Thursday, April 23, 2009

Useful article for applicants

Here is a link to "Applying for Residency in OBGYN". The article can be generally helpful for those applying for other specialties as well, so I am posting here:
Application Help

Monday, April 13, 2009

Applying to Multiple Specialties

If you are an International Medical Graduate, you are likely to apply to multiple specialties to have a safe margin. But have you considered these consequences- Do you have the personality for this specialty? Can you can be really happy in either specialty? Is one of them a back-up where you'll feel trapped and hopeless?

I hope you seriously consider these issues when you apply for Residency training. Waiting for one more match year may sound really painful, but it's better to take a year off and strengthen your credentials for the specialty of your dreams rather than commiting yourself to something you're not happy about. It makes more sense to apply to PGY-1 preliminary programs ( eg. prelim-surgery) if you have to think at all about back-up, because switching specialties is very difficult ( you will need a letter from your current program director, find an open slot, interview there while in PGY-1) and you don't want to burn bridges behind you when you leave your current program. Program Directors are not a bunch of ogres but they want you to come to their program happy and fulfilled.

The most popular combination seems to be IM and FM-I confess I am guilty to this offence :-) I am interested in primary care focused mainly towards adults, but broad enough to cover the extremes of age, and extra training in behavioral and psychosocial issues. I also liked the hours of outpatient practice better than inpatient practice- and FM programs usually has better focus on clinics in PGY-2 and PGY-3, as well as having "practice management" incorporated in the curriculum, which helps tremendously in learning to set up your own practice in the real world. Both IM and FM being primary care programs seemed to meet my goals, so in essence neither of them were back-up for me.

As I started digging further when applying, I actually found out that although it seemed like FM programs set their score filters lower (usually 85 or 80, sometimes no score filters but graduation year less than 2), the number of slots were only 4-5 per program. This means that if you get 2 interviews in an IM program with 30 slots, you may have a better chance of "matching" than interviewing at 6 FM programs with 4-5 slots! Also keep in mind that a lot of DOs also apply to Family Medicine as many DOs have strong interest in Sports Medicine. Since DOs are essentially schooled in the US and have formal US clinical experience, they may have an edge over IMGs. Also, a lot of Family Medicine programs are not even IMG-friendly. Even though it's a fact that most AMGs do not choose primary care programs, there are still many AMGs who go into Family Medicine for the lifestyle, family reasons, geographical flexibility, or pure interest. By the time most medical students apply to residency training, they are have a significant other, or are married with kids. This changes a lot of things in their career goals. Eg. In a metropolitan area where it's very desirable to live, with very good cultural activities, and job opportunities for the spouse, you'll find that FM programs are very, very hard to break into because of the stiff competition from AMGs.

That said, if you are applying to both FM and IM, make sure that in the CAF you mention ambiguous descriptions like "Medicine Wards/floors- 1 month externship" instead of using the words " Internal Medicine- 1 month externship". That way "IM" will not pop out when they screen the CAF to filter out people who look like 'fakes'. It really hurts a program's schedule when a PGY-1 switches to another program and they will do everything possible to screen them out early in the process. Plus, residents who come looking like they don't really want to be there come across very poorly with everyone and we all know how much "interpersonal skills" contribute to the evaluation of residents.

Also, FM interviews are very different from IM interviews and needs special preparation. In my opinion, interviews plays a more critical role in FM than in IM because of several factors, some of which I outlined above and mentioned in my previous entries. There will be a strong behavioral component to the interview with thorough analysis about the questions you ask, your percieved interest and knowledge about the specialty, your personality and suitability for the specialty, how "real" you look, etc.

Sunday, April 12, 2009

Family Doctor Video Game

This is funny. There's actually a videogame simulating a day-in-the-life of a family doctor. Sounds almost like Step 2 CS.

Wednesday, April 8, 2009

Applying to Family Medicine Programs

FM is such a broad specialty, and there are so many ways to build your practice, that you really HAVE to think about that practice before you ever choose a program.

