Will FM ever be replaced, etc.?

[blueskyguy]

Hello all,

I am a current 3rd year med student interested in pursuing a career in FM. I am interested in working in an outpatient clinic/walk-in clinic setting.

I have read online about other fields (nurse practitioners, etc.) possibly encroaching on FM in Canada. Is there any truth to this? Are FM salaries affected by this in any way, etc.?

Will FM ever be replaced by other fields, etc.? Will FM continue to be a solid and safe career choice in Canada for the future?

(What about FM in the U.S.?)

I love this field, I just want to be clear on its reliability and job security.

Thanks for the input!

[Raptors905]

The role for PA and and NP is increasing. Replace totally? Probably not. But they will replace some of the stuff GPS did 

[1D7]

No large specialty will ever be replaced, at least not suddenly. Although healthcare and medicine is ever evolving, it is at a slow pace. Physicians of any specialty will find something else to do if their current niche becomes unneeded or taken over.

As for Family Medicine specifically, I believe America is setting the trend in this regard. They are pumping out more NPs every year with an ever increasing scope of practice. In some states they can practice autonomously with minimal/ineffective pushback from medical organizations. Per patient and hours they make as much family doctors in some places. There are even cases in America where the primary care docs (family/peds) are being laid off so they can hire NPs/PAs instead. See: https://www.medpagetoday.com/publichealthpolicy/workforce/83576

I wouldn't avoid a career in family medicine if that's what you enjoy. You'll certainly have a job and you'll likely practice the way you expect or want to in the near future. 20+ years down the line who knows. Maybe you'll have to specialize in complex chronic conditions or stop doing urgent care because it's saturated by NPs; maybe not. The constant is that our healthcare system is becoming more strained each year and the government is looking for ways to try and save money.

[rmorelan]

also I think it would not really be in the best interests of PA or NP to actually replace the field. Their income is relatively high compared to other health care workers because by comparison the family doctor that earns even more. Removing that doesn't give them really an advantage.

Some of this NP/PA entry into the field seems logical as well - one of the issues with medicine is that everything is so hyper educated to perform their particular function - learning all kinds of stuff that is highly likely not of much real use. That is highly inefficient and takes forever (speaking as someone that is almost done the total 15 years of training it has taking to create well me. Ages upon ages ha). That doesn't mean we don't need family doctors - we still do and will always I believe but likely for more complex cases. 

Same with other fields. Take radiology as an example - reading mammograms is not easy, it takes a huge amount of skill, patience, and intelligence - those that are good at it are simply amazing. Still we have doctors doing that now that were trained again for 14 years at least end to end that spend the majority of their day doing that. There is a pretty strong argument that you can just train someone really well in less than 1/2 the time to do that one reading task and that task alone. Imagine 6-7 years of training in JUST mammography - we as residents and as specialized fellows in that area would only get at MOST 1.5 years and that includes more than just reading mammograms - so much more in fact with MRI, biopsies and so on. There is a huge number of people out there that would strongly consider that as a career and would be great at it (imagine it paying more than nursing, but has regular work hours - people would sign up). You don't need to know the vast field of radiology to do it, let along the much bigger field of medicine as a whole. You could have even much more detailed accreditation for that one area as well. Quite probably get much better results overall in the end - and as well probably with much lower costs - you could even centralize the reading for all mammograms in one place for all of the province to be even more efficient.

Yet we don't do that. There are several other fields in radiology that are pretty similar. I am sure there are similar areas in many other branches of medicine as well. I am not advocating for the breakdown of the entire medical system structure mind you - only pointing out that there are some strong arguments that we aren't operating a really old I would say even 18th century model of things in a 20th century world. Bound to be areas that can be improved upon. 

 

Edited December 30, 2019 by rmorelan

[blah1234]

1 hour ago, rmorelan said:

also I think it would not really be in the best interests of PA or NP to actually replace the field. Their income is relatively high compared to other health care workers because by comparison the family doctor that earns even more. Removing that doesn't give them really an advantage.

Some of this NP/PA entry into the field seems logical as well - one of the issues with medicine is that everything is so hyper educated to perform their particular function - learning all kinds of stuff that is highly likely not of much real use. That is highly inefficient and takes forever (speaking as someone that is almost done the total 15 years of training it has taking to create well me. Ages upon ages ha). That doesn't mean we don't need family doctors - we still do and will always I believe but likely for more complex cases. 

Same with other fields. Take radiology as an example - reading mammograms is not easy, it takes a huge amount of skill, patience, and intelligence - those that are good at it are simply amazing. Still we have doctors doing that now that were trained again for 14 years at least end to end that spend the majority of their day doing that. There is a pretty strong argument that you can just train someone really well is less than 1/2 the time to do that one reading task and that task alone. Imagine 6-7 years of training in JUST mammography - we are residents and as specialized fellows in that area would only get at MOST 1.5 years and that includes more than just reading mammograms - so much more in fact with MRI, biopsies and so on. There is a huge number of people out there that would strong consider that as a career and would be great at it (imagine it paying more than nursing, but has regular work hours - people would sign up). You don't need to know the vast field of radiology to do it, let along the much bigger field of medicine as a whole. You could have even much more detailed accreditation for that one area as well. Quite probably get much better results overall in the end - and as well probably with much lower costs - you could even centralize the reading for all mammograms in one place for all of the province to be even more efficient.

