Why does everyone lose their minds over FM having a wide scope of practice, but lets midlevels do literally anything?

[MedicineZ0Z]

Not intended to be a midlevel thread. I'm genuinely curious why people in medicine, especially in FM, think that we should have some sort of narrow scope of practice.

Anything with high acuity? Nope. Managing less common diagnoses? Nope. (have to refer it out, so they're see by the endocrinology PA!) Ob? Nope, we aren't qualified. Scopes? Nah... but totally okay if we let "GI NPs" do it. C-sections? No. But midlevels in UK can train to do "basic surgeries." Hospitalist? No, we aren't prepared with our 3 year residencies. But the "NP hospitalist can do it." We can't cover an ER either, yet midlevels can do it literally solo. Little more complex psych management? Leave that to the Psych NP.

I just can't wrap my head around this logic - that we as doctors shouldn't be doing anything outside a narrow scope of practice. But some random person can go way further with virtually zero supervision. It's such an insane double standard. We have to meet god-tier standards to do something, but why?

---

Members don't see this ad.

 

[deleted480308]

You haven’t been searching actual job listings

 

[MedicineZ0Z]

You haven’t been searching actual job listings

This is just about mentality and mindset.

 

[deleted87716]

Not intended to be a midlevel thread. I'm genuinely curious why people in medicine, especially in FM, think that we should have some sort of narrow scope of practice.

What "people in medicine" are you talking about? FM is a specialty of breadth.

Yes, I'm asking for quotes.

 

[MedicineZ0Z]

What "people in medicine" are you talking about? FM is a specialty of breadth.

Yes, I'm asking for quotes.

Lol. There was literally a thread on this forum about things that family docs refer out vs manage. Large portion of lesser common conditions were on the refer list for most. You can also head to the EM forums to see their opinions or the occasional IM forum opinion.
What quotes do you need? I'm just talking about what doctors think and say about family docs.

 

[deleted480308]

Lol. There was literally a thread on this forum about things that family docs refer out vs manage. Large portion of lesser common conditions were on the refer list for most. You can also head to the EM forums to see their opinions or the occasional IM forum opinion.
What quotes do you need? I'm just talking about what doctors think and say about family docs.

Link to the fm thread?

 

[deleted87716]

Lol. There was literally a thread on this forum about things that family docs refer out vs manage. Large portion of lesser common conditions were on the refer list for most. You can also head to the EM forums to see their opinions or the occasional IM forum opinion.
What quotes do you need? I'm just talking about what doctors think and say about family docs.

Cut and paste, dude. I do it all the time.

FWIW, I wouldn't look for accurate information about FM in the EM or IM forums. What you'll find is mostly inter-specialty ****-talking.

 

[MedicineZ0Z]

Link to the fm thread?

Wasn't able to find it. It was a 2-3 page thread with people stating which of the 10-15 conditions listed they manage vs refer. There are similar other threads too...

Cut and paste, dude. I do it all the time.

FWIW, I wouldn't look for accurate information about FM in the EM or IM forums. What you'll find is mostly inter-specialty ****-talking.

Forums also represent unfiltered views that you don't get face to face.

Anyway, this isn't an exclusive thing to FM at all. Other fields carry the exact same mentality. All of medicine does. Peds actually does it the worst by far... Most Peds interns aren't allowed to do anything autonomously and even their seniors have intense attending supervision. Their attendings consult/refer out every tiny thing. Surgery will do silly consults for irrelevant medical issues. Various specialties hold their procedures in such high regard (ex. GI with scopes) but will turn around and train NPs to do it.

I just find it strange with FM given that we're supposed to be "jack of all trades" yet so many in our field want to keep the scope of practice more narrow.

 

[deleted480308]

Wasn't able to find it. It was a 2-3 page thread with people stating which of the 10-15 conditions listed they manage vs refer. There are similar other threads too...



Forums also represent unfiltered views that you don't get face to face.

Anyway, this isn't an exclusive thing to FM at all. Other fields carry the exact same mentality. All of medicine does. Peds actually does it the worst by far... Most Peds interns aren't allowed to do anything autonomously and even their seniors have intense attending supervision. Their attendings consult/refer out every tiny thing. Surgery will do silly consults for irrelevant medical issues. Various specialties hold their procedures in such high regard (ex. GI with scopes) but will turn around and train NPs to do it.