What do you want to be trained to do? What do you not really care about?
Are you looking for great outpatient volume, a well-organized clinic, moderate hospital and minimal to zero OB exposure?
How about a zillion procedures but not much clinic?
How about 2 months of colonoscopy training that counts for your 2 months of required surgery? Lots of electives so you can get in more EM months? Built in moonlighting?
Urban? Rural? Suburban? Patient Population and language needs?
Do you want to do lots of dermatology, or lots of pedatrics?
Are you interested in a niche patient population? eg. geriatric patients, cancer patients ( pain management comes into the picture), rehab and addiction psychiatry ( better exposure in inner-city population), sports injuries, adolescents ( typically close to a high school or college/university)

It's all up to you, and there are programs that will prepare you well for any and all of this. But you have GOT to do your homework! Don't expect one program to have it all. Do ask lots of very specific questions, then sit down with your chart and figure it out. When reviewing applicants, if they don't have any idea of what kind of practice they want, it doesn't look very good to the admission committee. You need to come in with some kind of idea of what you want. Of course you can change that and people do, but at least give it some thought before you interview.Surgeons, OB GYN, EM, etc. can pretty much pick a program and end up being trained to do what they need to do (with varying degrees of quality, of course). Family Medicine Residents have the blessing and the curse of tailor-making our future practice, and it starts when you start interviewing. Check out the AAFP directory of all residency programs. Talk to people who matched and find out how they like their program. Find out where else they interviewed and what they liked. This is a great way to make connections and get inside scoops. The big things I saw as differences were:

1. OB ( most programs have 2 months which is the ACGME limit but some maybe very OB heavy that may not be right for you if you don't want to practice OB). On the other hand, if you want to practice OB and go for a women's health fellowship then you should choose a program with heavy OB numbers because you need to meet a certain number of deliveries. You want to make sure the program can meet that number, or be flexible to allow an away-elective where you can meet the numbers. It is forecasted that in the near future, OB will be a hospitalist specialty ( just like IM Hospitalists, working 7 days on and 7 days off in shifts) and a lot of OBGYNs will stick to their clinic doing pre- or post-term work and GYN follow-up, while contracting their OB delivery work with those who are interested only in full-time OB hospitalist work. If OB is your interest, now is the a good time to go for it.

2. Inpatient peds- Many programs have rotations in another Children's Hospital, this could be a problem if you have to commute back and forth, plus you do not want to rotate at a hospital where the patient population in pediatrics is very different from what you will see at your practice after 3 years, eg. If you rotate at a tertiary-care pediatric hospital, you'll see a lot of rare, acute and serious cases which may not be within the scope of your practice.

3. Surgery- There are 2 months of required Surgery rotations. In certain programs you work as the first-assist where you actively participate in the surgery, while in others you are a second assist. Generally inpatient surgery is beyond the scope of Family Medicine so spending too much time of your rotation doing inpatient surgery first-assist is not useful. The better programs tailor the surgery rotations to fit the scope of a Family Medicine resident- they have more outpatient surgical procedures, pre-op and post-op evaluations, and surgical consults. All of these are routinely done by family medicine physicians and internists in the real-world so it is more relevant.

4. PACS or equivalent for imaging, Electronic Health Records (can you stomach the idea of 3 yrs looking at X-ray, CT and MRI hard copies?)

5. Patient population and language needs - Make sure it reflects the type of practice you are looking for. eg. Certain hospitals may have too many Geriatric patients but not much Pediatric patients, or vice versa. Inner-city programs will have a lot of trauma patients and addiction cases, etc.

6. Work hours - there's "80 hrs" and there's 80 hrs .Some programs like to highlight that they have "home call" where seniors can take the call from home but that can be actually worse than taking the regular hospital call and going home with "protected" time. Dig deeper into call schedules when you interview.

7. Flexibility in electives - Can you leave the state? Can you choose more electives in your area of interest, eg. If you want to see more adult patients, you should choose a program with more electives in GI, Pulm, Cardio, etc. In many programs, you can even arrange international electives for a culturally-enriching experience.

8. Onsite support for FM - there's "opposed" and there's opposed. If you want to be credentialed in performing a certain procedure, eg. Colonoscopy, you need to have done it a certain number of times under supervision during your residency training ( it can be very painful if you graduate from your residency and were not able to meet the numbers). So choose the programs where you have support from faculty who can teach you that particular procedure (s) and where you will not have too many competing residents from other specialties.

9. Faculty time on wards - if they only do 2 wks/yr inpt, this may not be the teaching you want. Teaching type and time - When people say the teaching is great or bad, find out what they like and what they are getting. It can be as simple as someone who loves lectures and wishes they had more, whereas some may prefer bedside teaching more than lectures.

The research you do before applying and the questions you ask during interviews will turn out not to be the most important for you, but really you can only learn by going through the process. By the end, you will know exactly what you should have been asking all along.

