Wednesday, April 8, 2009

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

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