I just find it strange with FM given that we're supposed to be "jack of all trades" yet so many in our field want to keep the scope of practice more narrow.

I feel like you are making that sentiment up

 

[deleted87716]

I just find it strange with FM given that we're supposed to be "jack of all trades" yet so many in our field want to keep the scope of practice more narrow.

Still waiting for any sort of non-anecdotal evidence of that.

 

[AMEHigh]

Lol. There was literally a thread on this forum about things that family docs refer out vs manage. Large portion of lesser common conditions were on the refer list for most. You can also head to the EM forums to see their opinions or the occasional IM forum opinion.
What quotes do you need? I'm just talking about what doctors think and say about family docs.

I think I know which thread you’re referring to but don’t feel like pulling it up.

To be honest, I feel the beauty of FM is that if you are in a resource rich area and can refer then go for it. Not everyone enjoys every single aspect of FM. During residency I did refer some of the complicated diabetes patients because I could, but now that I’m in an underserved area I manage those patients myself for the most part even though I don’t really "enjoy" it.

I would say sports med is my least favorite area and most things are basic but yeah you’ll find me referring things quicker if able.

I "specialize" in reproductive health and will pretty much take on everything, but I completely understand why not all FM docs want to take care of miscarriages with MVA or mife/miso or learn how to do ultrasounds for pregnancy dating for example.

 

[scoopdaboop]

These mid levels have been learning on the job for their specialty under the doctor for a long time before they are able to do anything by themselves, and even then most of the time they’re likely being supervised by a doctor in their specialty in a hospital setting.

Of course, when the gi doctor and hospital wants the gi doc to hire nps to do 3 colonoscopies at one time to increase revenue and they do it for several months and years, the few small peepee np will boast and try to persuade everyone they’re at the level of a doctor.

 

[PikminOC]

These mid levels have been learning on the job for their specialty under the doctor for a long time before they are able to do anything by themselves, and even then most of the time they’re likely being supervised by a doctor in their specialty in a hospital setting.

Of course, when the gi doctor and hospital wants the gi doc to hire nps to do 3 colonoscopies at one time to increase revenue and they do it for several months and years, the few small peepee np will boast and try to persuade everyone they’re at the level of a doctor.

Bwahahah. If by supervision in a hospital, you mean an overworked doc who may look at 10 percent of a new midlevels chart. Not much more than that.

 

[MedicineZ0Z]

These mid levels have been learning on the job for their specialty under the doctor for a long time before they are able to do anything by themselves, and even then most of the time they’re likely being supervised by a doctor in their specialty in a hospital setting.

Of course, when the gi doctor and hospital wants the gi doc to hire nps to do 3 colonoscopies at one time to increase revenue and they do it for several months and years, the few small peepee np will boast and try to persuade everyone they’re at the level of a doctor.

There is no actual supervision when they do it themselves. And if an FM doctor is doing something, they did additional training in that area of practice too - no one just wakes up one morning and does something. The former hides under the umbrella of a "supervising" doctor (aka literally 0 supervision) and the latter practices independently.

I think I know which thread you’re referring to but don’t feel like pulling it up.

To be honest, I feel the beauty of FM is that if you are in a resource rich area and can refer then go for it. Not everyone enjoys every single aspect of FM. During residency I did refer some of the complicated diabetes patients because I could, but now that I’m in an underserved area I manage those patients myself for the most part even though I don’t really "enjoy" it.

I would say sports med is my least favorite area and most things are basic but yeah you’ll find me referring things quicker if able.

I "specialize" in reproductive health and will pretty much take on everything, but I completely understand why not all FM docs want to take care of miscarriages with MVA or mife/miso or learn how to do ultrasounds for pregnancy dating for example.

Agree but there are plenty of generalist docs who still freak out over the smallest uncommon thing and refer out. Anything beyond the most basic workup is referred out. Same story for specialists who consult medicine for minor issues or things that can be easily managed on their own.

 

[PikminOC]

Not intended to be a midlevel thread. I'm genuinely curious why people in medicine, especially in FM, think that we should have some sort of narrow scope of practice.