Useful links:

AAFP directory of residencies & fellowships

How to choose a Family Medicine Residency? I used this document as a rough guide during interviewing: How to Choose a Family Medicine Residency

Free wiki lists of residency program criteria

Is FM right for you? Check out:

Sample curriculum for Family Medicine ( Note the differences in types of rotations in these programs- each one is different):

UNC Chapel Hill

UT Southwestern

MCW Waukesha

FM vs IM-primary care and curriculum pros/cons

Points to keep in mind during Family Medicine Residency training summarized below ( Source-SDN discussion):

1. Focus on continuity clinic: FM residency views the continuity clinic as "the OR for family physician". You have your own clinic & own patients where faculty will help precept. It's varies from program to program, but generally R1s will have 1-2 half days per week, then it increases to 2-3 in R2, then 3-5 in R3 (ACGME doesn't care how many half days... they only care about how many patients you see). In IM-PC, you have 1 half day of clinic per week for all 3 years. Generally, most FM programs will be "front-heavy" (i.e. more inpatient months during R1 with more outpatient months in R3). You call schedule lightens up as you advance, which means less post-call days, which means more days available to be in clinic or on rotation. In IM they have a lot of inpatient time, which means they'll miss out on outpatient time due to post-call rules. This scheduling is very important and is something to think about. You don't want to be q3-4 call doing CP rule-outs, cocaine detox with post call days landing on days you could be in ortho clinic, cards clinic, or radiology for example. You'll miss out.

2. Preceptor rule:
FM residencies are exempt from certain preceptor rules (where faculty must see every one of your clinic patients after you). In FM, it's thought that faculty going into every clinic visit disrupts continuity of care. And so, you don't need to have a faculty see every patient unless you precept it. This isn't that important, but does affect your autonomy in making decisions in the clinic. You want to be able to make your own decisions (and live with the consequences). And, you want your patients to respect your decisions and not wait for the faculty to come in to the room and repeat everything you just said. It slows you down in clinic, and you end up seeing less patients. Less patients = less pathology exposure.

3. Ambulatory "blocks":
In IM-PC, you do these ambulatory blocks to get more outpatient experience. And in these ambulatory blocks (3 months per year), they squeeze in ortho, uro, ophtho, gyn, geri, etc. From what I've read, some programs do a mish-mash of different clinics. In FM, these specialities have their own discrete 4 week blocks (some are 2 weeks). I don't think it there's that much of a difference. Personally, I like how the FM continuity clinic increases as you advance. It makes you more available to your clinic patients and therefore allows you to see more. Could you imagine if your doctor only had 1 half-day of clinic per week? It'd be impossible to get into to see them that you'd end up going elsewhere.That said, the disadvantage is that as you advance, your time spent in rotation decreases because your continuity clinic time increases. So the curriculum chart is deceptive because you think you're getting all these blocks of rotations, but the actual time spent isn't that much. That's why you have to scrutinize the schedule and make sure the important rotations are mostly during 1st and 2nd year and then by the 3rd year, the rotations are there to refine what you've already seen in your continuity clinics.

No curriculum is perfect. No matter what specialty you choose, your time is limited. So spend it wisely.

FAQs about Family Medicine

This is a valuable post by a Family Medicine Attending Physician at SDN (credits below the post). I am copying and re-posting it here so everyone can benefit from this information:

What procedures can family physicians do?

Let me preface this by saying something that will ring true THROUGHOUT this FAQ, and that is, MEDICINE IS REGIONAL. Let me repeat that again so that it sinks in: MEDICINE IS REGIONAL. What goes down in rural Kansas does NOT necessarily go down in South Florida. What is acceptable in New York City might NOT be acceptable in Dallas. Other factors that contribute to what an FP can do are:- Availability of other practitioners to do a procedure in a particular region- POLITICS, POLITICS, POLITICS - Local hospital/regional politics play a MAJOR ROLE in what can be done by whom.-
How aggressive the particular FP has been in getting the necessary training in order to be competent in that procedure.-
What the local insurance companies are willing to pay for. Obviously, one is not going to do a procedure if there is no chance for reimbursement.-
How much EXTRA one is willing to pay in malpractice insurance premiums for the privilege of getting covered for that procedure.-
What the local hospital credentialing committee will allow in terms of staff privileges.That being said, here is a partial list of procedures that FPs can do, depending on the ABOVE factors:-

Joint injections (knee, shoulder, etc.)-
Suturing of lacerations- Biopsies (punch, excisional, shave, etc.)-
Cryotherapy- Central line and peripheral line placement-
Closed reduction of simple fractures-
Drainage of simple abscesses-
Normal vaginal deliveries-
Tubal ligation-
Newborn circumcision-
Chest tube placement-
Endotracheal intubation-
Conscious sedation

What can I do after completing my family medicine residency?

