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

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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.
Ever heard the saying "quantity has a quality all it's own"?

I think if you imagine 2 bell curves with an overlap that's the best way to picture that. One being IM inpatient training and one being FM. On average, they get more and better inpatient. Not 100% of course, but mostly.

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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.

Fair. That being said it's hard to argue that you have a significant volume of complex patients when you have a much lower volume of simple patients. You're gonna have a tough time convincing someone with 24 months of inpatient medicine that you saw comparable pathology of adequate complexity in 12 mos.
 
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What’s the point of this thread, again?

Are we going to be measuring distance or velocity in the contest of urination?
 
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What’s the point of this thread, again?

Are we going to be measuring distance or velocity in the contest of urination?

Distance dude.

Velocity is for nerds.
 
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Fair. That being said it's hard to argue that you have a significant volume of complex patients when you have a much lower volume of simple patients. You're gonna have a tough time convincing someone with 24 months of inpatient medicine that you saw comparable pathology of adequate complexity in 12 mos.

The lower quality IM programs are COPD/PNA/CHF shops where you have 4-5 patients per resident. That's different than having a near consistent 10 patients per resident ratio, with a lot of complex pathology/lots of codes and rapids/doing your own procedures and minimal social admits. I do know the latter is only a minority of FM programs but it's not realistic to say that the former cohort will be absolutely better suited for inpatient medicine.


Plus it all goes out the window 3-4 years into practice. And the individual factor plays a huge role, especially for inpatient medicine.

I'm a little confused about your bolded comment btw.
 
I think there is some misconception about "unsupervised" in the ED.
...
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.

I think you misunderstood my wording. Our rural ERs have midlevels working ALONE, there is no physician in the hospital at all. Sure, someone signs charts at a later date, but that physician is not present in the hospital at all. This amounts to complete autonomy.
 
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The lower quality IM programs are COPD/PNA/CHF shops where you have 4-5 patients per resident. That's different than having a near consistent 10 patients per resident ratio, with a lot of complex pathology/lots of codes and rapids/doing your own procedures and minimal social admits. I do know the latter is only a minority of FM programs but it's not realistic to say that the former cohort will be absolutely better suited for inpatient medicine.


Plus it all goes out the window 3-4 years into practice. And the individual factor plays a huge role, especially for inpatient medicine.

I'm a little confused about your bolded comment btw.


I'm confused why you insist on comparing the extreme margins of different specialties. Arguing that the top 5% of FM residents are getting better inpatient medicine training than the bottom 5% of IM residents seems irrelevant. Both training pathways offer adequate exposure to hospital medicine for a graduate of either to be an adequate hospitalist, but I don't see the controversy in saying that a specialty with much more exposure (in some cases literally twice as much) will be better prepared out of the gate.



I think you misunderstood my wording. Our rural ERs have midlevels working ALONE, there is no physician in the hospital at all. Sure, someone signs charts at a later date, but that physician is not present in the hospital at all. This amounts to complete autonomy.

I mean if there is no physician anywhere in the hospital at all then 1) I wouldn't call it a hospital and 2) this is clearly a systemic issue, not solely an EM staffing issue.


Most of these places that have solo midlevels are flaming piles of **** that don't pay enough to entice a BCEM doc anyway. If you want to work in an ER for the 75$/hr they pay most of these midlevels then go ahead.
 
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I read through most of these comments, a lot of this was off topic, but, going back to the original post, I think some of the problem comes down to stigma. This is my theory, I'm not claiming to be right but: Unfortunately, FM pays less than most specialties. So unfortunately, this specialty will become the "fall back" for students who are less successful. I know this isn't 100% true, but I'm willing to be there is a correlation between less successful students and work ethic. So, you have 15 years of FM being the lowest scorers / lowest work ethic students (maybe) and ultimately you might get a large proportion of Family Docs who just want to take care of the easy stuff, and because they're trying to capitalize on money they aren't getting because they deep down wanted to be a surgeon but didn't have the grades... they know that taking the time to dive deep to discover their own solutions to a patient's complex problems would just take away from their bottom line so they quickly rummage through cases and sift the harder cases to the specialists. Ultimately, this gets a bunch of specialists going "FM can't take care of this" because those select few FM docs didn't want to, and made the specialist think this way, and therefore others on a whole.