Anything with high acuity? Nope. Managing less common diagnoses? Nope. (have to refer it out, so they're see by the endocrinology PA!) Ob? Nope, we aren't qualified. Scopes? Nah... but totally okay if we let "GI NPs" do it. C-sections? No. But midlevels in UK can train to do "basic surgeries." Hospitalist? No, we aren't prepared with our 3 year residencies. But the "NP hospitalist can do it." We can't cover an ER either, yet midlevels can do it literally solo. Little more complex psych management? Leave that to the Psych NP.

I just can't wrap my head around this logic - that we as doctors shouldn't be doing anything outside a narrow scope of practice. But some random person can go way further with virtually zero supervision. It's such an insane double standard. We have to meet god-tier standards to do something, but why?

Youre right. Midlevel NP are able to see kids starting at five yo. I would need years more residency in a child psych residency to do so.

 

[AMEHigh]

There is no actual supervision when they do it themselves. And if an FM doctor is doing something, they did additional training in that area of practice too - no one just wakes up one morning and does something. The former hides under the umbrella of a "supervising" doctor (aka literally 0 supervision) and the latter practices independently.


Agree but there are plenty of generalist docs who still freak out over the smallest uncommon thing and refer out. Anything beyond the most basic workup is referred out. Same story for specialists who consult medicine for minor issues or things that can be easily managed on their own.

I guess my experience has been different. I don’t see many FM docs freak out, just prefer to refer if able for certain things they choose not to manage. I guess everyone’s experience is different.

 

[VA Hopeful Dr]

Link to the fm thread?

Do you refer to a specialist for the following conditions?

Just trying to find out the comfort level of FM docs on this board , feel free to just answer Y or N to the following DO you manage the following yourself , refer to specialist , or co-manage 1-PROTIENURIA in a non-diabetic , cause unknown 2-ELEVATED LFTS in nonalcoholic and cause unknown...

forums.studentdoctor.net

 

[Skindoc83]

Every field of medicine has turf wars. Neurosurgery took away interventional neuro from IR. Surgeons say they should do colonoscopies. Plastics think they’re the master of fillers when they Often just turf it to their NP. Plastics think they should be the gold standard for skin cancer extirpation despite mohs having higher clearance and mohs surgeons often Having better cosmetic outcomes because that is all they do. There are OBs doing breast implants and dermatologists doing face lifts and XRT for skin cancers. Everyone in medicine is fighting for their piece of the pie and often does so by trying to denigrate the other docs/fields around them. Don’t take it personally and don’t think that it is only found in family med. But as med schools expand and mid levels get independent practice I fear it’s only going to get uglier and more cut throat as the pie continues to shrink.

 

[deleted87716]

Do you refer to a specialist for the following conditions?

Just trying to find out the comfort level of FM docs on this board , feel free to just answer Y or N to the following DO you manage the following yourself , refer to specialist , or co-manage 1-PROTIENURIA in a non-diabetic , cause unknown 2-ELEVATED LFTS in nonalcoholic and cause unknown...

forums.studentdoctor.net

Maybe that's the thread, but I don't see anything there that supports his premise.

 

[VA Hopeful Dr]

Maybe that's the thread, but I don't see anything there that supports his premise.

Neither do I, but he's an intern and so very full of piss and vinegar about doing everything under the sun. You know how common that is.

 

[Goro]

Not intended to be a midlevel thread. I'm genuinely curious why people in medicine, especially in FM, think that we should have some sort of narrow scope of practice.

Anything with high acuity? Nope. Managing less common diagnoses? Nope. (have to refer it out, so they're see by the endocrinology PA!) Ob? Nope, we aren't qualified. Scopes? Nah... but totally okay if we let "GI NPs" do it. C-sections? No. But midlevels in UK can train to do "basic surgeries." Hospitalist? No, we aren't prepared with our 3 year residencies. But the "NP hospitalist can do it." We can't cover an ER either, yet midlevels can do it literally solo. Little more complex psych management? Leave that to the Psych NP.

I just can't wrap my head around this logic - that we as doctors shouldn't be doing anything outside a narrow scope of practice. But some random person can go way further with virtually zero supervision. It's such an insane double standard. We have to meet god-tier standards to do something, but why?

content removed by moderator

 

[Laetare]

(content removed by moderator)

This thread was a polite discussion between colleagues until you wandered in. Do you have any insight into why you behave the way you do when protected by the distance and anonymity of the Internet?

