed up for Dr. Pfenninger's course in Orlando this summer, three of them actually. I am doing the OB ultrasound, the Colonoscopy, and the Advanced Colonoscopy courses. I really look forward to getting to know him and most likely taking more of those courses in the future. I think that training with Dr Pfenninger in addition to what I get in residency here at UT and fellowship with Dr Rodney will make me able to pull off just about any procedure I feel like I would like to try.

I recommend checking out Dr Pfenninger's website at www.npinstitute.com

I feel ya ajce9. I like to do it all too. That's the very reason I am pursuing the training that I am and trying to get comfortable with all these different procedures, so that I can offer them to my patients who need them one day when I am on my own.

 

[deleted87716]

I think the point of this mess is that there are basically two types of people practicing FM these days....One could make an argument that there is a third type that likes the 9 to 5 but still does one or maybe even a few simple procedures.

I don't think it's that simple. Family medicine is a specialty of breadth, and its biggest advantage (IMO) is the ability for physicians to tailor their practice based on their own preferences and the needs of their patients. It's not really a training issue, and having different "tracks" in residency is not the right approach, nor is extending the length of training. I learned how to do lots of things in residency that I chose not to do in practice. I'm glad I learned how to do them, and I could probably pick most of them up again after a bit of a refresher, if the need ever arose.

In my case, it's not only that I prefer not to do obstetrics, vasectomy, colonoscopy, treadmills, etc...it's also that there is basically no need for me to do these things in my area. Doing most of these would require a significant investment (time and money), with very little return. OTOH, I see a ton of derm and ortho in my practice, so those are the procedures that I do. I'm happy, and my patients are happy. It's already a win-win as far as I'm concerned.

 

[deleted87716]

I'm sure KentW can fill you in on "P4P."

I don't have any experience with it at this point. Nobody has offered us a P4P contract.

 

[Miami_med]

I don't really think anyone is suggesting that all FPs should have urban procedure heavy practices. I think the concern was about the right to offer procedures if one chooses. The economic viability of choosing to do so in any particular market is variable and depends on both the market conditions AND the practicioner.

 

[FMMD]

I am starting this thread because one thread is already fully hijacked and one is in danger.

I think this is a worthy discussion...let it evolve into a discussion on p4, I don't care.

For my part:

I believe that there is no point in FPs trying to compete with specialists. I know that if I personally had the option of seeing my FP for an emergent appendectomy or a general surgeon, both were located the same distance from the hospital, knowing all I know, I would choose the surgeon.

And I'm about as big of a flag-waving FM fan there ever was.

It's a matter of supply and demand. I would not expect to have the same practice in the city that I'd have in the country because it wouldn't make sense to me. Where there are abundant specialists, they should be able to do their thing.

Now, if I live and work in an area where I can do enough scopes and deliveries and colpo to not only keep my skillls up but also to serve an actual need in the are, sign me up.

To try to have this macho-superhuman-full-spectrum-jack-of-all trades, "lie down in the back and I'll cut out your appendix after I do this throat swab" kind of practice in suburban Houston is kind of a fairy tale.

And just to be clear, there ARE programs that will train you well to do all that. That shouldn't even be the argument. Check out Ventura County, JPS, etc. The point is, where are you REALISTICALLY going to do all these sexy procedures when you are done?

You might be able to do some of them in a rural area, or some in a city, but you cannot do it all, all of the time.

TO OP, well it looks like your thread is now either getting "fully hijacked" or already "in danger." So I'll return to your original question and put it simply:

You point out something that has been debated time and again and I think you answered your own question. And that is the raw beauty of Family med. You can customize your practice to fit the needs of whatever community you choose to serve. I too am "as big of a flag-waving FM fan there ever was", but there is no perfect specialty, even FM.

 

[thedman888]

 

[Miami_med]