Family medicine subspecialties

[iyin0991]

Hello,

I am a 3rd yr medical student in the US. Plan is to match back to Canada for FM. I was torn between FM and urology for some time but decided that what I liked about urology were the minimally invasive procedures (TURP, vasectomy, circumcisions...etc) as opposed to prostatectomies or cystectomies. Therefore I realized I would be happy being in FM with the ability to add a few minimally invasive procedures. I am in the US so I came across a link that showed the procedures US FM physicians can do with additional training: https://www.aafp.org/dam/AAFP/documents/events/nc/handouts/nc17-procedures.pdf

I was wondering if that is the same in Canada regarding scope of practice? Also if a particular training is not offered in Canada, could one do additional training in the US and come back to practice in Canada? For example a subspecialty in possibly vaginal delivery/C-sections/hair transplant/liposuction/colonoscopies...etc, would be nice to add to FM practice. Also what difficulties and barriers do you all suspect would make this process more difficult? 

Thanks.

[freewheeler]

Procedures I am aware of rural family physicians in Canada performing (either US trained or Canadian trained with a +1 in surgery):

• Open inguinal and umbilical hernia repair
• Venous stripping
• Tubal ligation
• Vasectomy
• Lipoma excision
• Cesarean section
• Open spermatocele excision
• Colonoscopy
• Gastroscopy
• Dilation and currettage
• Insertion of IUD under GA
• Circumcision under GA for older patient

Have not heard of FM docs doing hair transplants, I think there was a story of a FM doing a liposuction in the mid to late 2000s and the patient died so I don't know if that is even still a thing.

I think you'd get better training if you're dead set on being a rural family physician with an interest in surgical procedures if you train in the US in a midsized centre where FM docs run the hospital. Do your 3 years there and then come back to Canada to practice in a rural setting. If you want to do additional surgical training in Canada you often need to have a rural town in need of a GP surgeon vouch for you as part of your application to the +1 training program, but then you are still beholden to the provincial health authority as to whether you are even given privileges to practice as a GP surgeon. A lot of the above procedures however are a routine component or more easily accessible afaik in a US FM residency whereas they would not be routine in a 2 year FM residency in Canada.

[ZBL]

Any FM doing the procedures you describe, like lipo, hair transplant, tubals, open hernias, colonoscopies, and some of the things listed like ear tubes, flaps, etc would be practicing some serious cowboy medicine. There is a chance of exactly zero percent that any of these would be done with any degree of skill or the necessary pre-knowledge after Canadian FM training, and the US “Fellowships” that claim to train people on this are not board regulated training, but rather going to work with a random doctor who does those things. Practice at your own risk, but prepare for bad outcomes and muchos lawsuits IMO. 

[IMislove]

Found two in Ottawa alone that do a ton of cosmetic stuff exclusively it seems :

https://www.tosonimd.com/why-dr-tosoni/

https://dramberbocknek.com/about/

guess fam med is as versatile as you can get.

[ralk]

Depends really on your definition of "minimally invasive procedure". Some things are common enough in FM that with some focused training (either as part of a +1 or, more commonly, with less formal training after completing residency) and with a lot of self-marketing to develop an adequate patient load, you could do them as a focused practice. Lumps and bumps clinics, vasectomies, IUD insertions, and some cosmetic work would all be well within the scope of an FP with dedicated training. Vaginal deliveries are routinely part of FP practice, though despite what the CCFP might say, additional training beyond the standard FM residency should be done to do these well.

Some of the other things mentioned have been done in the past by FPs, but are on their way out for very good reasons - no FP these days should be doing C-sections or colonoscopies. Even focused training wouldn't provide the breadth or depth of knowledge to do these competently once they move anywhere beyond routine, and there are plenty of specialists available to do them who have far greater expertise. These procedures are simple enough when everything goes right, but no FP has the training necessary to fix things when they inevitably go wrong, such as lancing a ureter or perforating the bowel. The PDF you linked talks about procedures that are fairly advanced and should absolutely be left to specialists - for example, colposcopy, which in Canada can't even be done by an OBGYN unless they have specific certification beyond standard residency training.

[bearded frog]

Both U of Sask and U of Alberta offer formal +1 for FP as an "enhanced surgical skills" training for basic gen surg procedures and c-sections. UBC, Manitoba, NOSM, and U of A offer a partial add-on year in ceserian section for family docs. So you can be fully qualified as a FD. See this page: https://ess.rccbc.ca/

[medigeek]

On 3/3/2019 at 3:23 AM, freewheeler said:

Procedures I am aware of rural family physicians in Canada performing (either US trained or Canadian trained with a +1 in surgery):

• Open inguinal and umbilical hernia repair
• Venous stripping
• Tubal ligation
• Vasectomy
• Lipoma excision
• Cesarean section
• Open spermatocele excision
• Colonoscopy
• Gastroscopy
• Dilation and currettage
• Insertion of IUD under GA
• Circumcision under GA for older patient

Have not heard of FM docs doing hair transplants, I think there was a story of a FM doing a liposuction in the mid to late 2000s and the patient died so I don't know if that is even still a thing.

I think you'd get better training if you're dead set on being a rural family physician with an interest in surgical procedures if you train in the US in a midsized centre where FM docs run the hospital. Do your 3 years there and then come back to Canada to practice in a rural setting. If you want to do additional surgical training in Canada you often need to have a rural town in need of a GP surgeon vouch for you as part of your application to the +1 training program, but then you are still beholden to the provincial health authority as to whether you are even given privileges to practice as a GP surgeon. A lot of the above procedures however are a routine component or more easily accessible afaik in a US FM residency whereas they would not be routine in a 2 year FM residency in Canada.

Pretty much sure the hair transplant guys in the GTA are FM docs lol. It's actually quite easy...

 

[iyin0991]

Thank you guys. I've asked some experienced FM docs and you guys are quite right. 

[medigeek]

On 3/3/2019 at 3:25 PM, ralk said:

Depends really on your definition of "minimally invasive procedure". Some things are common enough in FM that with some focused training (either as part of a +1 or, more commonly, with less formal training after completing residency) and with a lot of self-marketing to develop an adequate patient load, you could do them as a focused practice. Lumps and bumps clinics, vasectomies, IUD insertions, and some cosmetic work would all be well within the scope of an FP with dedicated training. Vaginal deliveries are routinely part of FP practice, though despite what the CCFP might say, additional training beyond the standard FM residency should be done to do these well.

Some of the other things mentioned have been done in the past by FPs, but are on their way out for very good reasons - no FP these days should be doing C-sections or colonoscopies. Even focused training wouldn't provide the breadth or depth of knowledge to do these competently once they move anywhere beyond routine, and there are plenty of specialists available to do them who have far greater expertise. These procedures are simple enough when everything goes right, but no FP has the training necessary to fix things when they inevitably go wrong, such as lancing a ureter or perforating the bowel. The PDF you linked talks about procedures that are fairly advanced and should absolutely be left to specialists - for example, colposcopy, which in Canada can't even be done by an OBGYN unless they have specific certification beyond standard residency training.

Colposcopy needs a special cert? What??