 

[VA Hopeful Dr]

This thread was a polite discussion between colleagues until you wandered in. Do you have any insight into why you behave the way you do when protected by the distance and anonymity of the Internet?

First, no it wasn't.

Second, the OP starts mid-level threads almost exclusively. Goro is asking a fair question.

 

[deleted480308]

This thread was a polite discussion between colleagues until you wandered in. Do you have any insight into why you behave the way you do when protected by the distance and anonymity of the Internet?

"protected"? That's a weirdly almost threatening choice of phrase akin to "you wouldn't say that to my face"

 

[MedicineZ0Z]

Every field of medicine has turf wars. Neurosurgery took away interventional neuro from IR. Surgeons say they should do colonoscopies. Plastics think they’re the master of fillers when they Often just turf it to their NP. Plastics think they should be the gold standard for skin cancer extirpation despite mohs having higher clearance and mohs surgeons often Having better cosmetic outcomes because that is all they do. There are OBs doing breast implants and dermatologists doing face lifts and XRT for skin cancers. Everyone in medicine is fighting for their piece of the pie and often does so by trying to denigrate the other docs/fields around them. Don’t take it personally and don’t think that it is only found in family med. But as med schools expand and mid levels get independent practice I fear it’s only going to get uglier and more cut throat as the pie continues to shrink.

Right, they fight with other doctors but then hand those things they fought for to their midlevels.

Neither do I, but he's an intern and so very full of piss and vinegar about doing everything under the sun. You know how common that is.

Not true at all and you realize this is FM. You're literally implying we should all be referalogists like you who also abstain from doing anything. Bit of a waste of 7 years of training.

 

[Splenda88]

The expansion continues

 

[VA Hopeful Dr]

Not true at all and you realize this is FM. You're literally implying we should all be referalogists like you who also abstain from doing anything. Bit of a waste of 7 years of training.

Hardly, I just recognize that there are things that other specialists can do better than I can. If I don't refer, I'm giving my patient inferior care. That's called being a bad doctor.

Now there are obviously exceptions to this. If you're rural and the nearest specialist in 3 hours away, the patient may refuse/be unable to make that trip. In that case, better care with you than nothing. Similarly, when I had my cash-only practice, I did way more than I do now because so many of my patients couldn't afford the specialists.

 

[FamilymedMD]

The OP has a good point.

I ran into this a few days ago yet again with a local Ob/Gyn who made it clear that she would oppose a new fellowship trained family doc to the area getting Ob privileges because "things go bad fast in Ob" yet almost all the labors here are managed by midlevels while she's oncall at home.

My daughter the PA student will be able to switch into jobs in other specialties depending on her skills, reputation and the demand for PAs without going back to do another 3 year residency like us family docs.

 

[MedicineZ0Z]

Hardly, I just recognize that there are things that other specialists can do better than I can. If I don't refer, I'm giving my patient inferior care. That's called being a bad doctor.

Now there are obviously exceptions to this. If you're rural and the nearest specialist in 3 hours away, the patient may refuse/be unable to make that trip. In that case, better care with you than nothing. Similarly, when I had my cash-only practice, I did way more than I do now because so many of my patients couldn't afford the specialists.

Then refer everything out. Endo can manage T2DM better I bet.

The OP has a good point.

I ran into this a few days ago yet again. I ran into the local Ob/Gyn who made it clear that she would oppose a new fellowship trained family doc to the area getting Ob privileges because "things go bad fast in Ob" yet almost all the labors here are managed by midlevels while she's at home.

My daughter the PA student will be able to switch into jobs in other specialties depending on her skills, reputation and the demand for PAs without going back to do another 3 year residency like us family docs.

Pretty much this example highlights my question.

Things can "go bad" is the excuse used to fight other doctors. Then they easily allow a non-physician to do the exact same thing.

Literally we have IM docs telling FM docs we shouldn't be hospitalists because "one day you'll have an unstable patient on the floor" then they have NPs covering the inpatient service at night.

 

[VA Hopeful Dr]

Then refer everything out. Endo can manage T2DM better I bet.

I bet they can't

 

[deleted480308]

Then refer everything out. Endo can manage T2DM better I bet.


Pretty much this example highlights my question.

Things can "go bad" is the excuse used to fight other doctors. Then they easily allow a non-physician to do the exact same thing.