The beauty of FM is that it is VERY flexible. One can mold their private practice based on their individual needs and interests. There is NOT one model of private practice. Some possible variations:- Outpatient-only practice- Inpatient-only practice (e.g., hospitalist)- Mixed inpatient and outpatient- Academic practice-- Administrative practice, and more.

Can an FP work as a hospitalist?

The answer is YES, it CAN happen, but one must consider the above factors (region, politics, etc.). It may be perfectly OK in one region, but not in another. For example, in South Florida and certain places in California, FPs CAN work for hosptialist groups, and make a good living doing hospital admissions for the various HMOs. Also in Wisconsin, Minnesota, Texas, and many states in middle America. I do not know the percentage of hospitalists who are FPs, but it is smaller in proportion to the number of internists who are hospitalists because FPs prefer more clinic-based practice anyway.

What about fellowships?

There are a limited number of fellowships available to FPs. The main options are:- Obstetrics- Sports Medicine- Geriatrics- Faculty Development ( If you are interested in teaching, academics and becoming the Program Director!)-Urgent Care. Others like Research, Medical Writing, Sleep Medicine, even Dermatology are coming up.

For a comprehensive list of fellowships available nationally, go to

How competitive is it to get into a family medicine residency program?

There are a large number of spots in FM ( and primary care IM) so it is not the most competitive, but with the number of IMGs applying each year this is changing. The most competitive FM has been was back in 1997-1998 when interest was at its peak and US med schools were actively encouraging people to go into FM. Since then, interest has decreased, as the culture of US med graduates is now tending to gravitate towards higher-paying specialties (anesthesiology, interventional radiology, IM subspecialties, etc.). Obviously, big city university programs ( eg. Chicago, Boston, San Francisco) will have a larger applicant pool, and thus be more competitive. California and Florida also has a large applicant pool. Every match season is different, and the applicant pool differs as well, so the competitiveness of individual programs differs year to year.

What does a family medicine residency consist of?

An FM residency is 3 years long and consists of a variety of rotations which include:- Inpatient medicine ( majority of rotations)- Pediatrics- OB-GYN- Internal medicine- Critical care- Surgery- Psychiatry- Community medicine- Rural medicine (depending on location)- IM subspecialties (cardiology, pulmonary, GI, etc.)- Continuity clinics (frequency per week depending on PGY level) inwhich you steadily grow your panel of patients and follow themthroughout residency. With the exception of certain rotations,continuity clinics are held no matter what rotation you are on; Elective rotations- several, depending on the program.

What combined family medicine programs are there?

There are programs that combine FM with IM, FM with psychiatry, FM with preventive medicine, and (recently) FM with EM. These programs lead to dual board certification.What do they mean by an "unopposed" program? An unopposed program means that the FM program is based in a hospital with no (or few) other residencies in it. You will find these in smaller community-based hospitals. You are unlikely to see this in a university hospital, which hosts multiple residencies. In the opinion of this writer, unopposed programs are better, because there is less competition for patients and procedures.

What kind of MONEY can I make being an FP?

This is the "million-dollar question." Although the PUBLISHED average is approx. $160,000 per year, this in NO WAY indicates how much YOU as an individual will make. There are many factors that will determine how much you can potentially make, on whether it is going to be 100K or 400K. Here is a partial list of them:

Years in practice - Remember that you will not be rolling in dough the first year. First of all, you do not have a Medicare or a Medicaid number yet. That can take up to 6 months OR MORE to get. When you first start out, you are not on ANY insurance plans yet, either (Blue Cross, Humana, Avmed, TriCare, etc.). Some of these plans are VERY slow to act, and it can sometimes take OVER A YEAR to get on. This is dependent on region, panel size, and whether a panel is open or closed. For example, it took me a WHOLE YEAR to get on Blue Cross and Humana. A panel may be closed on a particular month, and open the next month, so panels can be very whimsical.

Business Acumen - PLEASE remember this equation:MD =/= MBA (MD DOES NOT EQUAL MBA) That being said, just because you had the intellectual acumen to finish medical school and residency, that DOES NOT mean that you have the business acumen to run a successful business and manage money. The two are NOT one in the same. If you are not good at being frugal and sensible and making good business decisions, you will fall into situations that will not be financially beneficial to you, and you will lose money.

