Wednesday, April 8, 2009

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.

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