Literally we have IM docs telling FM docs we shouldn't be hospitalists because "one day you'll have an unstable patient on the floor" then they have NPs covering the inpatient service at night.

Well those are what we call lies. It’s about money

 

[Splenda88]

Literally we have IM docs telling FM docs we shouldn't be hospitalists because "one day you'll have an unstable patient on the floor" then they have NPs covering the inpatient service at night.

The IM docs who say such thing are in a very small minority... Not an IM doc yet but I am an IM PGY2 managing patients with very little attending input, so I am not sure why an FM doc cant be a hospitalist?

 

[VA Hopeful Dr]

Then refer everything out. Endo can manage T2DM better I bet.

To expand upon this a little bit: in this example I can probably do 90% of what endocrine can for diabetes. Its that last 10% that gets tricky - pumps, U-500, stuff like that.

Same with most fields. I can do CHF about as well as cards up to a point, and that point is when they start talking about the need for ICDs, LVADs, and transplant.

Its why the traditional way of thinking about it is accurate. If we imagine medical knowledge as a swimming pool, FPs know the first 2 feet of the whole pool. A specialist knows the full 6 feet depth but only in their corner of the pool.

 

[VA Hopeful Dr]

The IM docs who say such thing are in a very small minority... Not an IM doc yet but I am an IM PGY2 managing patients with very little attending input, so I am not sure why an FM doc cant be a hospitalist?

Multifactorial.

First, money. Always look for money behind everything in medicine - its usually there.

Second, if you trained somewhere with a very weak program it will skew your view of FM. My wife trained at a place with notoriously weak FM residents. Had she not been married to me, she'd have assumed that all FPs came from places like that and wouldn't have wanted them to be hospitalists either.

Third, FM is a very diverse field knowledge/interest wise. For instance, one of my residency classmates took a job in a traditional practice so he did 3 extra months inpatient during his elective months to make sure he was ready for it. We had another person who was going to work UC so she did several extra months at the EDs fast track. I liked women's health so did extra months with the GYNs doing colpos and IUD placement. Its hard to tell what extra experience FPs got in residency from a quick glance. I was offered a hospitalist job 1 year out of residency that I turned down because I hadn't really kept up with the inpatient literature and knew I was likely too rusty to be safe without considerable effort to get back up to speed.

 

[FamilymedMD]

Well those are what we call lies. It’s about money

In my experience, less outright lies and more motivated reasoning by biased procedural specialists who are otherwise good colleagues. That doesn't make it any less of a problem.

 

[deleted480308]

In my experience, less outright lies and more motivated reasoning by biased procedural specialists who are otherwise good colleagues. That doesn't make it any less of a problem.

I am willing to back down to that description although it’s a bit of a tomatoes/tom-ah-toes thing to me

 

[MedicineZ0Z]

The IM docs who say such thing are in a very small minority... Not an IM doc yet but I am an IM PGY2 managing patients with very little attending input, so I am not sure why an FM doc cant be a hospitalist?

It was just an example. We have FM PGY2s managing inpatient with minimal attending input too.
But yeah different specialties do it to each other too.

Multifactorial.

First, money. Always look for money behind everything in medicine - its usually there.

Second, if you trained somewhere with a very weak program it will skew your view of FM. My wife trained at a place with notoriously weak FM residents. Had she not been married to me, she'd have assumed that all FPs came from places like that and wouldn't have wanted them to be hospitalists either.

Third, FM is a very diverse field knowledge/interest wise. For instance, one of my residency classmates took a job in a traditional practice so he did 3 extra months inpatient during his elective months to make sure he was ready for it. We had another person who was going to work UC so she did several extra months at the EDs fast track. I liked women's health so did extra months with the GYNs doing colpos and IUD placement. Its hard to tell what extra experience FPs got in residency from a quick glance. I was offered a hospitalist job 1 year out of residency that I turned down because I hadn't really kept up with the inpatient literature and knew I was likely too rusty to be safe without considerable effort to get back up to speed.

To your second point. Exceptionally weak FM programs are out there, but that's the case with every specialty. There are gen surgery PGY4s who aren't confident operating yet on basic cases.
And your third point, you mainly didn't want to out of pure interest which is more than okay. But were you less prepared than some midlevel who is going to cover an inpatient unit overnight? lol. Because the IM hospitalists seem to be okay with the latter, and then some would outrage over the FM doing it.
Once again, this is just an example. Same thing applies to Ob, or ED or whatever else.