Who is working your front desk? - This is often overlooked. Your front desk person can help you MAKE money, and some can make you LOSE money. This is done by their attitude over the phone, how they treat patients when they come in, how they handle the cash, etc. Remember, physicians are all at risk for being embezzled.

Who is doing your billing? - This is another MAJOR factor. Are they making sure that money is collected, do they properly handle rejected claims and correct them so that you can get paid? Do they give you a heads-up regarding incorrectly coded claims?-

How many plans are you on? - We always complain about the reimbursement, but most of the managed care plans do bring a significant volume to your practice. Of course, if a plan's reimbursement is sub-par (it always pays to examine a plan's fee schedule closely), you may choose (wisely) not to participate. There's no point seeing patients if you lose money on them.-

Type of practice - Do you have an inpatient-only practice? Outpatient-only practice? Mixed inpatient/outpatient practice? If you do inpatient work, do you take on call for unassigned admissions? If so, what type of hospital (county or private?) Obviously, if it is county, you will get a higher percentage of uninsured admits who may or may not pay you. A private facility will have a higher percentage of insured patients. - Do you do procedures? - Procedures reimburse quite well. Don't lose those skills. - Group or solo? - This plays a role, too. In a group, expenses are shared, thus lower overhead, but in a solo situation, all the expenses are borne by you. - Are you coding right? - If you code all of your visits a certain level and miss out on opportunities to code a higher level based on your documentation, you will leave money on the table.- Employed vs. Partner - Are you an employee of the practice, or are you a full partner? Keep in mind that one is not necessarily better than the other, because in a partnership, everybody ELSE has to get paid before you do (secretary, nurse, bills, etc.) If there isn't anything left after everybody else gets paid, then you don't get any money that month. As an employee, you have to get paid no matter what, because you are on a fixed salary.As you can see, I just scratched the surface on the factors that make a difference in how much money you make.

What is the lifestyle of an FP like?

Given the above variables, it is IMPOSSIBLE to say what one's lifestyle will be like. No two FPs are alike, thus no two lifestyles are alike.

How is FM viewed by the other specialties?

This is another variable situation depending on where you are. Local and regional politics play a BIG role in this. For example, in an academic university hospital setting that also has a department of internal medicine, it is often the case that FM plays a "second-fiddle" role. The good cases go to the IM folks, the leftovers go to FM. The situation is often OPPOSITE in a private hospital. I will use my hospitals as an example. Whereas in many places in midwest, southwest, and southeastern states, IM and FM are treated equally and interchangeably. There is just ONE on-call list for medicine for unassigned admissions that both FM and IM participate in. One day, it might be me on call for medicine, another day, it might be one of the IM docs. As far as the specialists are concerned, they NEED FM and IM as a source of referrals. When I admit, I decide who I want to consult. So if they want me to call them for referrals, they'd better be nice to me. As an interesting side note, check out your local FP's office around Christmas will see it FULL of various gift bags and food, all sent from the local specialists. If you are good at what you do and interact well with others, you will be viewed positively by the other docs. If, on the other hand, you are lazy, shiftless, don't get along with others, don't evenly distribute consults, etc., then you will not be looked on favorably by other specialists.

What is the role of FP's in the Emergency Department?

This is another case that depends on region and local politics. Throughout the country, FPs work in EDs in various capacities. In a large city ED, this may be restricted to only board-certified EM docs. A long time ago, when EM was beginning as a specialty, some FPs were grandfathered into board certification if they worked a certain number of hours in the ED and documented it. That option no longer exists. In certain big EDs, FM can still work there, but they make them work in the fast-track section of the ED. That is the area where people with minor stuff are seen (lacerations, cold/flu, etc.). Each hospital will have their own policy with regards to FPs working in the ED. Some FPs use the ED work for extra income, whereas some make it their full time gig. That is the beauty of FM, one can tailor it to fit their preferences.

Can FPs be consultants?

YES. Although your role is that of a primary care doc 90+% of the time, there are times when you are called in for a medicine consult both in the office as well as hospital setting, and thus can BILL accordingly. For example:- OB-GYNs sometimes want a medicine consult.- Surgeons sometimes want a medical consult and/or clearance prior to a procedure.

What about kids? What is the difference between the care provided by a pediatrician vs. an FP?