Like I said, this is just a theory, to defend the OP, as a medical student foraging through these forums, I have actually seen this sentiment before. I too cannot Copy and Paste exact quotes because I don't even know where I'd begin searching, it's not typically a whole "thread" because no one would attack the FM specialty like that, but random comments here and there. But there definitely is this culture, at least on SDN, of deconstructing the Family Physicians scope. I think it comes down more to turf protection rather than purely thinking FM is not capable, but regardless of the reason, I've seen it, although it's not too wide spread.

I think too a lot of FM might only refer a lot of complicated patients out and therefore students rotating through their offices love FM, they just think it's "Boring" - which in my mind seems silly because they can treat EVERYTHING, but maybe because those FM docs spend so much time on HTN, TIIDM, COPD, CHF, that they think that's all the specialty is because they just reflex triage to the specialist for anything complicated.

I am interested in FM because I am interested in every subspecialty, and I don't care about money and just wanna be a well-rounded Doctor, so I definitely hope this trend doesn't appear in real life, because I want patient's to trust me to be the detective I know I can be, and be able to save them money from not sending them from specialist to specialist. Keep your head up OP, be a good FM doctor for the future generations to get a better rep!
 
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It's actually much simpler than that.

Complicated patients take time. Simple patients take less time.

We aren't lawyers and don't bill based on time. I make the same amount of money spending 5 minutes on a poison ivy patient as I do spending 30 on a CHF/CKD/DM patient.

Lots of us use the easy patients to make up for the complicated ones. Sadly, lots of FPs keep the easy and punt the complicated ones.
 
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It's actually much simpler than that.

Complicated patients take time. Simple patients take less time.

We aren't lawyers and don't bill based on time. I make the same amount of money spending 5 minutes on a poison ivy patient as I do spending 30 on a CHF/CKD/DM patient.

Lots of us use the easy patients to make up for the complicated ones. Sadly, lots of FPs keep the easy and punt the complicated ones.
Primary care IM does this too lol. If anything I've seen (through my observation) way more referrals from IM than FM. And primary care Peds? Drastically more referrals.
 
I'll try to be civil here, but for every good pcp who manages their patients with complex diseases without consults there are those who are playing outside of their area of training and exposure and simply based on what they've read in a book or based on the notion that they've seen it work or experienced it work a few times.

Also I think it's weird that you continue to focus weirdly on this notion that your inpatient training is extremely active and you're seeing all of these zebras and that this thus makes you a good inpatient physician or better or equal to IM trained doctors. Except that's simply not what inpatient is about. Medicine is nuance and complex and the most complicated patients are not the zebras, those you will always get and have specialists to help you out with or be shipped out to a different division or institute entirely for better treatment ( Because fundamentally their care will be better withe early consults and specialized and superspecialized specialists will simply as a fact make less mistakes than generalists).
The most complicated patients are the ones who have simple and abundant chronic illnesses and need time to stratify and understand their interplay. The patient who is in heart failure, but not really or the patient with a differential of 3 separate possible illnesses and the need to figure out which one is better to treat first. And fundamentally these are the ones that give me more grief when I'm rounding than the ones who come in with either a very severe and acute illness or something that needs me to work up.

Either way I think you need to decide whether what you're doing is right for the patient. Not just right for your ego.
 
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The lower quality IM programs are COPD/PNA/CHF shops where you have 4-5 patients per resident. That's different than having a near consistent 10 patients per resident ratio, with a lot of complex pathology/lots of codes and rapids/doing your own procedures and minimal social admits. I do know the latter is only a minority of FM programs but it's not realistic to say that the former cohort will be absolutely better suited for inpatient medicine.


Plus it all goes out the window 3-4 years into practice. And the individual factor plays a huge role, especially for inpatient medicine.

I'm a little confused about your bolded comment btw.

I think there's some issues with having a 'general wards' rotation where you're exclusively dealing with just complex pathology or not dealing with social admits. It's general for a reason. The sub specialty rotations are more or less for that and for learning that.