 

[VA Hopeful Dr]

It was just an example. We have FM PGY2s managing inpatient with minimal attending input too.
But yeah different specialties do it to each other too.

To your second point. Exceptionally weak FM programs are out there, but that's the case with every specialty. There are gen surgery PGY4s who aren't confident operating yet on basic cases.
And your third point, you mainly didn't want to out of pure interest which is more than okay. But were you less prepared than some midlevel who is going to cover an inpatient unit overnight? lol. Because the IM hospitalists seem to be okay with the latter, and then some would outrage over the FM doing it.
Once again, this is just an example. Same thing applies to Ob, or ED or whatever else.

I feel like this gets explained fairly often: midlevels are under your authority, other doctors aren't.

 

[AMEHigh]

Then refer everything out. Endo can manage T2DM better I bet.


Pretty much this example highlights my question.

Things can "go bad" is the excuse used to fight other doctors. Then they easily allow a non-physician to do the exact same thing.

Literally we have IM docs telling FM docs we shouldn't be hospitalists because "one day you'll have an unstable patient on the floor" then they have NPs covering the inpatient service at night.

I guess I misunderstood your OP.
I thought you were saying FM docs themselves were "freaking out" and referring.
Now you’re talking about other specialists not feeling confident in our skills like your hospitalist example.
Well FM has been **** on for awhile now with the rise of specialists and fragmented care. I certainly don’t take it personal. Everyone thinks they do their jobs the best.
As far as mid levels go, that often comes down to money.

 

[Slatches]

We docs are our own worst enemies. I knew that from day one of my clinical rotations as a student. The surgery chief would yell and act tough towards us but then runs and cuddles the nurses. Show love, but come on man/woman show love more to your fellow brethren. This negative behavior has continued all the way and it is the main reason we have been sold out by our superiors and we’ve created the rise of mid levels. Why do we even call them midlevels, when we give the privileges of a doc. It’s gone to their heads and now all are claiming equality. Now we want to put up a fight?

 

[VA Hopeful Dr]

I guess I misunderstood your OP.
I thought you were saying FM docs themselves were "freaking out" and referring.
Now you’re talking about other specialists not feeling confident in our skills like your hospitalist example.
Well FM has been **** on for awhile now with the rise of specialists and fragmented care. I certainly don’t take it personal. Everyone thinks they do their jobs the best.
As far as mid levels go, that often comes down to money.

Maybe my situation isn't common, but the specialists everywhere I've worked kiss our asses (we are the source of a lot of their business after all) and patients value our opinions more than their's quite often. Its very possible that behind closed doors the specialist talk badly about us, but they know better than to say that to either us or our patients.

How many times have you had a patient come back to you and say "Dr. Specialist said I need this test/procedure, what do you think?" I get that at least weekly.

 

[SLC]

Maybe my situation isn't common, but the specialists everywhere I've worked kiss our asses (we are the source of a lot of their business after all) and patients value our opinions more than their's quite often. Its very possible that behind closed doors the specialist talk badly about us, but they know better than to say that to either us or our patients.

How many times have you had a patient come back to you and say "Dr. Specialist said I need this test/procedure, what do you think?" I get that at least weekly.

My experience too. And I remember on quite a few occasions in Med-school and residency when a patient would tell a specialist “I’m going to talk to my doctor about it first” when an intervention was proposed.

 

[Lexdiamondz]

I feel like this gets explained fairly often: midlevels are under your authority, other doctors aren't.

This.

I can't tell if OP is just wilfully obstinate about this or really is just too obtuse to see this point of nuance (either due to inexperience or organic shortcomings). Your license gives you free reign to do basically anything an employer will credential you for. That being said, it takes a decent amount of self reflection before you start doing things well outside the commonly accepted scope of your training - if one accepts the potential liability on their end for bad outcomes and understands that you'll be under the microscope as someone not formally trained in XYZ.

 

[AMEHigh]

Maybe my situation isn't common, but the specialists everywhere I've worked kiss our asses (we are the source of a lot of their business after all) and patients value our opinions more than their's quite often. Its very possible that behind closed doors the specialist talk badly about us, but they know better than to say that to either us or our patients.