This is another issue that depends on region. I need to point out TWO important concepts:1) The world of residency and the world of private practice are COMPLETELY DIFFERENT WORLDS2) MEDICINE IS REGIONAL (I cannot say that ENOUGH)That being said, let me start off with the differences in training during residency:PEDS - This residency consists of 3 years of KIDS ONLY less than 18 y/o. During the 3 years, one rotates through the various pediatric subspecialties (cardiology, pulmonoly, neurology, hematology-oncology, general inpatient ward, NICU, PICU, etc.) as well as continuity clinics where they follow a panel of patients throughout the 3 years. After training, there are 2 common pathways: one is a fellowship in one of the pediatric subspecialties, and the other is general pediatric practice which may be outpatient only, outpatient/inpatient mixed, or inpatient only (e.g., hospitalist).FM - This residency consists of 3 years of various adult AND pediatric rotations. Most of the pediatric rotations will center around general peds with some subspecialty exposure. Of the 36 months of FM residency, approx. 6 of those are devoted to pediatrics and peds-related subspecialties (general outpatient peds, general inpatient pediatrics ward, NICU). In addition to that, when one is on the FM inpatient service, this will be a mixed service made up of both adults and kids of all ages, so your rounds may consist of a trip to the NICU, Labor & Delivery, as well as the adult ICU. In addition to that, one has electives in which one may choose to do an extra month of peds or a peds-related subspecialty (I did one in pediatric dermatology when I was a senior resident). Even further experience is gained through your continuity clinics, which you do from day one. In your continuity clinics, you follow ALL ages, from newborn babies to the elderly. Through the 3 years, you get a well-rounded balanced pediatric experience that mirrors the issues you will encounter in private practice. This leads me to the next question.
Wait a minute, peds residents get many more months of exposure during their training, aren't they better equipped in the private practice setting to handle kids vs. an FP?Before answering that question, let me remind you of the two concepts I stated before:- MEDICINE IS REGIONAL- THE WORLD OF RESIDENCY AND THE WORLD OF PRIVATE PRACTICE CAN BEVERY DIFFERENT.In a residency setting, peds residents see, on average, more "sicker" patients and do more inpatient work than FM residents. However, this is not the reality of private practice. In the world of private practice, peds clinic is the main source of income (unless you are a hospitalist, which in that case you are probably salaried). In an FM residency, you will get plenty of exposure to the bread & butter stuff that you will likely see in private practice. Yes, you will have some sick/critical cases, but not the same volume as your peds counterparts. The scenario changes in private practice.For a pediatrician in private practice, 95% of the cases seen in that clinic are what we call "bread & butter" cases (well child checks/vaccinations, upper respiratory infections, otitis media, gastroenteritis, rash, ADHD, asthma, school/sports physicals, etc.). If you admit to the hospital, most admissions will be bread & butter as well (asthma exacerbation, dehydration, meningitis, pneumonia, etc.). Anything exotic or beyond the bread & butter gets a referral/consult to a specialist or possible transfer, PERIOD. The reasoning is twofold. One is LIABILITY. In this lawsuit-happy culture that we live in, you WILL be faulted for not consulting a specialist if the child had a serious condition that could have been prevented from getting worse. Second is REIMBURSEMENT. In private practice, a LARGE proportion of kids will fall under the state Medicaid program. In most places, these programs are CAPITATED HMOs. That means you get a fixed dollar amount per month per patient WHETHER YOU SEE THEM OR NOT. After you see someone for 1 or 2 visits for a particular problem, it works AGAINST you to keep on seeing them for the same problem. It is the prudent thing to refer out after 2 visits for the same problem, especially if you are on a capitated Medicaid plan. Even if the child has a fee-for-service PPO (which is not capitated), it's still prudent to refer out if the problem hasn't been solved in 2 or 3 visits. An FP in PRIVATE PRACTICE functions pretty much the same way as a pediatrician in private practice. The only difference is that you see adults as well, and you can wind up seeing the WHOLE family from grandma to grandkids (the true meaning of FAMILY practice). Because of this, the volume of kids you see in the office may not be as high as your peds counterparts. In some small towns, there are no pediatricians, so ALL of the peds work is done by FM. In the larger cities, there is a large volume of peds, thus the number of kids who are seen by FM is probably less. There isn't one specific pattern; it all depends on REGION. Irrespective of FM vs. peds, no matter where you are, a REALLY bad/sick/crashing kid WILL get shipped off to the nearest tertiary care facility, as most smaller private hospitals do not have peds sub-specialists, nor the capabilities to handle a very sick kid. I hope this puts to rest the FM vs. peds issue.