General wards is, well just that. To learn how to be a general internist/hospitalist.
 
I'll try to be civil here, but for every good pcp who manages their patients with complex diseases without consults there are those who are playing outside of their area of training and exposure and simply based on what they've read in a book or based on the notion that they've seen it work or experienced it work a few times.

Also I think it's weird that you continue to focus weirdly on this notion that your inpatient training is extremely active and you're seeing all of these zebras and that this thus makes you a good inpatient physician or better or equal to IM trained doctors. Except that's simply not what inpatient is about. Medicine is nuance and complex and the most complicated patients are not the zebras, those you will always get and have specialists to help you out with or be shipped out to a different division or institute entirely for better treatment ( Because fundamentally their care will be better withe early consults and specialized and superspecialized specialists will simply as a fact make less mistakes than generalists).
The most complicated patients are the ones who have simple and abundant chronic illnesses and need time to stratify and understand their interplay. The patient who is in heart failure, but not really or the patient with a differential of 3 separate possible illnesses and the need to figure out which one is better to treat first. And fundamentally these are the ones that give me more grief when I'm rounding than the ones who come in with either a very severe and acute illness or something that needs me to work up.

Either way I think you need to decide whether what you're doing is right for the patient. Not just right for your ego.

PGY3 FM resident here at an academic medical center with the majority of specialty residencies present.

IM program here has multiple medicine floor teams with a rotating cap that pawns new patients onto the next team when capped (set at a modestly low number) and then to the private hospitalist group once all teams cap. Also, private hospital in town that they do not work at. They admit all clinic patients up to the cap and if anyone needs ICU they transfer care to the unit team.

FM program has one floor team at each hospital. At the university hospital we also admit all clinic patients and utilize the MICU, CICU, SICU, and NeuroICU as open units and manage all our own patients in the unit. Service never caps and frequently hits 25-30 patients for 3-4 residents. Vast majority of patients have many comorbidities at odds with one another (ESRD on HD, CHF with EF < 20, high MELD cirrhosis, etc) with very few bread and butter pyelo in an otherwise healthy admissions. Manage our own inpatient pediatrics and on call FM labor and delivery with this team, as well.

Private hospital similarily has a single team covering that functions as a private hospitalist group and is on 24 hour unassigned call every 4 days. ICUs largely open over there too with us managing the majority of our critical patients.

At the university hospital, patient census volumes are private hospitalist >>> FM > IM, not including the extra volume at the second hospital.

So, are we just a unique residency or is the difference between FM and IM general inpatient training less pronounced than many would indicate?
 
So, why are you slumming in the FM forum? Surely, you aren't trying to convince us that being a referral machine is supposed to be the norm in primary care?

No, just responding the OP mainly. We've butted heads many times. Also your forum is more entertaining than the IM forum.

What kind of wine are we going to get?
 
No, just responding the OP mainly. We've butted heads many times. Also your forum is more entertaining than the IM forum.

What kind of wine are we going to get?

Whatever @MedicineZ0Z is buying. Apparently, it's his party. I'm no wine snob. Four buck Chuck is fine with me.
 
PGY3 FM resident here at an academic medical center with the majority of specialty residencies present.

IM program here has multiple medicine floor teams with a rotating cap that pawns new patients onto the next team when capped (set at a modestly low number) and then to the private hospitalist group once all teams cap. Also, private hospital in town that they do not work at. They admit all clinic patients up to the cap and if anyone needs ICU they transfer care to the unit team.

FM program has one floor team at each hospital. At the university hospital we also admit all clinic patients and utilize the MICU, CICU, SICU, and NeuroICU as open units and manage all our own patients in the unit. Service never caps and frequently hits 25-30 patients for 3-4 residents. Vast majority of patients have many comorbidities at odds with one another (ESRD on HD, CHF with EF < 20, high MELD cirrhosis, etc) with very few bread and butter pyelo in an otherwise healthy admissions. Manage our own inpatient pediatrics and on call FM labor and delivery with this team, as well.

