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

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