What is the difference between family medicine and internal medicine?

The main difference is that internal medicine is the specialty that deals with ADULT disease and treatment ONLY. Nobody under 18 (generally), and no OB. Family medicine deals with adult medicine, but also includes all other age groups (from newborn to elderly) and may or may not include an OB component (depending on region and personal preference of the practitioner). First, let me compare the residency training.For IM residents, ALL rotations are in adult medicine and subspecialties. There is NO OB or peds. The only interaction with pregnant patients will be as a consultant for women in labor & delivery who develop a medical problem on top of their pregnancy (e.g., out-of-control diabetes, cardiac problems, etc.). As an IM resident, you will get more ICU exposure then the FM residents, and you will get to do more of certain procedures then the FM residents (central lines, Swan-Ganz catheters, etc.)FM residents not only do adult medicine rotations, but pediatric rotations as well. They also have to do certain months of Labor & Delivery, where they not only play an active role in delivery and management of pregnant women, but also the management of medical conditions on top of the pregnancy that may occur (with the appropriate consultations, of course). Another difference is what occurs after residency. IM residents can do a fellowship in the various subspecialties, whereas FM has a limited number of fellowships. These have been described earlier in this document.Here is the interesting twist...In the world of PRIVATE PRACTICE, these differences are not as profound as in residency. The reason being is that as a private practitioner, your malpractice insurance as well as your hospital privileges WILL NOT cover the broad range of things you once did as a resident, especially when there are enough specialists around to do them. YES, an IM resident has put in more central lines than an FM resident, and floated more Swans, etc., but in private practice, you will be HARD PRESSED to find ANY private practice general internist who does those things for the reasons described above. In a nutshell, when it comes to the private practice world of an IM doc vs. an FP, basically BOTH FPs and IMs on a daily basis handle the SAME bread & butter type of adult cases (hypertension, diabetes, thyroid disorders, upper respiratory infections, gastroenteritis, heart disease, rashes, etc. - which will make up 90+% of your office day), and are reimbursed the SAME from Medicare and managed care insurance companies. A level 3 outpatient visit (there are 5 possible levels) - (a.k.a. 99213) is reimbursed the SAME whether you are an internist or an FP. Anything beyond bread & butter management is referred out for the SAME reasons as I described in my peds vs. FM comparison.When it comes to inpatient medicine in the PRIVATE PRACTICE world, FM and IM function the same way as well. Both handle bread & butter admissions (exacerbation of CHF, chest pain-r/o MI, sepsis, MI, altered mental status, pneumonia, nursing home "trainwrecks", etc.) and BOTH will obtain the appropriate consults when warranted - no difference. Did the internist get more experience managing a vent in residency? YES, but again, you are going to have a VERY hard time finding an internist in private practice who manages his own vents without calling pulmonology consult, because if there is a bad outcome because you didn't get a consult, you WILL get nailed!FM and IM are both employed interchangeably by hospital staffs as well as managed care companies. ONE exception is in places that do not have any IM sub-specialists (cardiology, pulmonology, gastroenterology, etc.), the local internist may be the one who has to do certain procedures (reading echocardiograms, placing central lines, floating Swan-Ganz cathethers, stress tests, bone marrow biopsies, etc.), primarily because there is no one else around to do it. This phenomenon exists primarily in small towns with NO sub-specialists.

What is the difference between FM residency and Med/Peds residency, and what is the significance in private practice?

Basically, Med/Peds is a combination residency that combines IM and peds into a 4-year residency (half medicine rotations, half peds rotations). These programs do not include OB rotations or general surgery. At the end, one must obtain and maintain board certification in BOTH specialties (that means 2 separate exams, plus CME and recertification). In FM, there is just ONE board certification to maintain. For Med/Peds, after residency, one may elect to do a fellowship in either an adult, pediatric, or a combined adult/peds subspecialty. In FM, there are limited fellowships which have already been described. Here is where the differences end. In the world of private practice, BOTH function the same. The only difference is IF the FP decides to include OB in his/her practice, then the med/peds doc cannot cross-cover. BOTH groups will handle the same type of bread & butter adult and peds cases with the APPROPRIATE referrals to specialists when warranted. There is no difference in insurance reimbursement between the two for a particular case.

What about the OB component of FM? What is the difference between care provided by an FP vs. an OB-Gyn?