Private hospital similarily has a single team covering that functions as a private hospitalist group and is on 24 hour unassigned call every 4 days. ICUs largely open over there too with us managing the majority of our critical patients.

At the university hospital, patient census volumes are private hospitalist >>> FM > IM, not including the extra volume at the second hospital.

So, are we just a unique residency or is the difference between FM and IM general inpatient training less pronounced than many would indicate?

Shrugs, I'm not in FM. And I only know how a few FM ppl are doing their residencies. They range from not being in the hospital outside of like 3 months a year to a solid 16-18 their total.

Also I could be wrong, but that is what bread and butter IM is. Albeit... busy. 20-25 pts split between 3 interns is probably busy, but do able. 20-25 with half in ICUs that will need procedures and or who need significant baby sitting? Sounds unsustainable...
 
I'll try to be civil here, but for every good pcp who manages their patients with complex diseases without consults there are those who are playing outside of their area of training and exposure and simply based on what they've read in a book or based on the notion that they've seen it work or experienced it work a few times.

Also I think it's weird that you continue to focus weirdly on this notion that your inpatient training is extremely active and you're seeing all of these zebras and that this thus makes you a good inpatient physician or better or equal to IM trained doctors. Except that's simply not what inpatient is about. Medicine is nuance and complex and the most complicated patients are not the zebras, those you will always get and have specialists to help you out with or be shipped out to a different division or institute entirely for better treatment ( Because fundamentally their care will be better withe early consults and specialized and superspecialized specialists will simply as a fact make less mistakes than generalists).
The most complicated patients are the ones who have simple and abundant chronic illnesses and need time to stratify and understand their interplay. The patient who is in heart failure, but not really or the patient with a differential of 3 separate possible illnesses and the need to figure out which one is better to treat first. And fundamentally these are the ones that give me more grief when I'm rounding than the ones who come in with either a very severe and acute illness or something that needs me to work up.

Either way I think you need to decide whether what you're doing is right for the patient. Not just right for your ego.

I think there are two different arguments here.

1.) We are in agreement that no body should treat something purely for their ego. With that being said, I think if a patient is presenting with new symptoms and you clearly diagnose said individual, you should be able to treat them with the first couple lines of therapy if you've done your homework, know what to watch for, know what blood tests they need to be monitored for, and any sequelae of that. Obviously this post is not about never sending anyone to a specialist - Medicine is a team sport - But just as the specialist is an expert, inevitably a smart person who's referred a patient to a specialist several times and picks up their patterns will know what they might do next and how you can predict their care patterns and therefore have the patient 100% fattened up before serving them all juicy for the specialist to dig in and know immediately "what's up". A good PCP can make the life of that specialist (and patient) way easier, but only if they exercise their ability to do so, and not get content just triaging and treating 5 things. But, that does require "exercising", you don't use it, you lose it.

2.) I think when people talk about FM they traditionally mean outpatient. With that being said, a FM doc who's done more inpatient and has worked several years as a hospitalist I have no doubt in my mind they are just as competent inpatient as an IM doctor. It's all about what the physician has trained and prepared themselves for, just as it might be a bit of a shock for an inpatient IM or FM doc to move outpatient after several years of inpatient work. It's good for FM to get this exposure inpatient because you need to know what will happen in the hospital and more importantly, what can land your patients in the hospital. In the hospital, you can have your way with anyone - They're yours. You want that specialist? They're there. You want that patient to get that med or take that test? They do it, with an aid/nurse personally bringing them directly to it. The outpatient animal is, yes, the patient with 3-4 chronic complaints that are difficult to manage needs to see 2 specialists. But...... due to any number of social determinants of medicine, there is a high likelihood that patient WILL NOT be able to follow up with said specialists. Whether it be financial, psychiatric, physical, whatever. So ultimately, if you're not prepared to do that for your patient, you're doing them a disservice, but you can only do that for them if you've been committed to learning and not just passing off anyone difficult.

I think outpatient and inpatient are completely different animals. I think it's sad that PCPs no longer round on their patients in the hospital. I obviously understand why it's just not feasible with the complexities of todays world. But it's sad because this person who really should have an intimate relationship with the patient seeing them could probably save so much time and money by not re-inventing the wheel.