How many times have you had a patient come back to you and say "Dr. Specialist said I need this test/procedure, what do you think?" I get that at least weekly.

Yeah I guess I should’ve clarified. The judging of FM seems to mostly occur in the academic setting like during med school and a little bit in residency (I guess per your previous post the OP is in residency?) FM certainly isn’t seen as a rigorous specialty when people talk about what they want to apply to.

But yes I absolutely agree with you that once you get in the "real world" community good FM docs are well respected.

It’s kind of like the DO vs MD thing. It gets talked about practically every day but again once you get in the real world no one cares whether you’re a DO or MD.

 

[MedicineZ0Z]

I guess I misunderstood your OP.
I thought you were saying FM docs themselves were "freaking out" and referring.
Now you’re talking about other specialists not feeling confident in our skills like your hospitalist example.
Well FM has been **** on for awhile now with the rise of specialists and fragmented care. I certainly don’t take it personal. Everyone thinks they do their jobs the best.
As far as mid levels go, that often comes down to money.

I was saying that. This is both within the specialty and outside of it. Like some give FM heat for doing cosmetic injections, and those people have 0 personal vested interest in it. Yet RNs are doing it. Like cmon...

We docs are our own worst enemies. I knew that from day one of my clinical rotations as a student. The surgery chief would yell and act tough towards us but then runs and cuddles the nurses. Show love, but come on man/woman show love more to your fellow brethren. This negative behavior has continued all the way and it is the main reason we have been sold out by our superiors and we’ve created the rise of mid levels. Why do we even call them midlevels, when we give the privileges of a doc. It’s gone to their heads and now all are claiming equality. Now we want to put up a fight?

True. I strive to be the opposite of your chief everyday.

 

[styphon]

To expand upon this a little bit: in this example I can probably do 90% of what endocrine can for diabetes. Its that last 10% that gets tricky - pumps, U-500, stuff like that.

I do not feel the same way. Each attending will have their strengths and weaknesses. For example, as family medicine I start and manage Insulin pumps. I have used U-500. I have two educators/nutritionist. There is nothing an endo can offer re: DM that I can't.

I do feel push back from specialists. I am the only FM in my large hospitalist group, and they were hesitant to hire me because of this and at the same time we hire brand new PA/NPs. Another example: When I was doing OB, some OB's refused to include me into coverage groups. Another example: The local rural ER's would not interview me because I am FM boarded and not EM, yet hired midlevels to work unsupervised.

 

[MedicineZ0Z]

I do not feel the same way. Each attending will have their strengths and weaknesses. For example, as family medicine I start and manage Insulin pumps. I have used U-500. I have two educators/nutritionist. There is nothing an endo can offer re: DM that I can't.

I do feel push back from specialists. I am the only FM in my large hospitalist group, and they were hesitant to hire me because of this and at the same time we hire brand new PA/NPs. Another example: When I was doing OB, some OB's refused to include me into coverage groups. Another example: The local rural ER's would not interview me because I am FM boarded and not EM, yet hired midlevels to work unsupervised.

Bingo

 

[VA Hopeful Dr]

I do not feel the same way. Each attending will have their strengths and weaknesses. For example, as family medicine I start and manage Insulin pumps. I have used U-500. I have two educators/nutritionist. There is nothing an endo can offer re: DM that I can't.

I do feel push back from specialists. I am the only FM in my large hospitalist group, and they were hesitant to hire me because of this and at the same time we hire brand new PA/NPs. Another example: When I was doing OB, some OB's refused to include me into coverage groups. Another example: The local rural ER's would not interview me because I am FM boarded and not EM, yet hired midlevels to work unsupervised.

You'll notice that in my post I specifically said "I can probably do 90% of what endocrine can for diabetes." There are FPs out there who are good with U-500 and pumps. They are not me. As you point out, we all have strengths and weaknesses. I have never met an FP who was the equal of every single subspecialist in every pathology. When you refer is up to a combination of your personal comfort level and the local culture. For instance, I'm a fair hand at injections for carpal tunnel (get it, fair hand?). But when I moved 3 years ago, the local hand guys would always do an injection when I referred the patient even if I had already done one. After the first dozen or so got no better with that second injection, I stopped doing them myself. It obviously had nothing to do with my technical skills (since the ortho didn't get better results than I did) but they weren't going to change their practice and it didn't seem right subjecting the patient to 2 injections that didn't work.