Here is where the results are VARIED based on REGION. While FM does require certain rotations in Labor & Delivery, the experience varies by the program and location. An FM resident will get more OB experience in an UNOPPOSED residency vs. a university-based one with OB residents. After residency, many FPs elect NOT to incorporate OB in their practice (including yours truly). This is done primarily because of the numerous liability issues involved (your malpractice premium will SKYROCKET if you include OB). Plus, it may be VERY difficult to get the necessary hospital privileges to do OB (all dependent on region). Furthermore, you'd BETTER have a sufficient volume of OB work to justify and offset the increase in your malpractice premium or you will LOSE money.In those areas of the country where FPs do OB, they work together with the OB-Gyns and share call coverage for Labor & Delivery. FPs who do OB commonly handle routine non-complicated pregnancies and deliveries. Complex situations are automatically referred to an OB-Gyn or transferred to a tertiary care facility. SOME FPs in certain areas have C-section privileges, and some don't. It all depends on regional and local politics as well as the training of the individual practitioner.

And last but not least? Is FM right for me?

There is NO WAY that anyone can answer this question for you other than yourself. You have to take MULTIPLE factors into consideration like you would with any field. If you go into FM because you are TRULY interested in it, then you will find it rewarding and fulfilling despite the fact that other specialties may make more money. However, if you go into FM by default (e.g., couldn't get anything else), then there is a SIGNIFICANT chance that the stressors will begin to wear on you and your satisfaction will decline. No matter what the political pundits and commissions say, I can tell you categorically, there IS and ALWAYS WILL BE a need for a GOOD primary care physician who cares for his/her patients and makes people feel better and live longer - PERIOD! ~ Anonymous

Source: SDN Family Medicine Discussion @ Student Doctor Network

History of Family Medicine

What is the definition of Family Medicine?

Here is the official definition from the American Board of Family Medicine (ABFM):

"Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity."

What are the history/origins of the specialty?

[Excerpt from the American Board of Family Medicine (ABFM) Web site]The American Board of Family Practice* was born many years before it was officially recognized in February, 1969 as the 20th primary medical specialty.The history of the Board is a fascinating saga of travails, with frustrations and impediments punctuating its formative days. Despite the fact that by the early 1960s the number of physicians in a general type of practice was dwindling rapidly, the medical establishment opposed the creating of a specialty that would fill this void. Therefore, the founding fathers of the Board deemed it necessary and rational, particularly in the face of this opposition, to document meticulously and persuasively the need for the specialty.Various studies in the 1950s and 1960s concluded that "General Practice" was moribund. An analysis was made of specialty distribution of all graduates of every medical school by five-year periods since 1900 and from this data it was learned that the number of general practitioners was rapidly and steadily dwindling. In 1964, the percentage of graduates going into General Practice fell to 19%, down from 47% in 1900 and continuously diminishing. It was also noted that the ratio of physicians in private practice was dropping rather rapidly, and the deficit was obviously in what was termed the "Family Physician Potential."The general response to this precipitous decline was "this is an age of specialization." The founders of the Board could only affirm this fact, believing that this response to the dearth of General Practitioners strengthened their argument for a new generalist-type of specialty called "Family Practice." Many students expressed the concern that the broad body of knowledge required for general practice was too great. This concern was also based in truth, in light of the tremendous expansion of medical knowledge and skills in the past few decades. Four years of medical school and a year of internship was indeed not adequate. The inadequacy of this training could be remedied only by having residency programs in a new specialty, Family Practice, argued the proponents of the specialty.Additional factors explaining the decline were the lack of "prestige" assigned to the general practitioner in comparison to his/her more "specialized" colleagues as well as the difficulty experienced by the general practitioner in obtaining hospital privileges which were being given increasingly only to those physicians who were board certified.In view of the data gathered by the Board proponents, it was proposed that:* Family Practice IS a specialty, and* as a specialty, Family Practice deserves well-defined but flexible graduate training programs, and* that a Board of Family Practice is essential for the certification of competency of Family Physicians and for the participation in the guidance and approval of training programs. The specialty of Family Practice, based on the heritage of General Practice, would have graduate programs (residencies) for physicians whose training would encompass 1) first-contact care; 2) continuous care; 3) comprehensive care; 4) personal care (caritas); 5) family care; and, 6) competency in scientific general medicine.

Nicholas J. Pisacano, M.D.First Executive Director, Deceased* Renamed in 2005 to the American Board of Family Medicine.

Source: SDN