I think telemedicine is going to have the biggest impact on the life of a PCP. Imagine being able to "tele-consult" with such fluidity and ease. Put a go-pro on my head, watch me do this physical exam, ask the patient questions in real time, share-screen the patient chart, etc. etc. And this could definitely change the landscape as to how fast and efficient patients can get treated, but ultimately the PCP needs to stretch and workout their brain so they can be more efficient to rely less on specialists, but know they're always there when you need them. I think we are in agreement and this is more semantics, I think specialists might sometimes get this motherly instinct kick-in like when they have to watch their kid use a butcher knife for the first time. They have to trust, be always be ready to jump in or critique as needed, but eventually the PCP should be trusted and know what they are / are not good at.
 
Primary care IM does this too lol. If anything I've seen (through my observation) way more referrals from IM than FM. And primary care Peds? Drastically more referrals.
I think it depends on the area. For instance IM tends to refer MSK more quickly then FM does, but they tend to refer to cardiology less than we do.

Outside of GYN (which peds seem very uncomfortable with), everyone refers peds patients quickly as you should.
 
I think there are two different arguments here.

1.) We are in agreement that no body should treat something purely for their ego. With that being said, I think if a patient is presenting with new symptoms and you clearly diagnose said individual, you should be able to treat them with the first couple lines of therapy if you've done your homework, know what to watch for, know what blood tests they need to be monitored for, and any sequelae of that. Obviously this post is not about never sending anyone to a specialist - Medicine is a team sport - But just as the specialist is an expert, inevitably a smart person who's referred a patient to a specialist several times and picks up their patterns will know what they might do next and how you can predict their care patterns and therefore have the patient 100% fattened up before serving them all juicy for the specialist to dig in and know immediately "what's up". A good PCP can make the life of that specialist (and patient) way easier, but only if they exercise their ability to do so, and not get content just triaging and treating 5 things. But, that does require "exercising", you don't use it, you lose it.

I think there are clear guidelines when you should send a patient to a specialist. I think it's also more complicated than just watch for the common sequale and knowing what drug. A common disease such as osteoporosis can be really mismanaged to the point that we actually saw increased fracture rates because people didn't know enough about the second line agents they started prescribing as quazi first line agents. Same thing with seroquel being a fad until people needed to slam the hammer and tell people it was making old folk delirious and caused more trouble. I think there's plenty of room for a second opinion and extra management if it means the patient will have statistically better outcomes.

I mean there's really a lot that I'm not allowed to do. If a pt has HIV I could easily order all the labs for genotype testing and start them on a first line anti-retroviral. But I also don't see enough of these patients to be 100% sure I'm missing something big or some new guideline that came out in the I.D literature. So to the ID doctor they go.


2.) I think when people talk about FM they traditionally mean outpatient. With that being said, a FM doc who's done more inpatient and has worked several years as a hospitalist I have no doubt in my mind they are just as competent inpatient as an IM doctor. It's all about what the physician has trained and prepared themselves for, just as it might be a bit of a shock for an inpatient IM or FM doc to move outpatient after several years of inpatient work. It's good for FM to get this exposure inpatient because you need to know what will happen in the hospital and more importantly, what can land your patients in the hospital. In the hospital, you can have your way with anyone - They're yours. You want that specialist? They're there. You want that patient to get that med or take that test? They do it, with an aid/nurse personally bringing them directly to it. The outpatient animal is, yes, the patient with 3-4 chronic complaints that are difficult to manage needs to see 2 specialists. But...... due to any number of social determinants of medicine, there is a high likelihood that patient WILL NOT be able to follow up with said specialists. Whether it be financial, psychiatric, physical, whatever. So ultimately, if you're not prepared to do that for your patient, you're doing them a disservice, but you can only do that for them if you've been committed to learning and not just passing off anyone difficult.

Most FM docs can probably do either inpatient or outpatient. Same thing with IM. The difference is that IM's curriculum is loaded with more subspecialty rotations and ICU management. Most IM seniors will be managing a lot more critically ill patients and their volume and exposure with decompensated patients will influence their clinical decision making and triage. There are limits to what we can learn from our exposures.