Beyond that, I feel like you're making the same arguments that keep getting addressed.

You have trouble getting inpatient privileges because lots of FP programs are very weak on the inpatient end. Even weak IM programs get more inpatient experience than all but the absolute best FP programs.

Midlevels aren't doctors. I would wager those NP/PAs are working under someone elses license - even if you're in a state where they can practice without supervision that doesn't mean the hospital will let them do that. Or barring that, paying them way less than you (hence point #1 in post #34). Same applies to the ED groups you've tried to find work with. Its one of those 2 things, no question. Usually both.

Hearing from former classmates of mine who did OB work after residency, the issue with sharing OB coverage is usually because they don't trust us to be able to manage c-sections or more commonly some of the complications resulting from c-sections.

 

[Vandalia]

I do feel push back from specialists. I am the only FM in my large hospitalist group, and they were hesitant to hire me because of this and at the same time we hire brand new PA/NPs. Another example: When I was doing OB, some OB's refused to include me into coverage groups. Another example: The local rural ER's would not interview me because I am FM boarded and not EM, yet hired midlevels to work unsupervised.

I think there is some misconception about "unsupervised" in the ED.

At least where I have worked, there were very tight parameters on what a mid-level was expected and allowed to do. YOU WILL use only these medications in these doses for these indications. There was a very specific algorithm for how cases would be handled and at what point the attending needed to be consulted. Follow the algorithm. No thinking. I/we did not want creativity. Now, there were exceptions for specialized circumstances. Years ago we had a patient come in s/p recent liver transplant. Nothing terribly significant. The NP had worked for over a decade on a university transplant service and suggested that a particular medicine seemed to work well for this particular symptom in that population. Fine, it was an option I would have considered, so why not?

The same appears to be true for other specialties. Yes, they may end up working in a lot of different practices, but the same basic rules hold true: do it my way (the physicians's way) or else. My wife is a patient for a pain management practice and sees a NP for follow-up visits. The NP can basically keep things the same, but anything else requires a physician visit.

The difference is that family med docs are physicians and rightfully expect to approach a case as a physician. That can create a problem. I know exactly what to expect from an NP/PA since if they don't do it my way, they are gone. Unfortunately, that is not true for a physician. What might be brilliant management for an outpatient could be malpractice int he ED.

Apples and oranges.

So yes, often we prefer midlevels to physicians in the ED - and probably the same in other specialties. A physician doing their own thing is better than a PA/NP doing their own thing.... but an NP doing exactly what I want beats a physician from another specialty doing their own thing.

 

[MedicineZ0Z]

You'll notice that in my post I specifically said "I can probably do 90% of what endocrine can for diabetes." There are FPs out there who are good with U-500 and pumps. They are not me. As you point out, we all have strengths and weaknesses. I have never met an FP who was the equal of every single subspecialist in every pathology. When you refer is up to a combination of your personal comfort level and the local culture. For instance, I'm a fair hand at injections for carpal tunnel (get it, fair hand?). But when I moved 3 years ago, the local hand guys would always do an injection when I referred the patient even if I had already done one. After the first dozen or so got no better with that second injection, I stopped doing them myself. It obviously had nothing to do with my technical skills (since the ortho didn't get better results than I did) but they weren't going to change their practice and it didn't seem right subjecting the patient to 2 injections that didn't work.

Beyond that, I feel like you're making the same arguments that keep getting addressed.

You have trouble getting inpatient privileges because lots of FP programs are very weak on the inpatient end. b]Even weak IM programs get more inpatient experience than all but the absolute best FP programs.[/b]

Midlevels aren't doctors. I would wager those NP/PAs are working under someone elses license - even if you're in a state where they can practice without supervision that doesn't mean the hospital will let them do that. Or barring that, paying them way less than you (hence point #1 in post #34). Same applies to the ED groups you've tried to find work with. Its one of those 2 things, no question. Usually both.

Hearing from former classmates of mine who did OB work after residency, the issue with sharing OB coverage is usually because they don't trust us to be able to manage c-sections or more commonly some of the complications resulting from c-sections.

Only thing I disagree with here is that it's deferring to quantity over quality. Treating simple cases endlessly isn't the same as treating a multitude of complex patients. And you can't put a 1:1 time ratio on it.