I think that's fair. That being said, if my patient who has advanced cardiomyopathy or cirrhosis isn't going to their Cards or GI doctor. Then the most I can do is basic medical management. They need more than that and they'll either die on the way to getting it or get it in patient.


I think outpatient and inpatient are completely different animals. I think it's sad that PCPs no longer round on their patients in the hospital. I obviously understand why it's just not feasible with the complexities of todays world. But it's sad because this person who really should have an intimate relationship with the patient seeing them could probably save so much time and money by not re-inventing the wheel.

I think telemedicine is going to have the biggest impact on the life of a PCP. Imagine being able to "tele-consult" with such fluidity and ease. Put a go-pro on my head, watch me do this physical exam, ask the patient questions in real time, share-screen the patient chart, etc. etc. And this could definitely change the landscape as to how fast and efficient patients can get treated, but ultimately the PCP needs to stretch and workout their brain so they can be more efficient to rely less on specialists, but know they're always there when you need them. I think we are in agreement and this is more semantics, I think specialists might sometimes get this motherly instinct kick-in like when they have to watch their kid use a butcher knife for the first time. They have to trust, be always be ready to jump in or critique as needed, but eventually the PCP should be trusted and know what they are / are not good at.

Honestly for half of my clinic patients I really kiss the ground that a lot of subspecialists walk on. Why? Because those patients need an extra person following them to keep them from dying. One visit to me q 1 to 3 months is great, but now they have someone watching them and being specific about their chronic problem. Half of my patients I cannot even get to their chronic medical problems because they come in with new issues ex I'm in a COPD AE or I broke my arm or etc. But then they go to their GI doctor and they can say I only care about your varices and make sure those aren't getting worse.

I think there is a whole lot of things we can do in primary care. And no you don't need to be a referologist. But sometimes pts benefit because you don't know the diseases as well as a specialist.
 
FM physicians who work outpatient are God... How do you guys do it?

I only work 5 hrs/wk outpatient as an IM resident and I always have a bunch of messages every week that patients need this or that. They want me to call them. I can't imagine how many messages I would have in my EPIC in-basket if I do outpatient 40hrs/wk.

Also, my program requires that we call every patient to discuss test results with them even if they are normal...


How do you guys deal with these things?
 
FM physicians who work outpatient are God... How do you guys do it?

I only work 5 hrs/wk outpatient as an IM resident and I always have a bunch of messages every week that patients need this or that. They want me to call them. I can't imagine how many messages I would have in my EPIC in-basket if I do outpatient 40hrs/wk.

Also, my program requires that we call every patient to discuss test results with them even if they are normal...


How do you guys deal with these things?
I haven't called a patient personally (before COVID) in several years.

I don't fill out forms, my staff does and I just sign them.

99% of refills require an office visit, train your patients in this and life gets way better.
 
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FM physicians who work outpatient are God... How do you guys do it?

I only work 5 hrs/wk outpatient as an IM resident and I always have a bunch of messages every week that patients need this or that. They want me to call them. I can't imagine how many messages I would have in my EPIC in-basket if I do outpatient 40hrs/wk.

Also, my program requires that we call every patient to discuss test results with them even if they are normal...


How do you guys deal with these things?

Your residency program has you doing this all wrong. You can’t work harder than your patients do.

I don’t call patients, I don’t speak to them on the phone. I will communicate through my MA. But if they want to speak to me personally then it’s an office visit.

I don’t fill out nonsense paperwork, if you have a form you need filled out, you come in to the office so we can work on it together.

We have a patient portal, all results communication goes through there. If it’s critical, my staff will call the patient at my direction but otherwise people know to check their portal. And if they call for results, they’re directed to the portal where generally I’ve typed a message explaining the results and their significance and any recommended course of action.

In to work at 8, out by 5 is my motto.
 
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I thought my program was typical. I sometimes intentionally not log into EPIC when I am off because there will be a few messages from our MA/LPN/RN about patients that I saw months ago needing this or that. Or patient left some form in the clinic for me to fill out.

The program has ~80 residents and I only know 1 or 2 residents who do not hate going to that clinic. It's madness!
 
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Your residency program has you doing this all wrong. You can’t work harder than your patients do.

I don’t call patients, I don’t speak to them on the phone. I will communicate through my MA. But if they want to speak to me personally then it’s an office visit.

I don’t fill out nonsense paperwork, if you have a form you need filled out, you come in to the office so we can work on it together.

We have a patient portal, all results communication goes through there. If it’s critical, my staff will call the patient at my direction but otherwise people know to check their portal.

In to work at 8, out by 5 is my motto.

Idk how everyone else's resident clinics are but my clinic is basically populated by patients teetering on the edge of demise with 5 chronic problems attempting to kill them at all times. I've at least once a month I will literally beg people to take medicines to keep them from dying. If I don't care more than they do, then no one will.
 
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FM physicians who work outpatient are God... How do you guys do it?

I only work 5 hrs/wk outpatient as an IM resident and I always have a bunch of messages every week that patients need this or that. They want me to call them. I can't imagine how many messages I would have in my EPIC in-basket if I do outpatient 40hrs/wk.

Also, my program requires that we call every patient to discuss test results with them even if they are normal...


How do you guys deal with these things?

Because not a single practical outpatient clinic should ever mirror an Internal Medicine run resident clinic. We are literally the last line for the patients who everyone else has fired.
 
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Idk how everyone else's resident clinics are but my clinic is basically populated by patients teetering on the edge of demise with 5 chronic problems attempting to kill them at all times. I've at least once a month I will literally beg people to take medicines to keep them from dying. If I don't care more than they do, then no one will.
How many times can we keep begging someone with HFrEF, ESRD, HTN, DM2 with an A1C of 12+ to take their meds?
 
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Idk how everyone else's resident clinics are but my clinic is basically populated by patients teetering on the edge of demise with 5 chronic problems attempting to kill them at all times. I've at least once a month I will literally beg people to take medicines to keep them from dying. If I don't care more than they do, then no one will.
Hard pass.

I will explain why they should take their medications. After that, it's on them.
 
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Idk how everyone else's resident clinics are but my clinic is basically populated by patients teetering on the edge of demise with 5 chronic problems attempting to kill them at all times. I've at least once a month I will literally beg people to take medicines to keep them from dying. If I don't care more than they do, then no one will.

Including them apparently.

And that type of chronic disease burden is very common. And non-compliance is often a conditioned response.

I’m always clear with people that I worry they may die if they don’t take their meds or follow advice. I document these discussions in the chart. I also do a LOT of education during visits. My patients know why I am recommending a course of action when I do. They know my assessment of the risks of not following my advice.

In the end, patients have the right to let themselves go. And I’m very willing to stress to them that they shouldn’t do it, but ultimately it’s their call.
 
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I have patients who are admitted to the hospital literally every month for the same thing...

Not your fault if you’ve been recommending and providing appropriate management. Patients are responsible for their own health, we’re in an advisory and facilitation role only.
 
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How many times can we keep begging someone with HFrEF, ESRD, HTN, DM2 with an A1C of 12+ to take their meds?


Honestly, I do it once or twice. Then I ask for the patient to be reassigned to a different resident.
 
Honestly, I do it once or twice. Then I ask for the patient to be reassigned to a different resident.

Have you ever asked a patient what barriers they face to following your recommendations? Asked them why they don’t follow them if they can’t identify any socioeconomic barriers? Invited them to take ownership of their own health (I.e. stressed your inability to make them healthy, but rather that you can only provide them an avenue that THEY can CHOOSE to follow in order to become more healthy)? Or helped them see the ties their health has to the other trials they face (difficulty working; pursuing hobbies and interests, feeling fulfilled with life, maintaining relationships etc)?

If the answer is no to any of that, give it a try. If yes to all of it, then stop beating yourself up; and set some realistic expectations (and share them with your patients).
 
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Have you ever asked a patient what barriers they face to following your recommendations? Asked them why they don’t follow them if they can’t identify any socioeconomic barriers? Invited them to take ownership of their own health (I.e. stressed your inability to make them healthy, but rather that you can only provide them an avenue that THEY can CHOOSE to follow in order to become more healthy)? Or helped them see the ties their health has to the other trials they face (difficulty working; pursuing hobbies and interests, feeling fulfilled with life, maintaining relationships etc)?

If the answer is no to any of that, give it a try. If yes to all of it, then stop beating yourself up; and set some realistic expectations (and share them with your patients).
I am sure all PCP do that and have SW involved if patients have barriers... Some patients have no barriers but for one reason or another, they decide not to follow your recs.

I have a few wonderful patients that will follow to the T your recs, but many of my patient don't care. I don't want start my career feeling that I am powerless to do what I am trained to do.
 
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I am sure all PCP do that and have SW involved if patients have barriers... Some patients have no economic barriers but for one reason or another, they decide not to follow your recs.

I have a few wonderful patients that will follow to the T your recs, but many of my patient don't care. I don't want start my career feeling that I am powerless to do what I am trained to do.
You aren’t trained to make them take meds and act right, so you are powerless for that which is fine because it’s not your job

you should be trained to prescribe the right thing and give good advice. That is the end of your responsibility
 
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Or helped them see the ties their health has to the other trials they face (difficulty working; pursuing hobbies and interests, feeling fulfilled with life, maintaining relationships etc)?

ED, desire for liposuction surgery...
 
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I am sure all PCP do that and have SW involved if patients have barriers... Some patients have no barriers but for one reason or another, they decide not to follow your recs.

I have a few wonderful patients that will follow to the T your recs, but many of my patient don't care. I don't want start my career feeling that I am powerless to do what I am trained to do.

You aren’t powerless. You seem to just have unrealistic expectations.
 
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I am sure all PCP do that and have SW involved if patients have barriers... Some patients have no barriers but for one reason or another, they decide not to follow your recs.

I have a few wonderful patients that will follow to the T your recs, but many of my patient don't care. I don't want start my career feeling that I am powerless to do what I am trained to do.
Many residents and early attendings (and I was guilty of this as well) get too invested in their patients. Our job is to give recommendations. If the patient doesn't take them, that's not your fault. You educate, warn about the consequences if they don't take your advise, and that's that. Move on to the next patient, they might actually want your help.
 
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Idk how everyone else's resident clinics are but my clinic is basically populated by patients teetering on the edge of demise with 5 chronic problems attempting to kill them at all times. I've at least once a month I will literally beg people to take medicines to keep them from dying. If I don't care more than they do, then no one will.

It is ok to care about your patients and go the extra mile. It is unnecessary to think you OWE your patient that extra mile. Presumably, you're doing good work with your patients as part of your regular day, which is what you owe them. Don't confuse martyrdom with responsibility.


Patients have to take responsibility for their own lives too.
 
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Your residency program has you doing this all wrong. You can’t work harder than your patients do.

I don’t call patients, I don’t speak to them on the phone. I will communicate through my MA. But if they want to speak to me personally then it’s an office visit.

I don’t fill out nonsense paperwork, if you have a form you need filled out, you come in to the office so we can work on it together.

We have a patient portal, all results communication goes through there. If it’s critical, my staff will call the patient at my direction but otherwise people know to check their portal. And if they call for results, they’re directed to the portal where generally I’ve typed a message explaining the results and their significance and any recommended course of action.


In to work at 8, out by 5 is my motto.

You must definitely live in an area in which people have the technology skills, reading skills and money to do that. Some of my patients don't even have phones. I'll often have patients sign up for the portal on our desk top while I'm putting in orders or filling out something and the ability of many of them to read and get through the instructions is often low. For those that are signed up on the portal I'd say about half the messages I send end up going unread.

I love my patients and the work that I do but for the person who asked about how we do it, it's not always a simple we can just send them everything through a portal and never call them to follow up or discuss issues. I don't mind calling patients and working on paperwork. Often times the expense to take public transportation to get to us is a burden or if they have childcare issues. I'd rather not make them drag 3 kids in to the office if I can just fill the paperwork out when their company faxes it to me.

Just wanted to point that out in case someone reading does work with a population similar to mine.
 
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