Yet we don't do that. There are several other fields in radiology that are pretty similar. I am sure there are similar areas in many other branches of medicine as well. I am not advocating for the breakdown of the entire medical system structure mind you - only pointing out that there are some strong arguments that we aren't operating a really old I would say even 18th century model of things in a 20th century world. Bound to be areas that can be improved upon. 

 

I agree with this line of thinking. The rate at which medical knowledge is growing is resulting in longer and longer training times which creates Human Resource planning and staffing problems. I think in the future we'll need more mid-level providers who are trained really well to do one thing in order to accommodate service demands in a more timely fashion. Given how sub-specialized medicine is becoming we really don't need to elongate training time for our students given the fact that they won't practice the majority of their skills. It's unfortunate that we can't hold onto the generalist skill set that makes us so knowledgeable, but at some point there will be too much knowledge for one person to take in during their training.

[bearded frog]

Family medicine won't go away, but it might change in that you will be working alongside and supervising midlevels, which isn't a bad thing. Think a FM practice where you have a NP to do your immunizations/paps/well baby checks/check-up visits, which will allow you to focus your time on patients with complex problems and new issues that you can use your full degree and expertise. This increases efficiency overall, and helps patients get seen, especially in areas with low numbers of docs, without taking away from your practice.

[medigeek]

On 12/29/2019 at 6:39 PM, blueskyguy said:

Hello all,

I am a current 3rd year med student interested in pursuing a career in FM. I am interested in working in an outpatient clinic/walk-in clinic setting.

I have read online about other fields (nurse practitioners, etc.) possibly encroaching on FM in Canada. Is there any truth to this? Are FM salaries affected by this in any way, etc.?

Will FM ever be replaced by other fields, etc.? Will FM continue to be a solid and safe career choice in Canada for the future?

(What about FM in the U.S.?)

I love this field, I just want to be clear on its reliability and job security.

Thanks for the input!

In USA, midlevels are WAY ahead than in Canada and FM still does really well there. But yes the situation is worsening. 

 

6 hours ago, bearded frog said:

Family medicine won't go away, but it might change in that you will be working alongside and supervising midlevels, which isn't a bad thing. Think a FM practice where you have a NP to do your immunizations/paps/well baby checks/check-up visits, which will allow you to focus your time on patients with complex problems and new issues that you can use your full degree and expertise. This increases efficiency overall, and helps patients get seen, especially in areas with low numbers of docs, without taking away from your practice.

lol wtf? so I should spend my time seeing only complex patients aka keeping myself stressed nonstop and then the midlevel can see the easy ones and make like 75% of my income? Please put this nonsense talking point in the garbage. There's NO reason doctors should only see complex stuff and what may be "easy" can be an atypical presentation of something difficult. 

[Raptors905]

On 12/31/2019 at 11:23 PM, medigeek said:

In USA, midlevels are WAY ahead than in Canada and FM still does really well there. But yes the situation is worsening. 

 

lol wtf? so I should spend my time seeing only complex patients aka keeping myself stressed nonstop and then the midlevel can see the easy ones and make like 75% of my income? Please put this nonsense talking point in the garbage. There's NO reason doctors should only see complex stuff and what may be "easy" can be an atypical presentation of something difficult. 

It’s irrelevant what you think. It saves the government money to pay doctors to see the complex patients and mid levels to see the easier ones. 
 

hiring one doc and 2 NPs is better than 2 docs doing the same work from a cost effective standpoint 

[JohnGrisham]

47 minutes ago, Raptors905 said:

It’s irrelevant what you think. It saves the government money to pay doctors to see the complex patients and mid levels to see the easier ones. 
 

hiring one doc and 2 NPs is better than 2 docs doing the same work from a cost effective standpoint 

Actually, it depends. 2 docs can probably still see same or more patients than 1 doc and 2 NPs, and the costs aren't as cheap as you think.

There is a reason NPs have been trained and available in some provinces for >10 years but haven't recieved as much traction or funding to actually work as NPs rather than RN roles.

NPs generally see simpler patients and at a far slower rate, with dedicated breaks etc. Even when I was a late in year MS3, I saw more patients than the NP in one outpatient specialty clinic (of course reviewing with staff) during a full day. Granted they were a relatively newish NP 1 year into practice...but I was a lowly and below average ms3. 

Other NPs I've worked with generally operate at an r1 level with a bit more independence, and once they are in the same role for a few years, at an r2 level for that specific role. Its simply just a different training model they receive.

[Raptors905]

7 minutes ago, JohnGrisham said:

Actually, it depends. 2 docs can probably still see same or more patients than 1 doc and 2 NPs, and the costs aren't as cheap as you think.

There is a reason NPs have been trained and available in some provinces for >10 years but haven't recieved as much traction or funding to actually work as NPs rather than RN roles.

NPs generally see simpler patients and at a far slower rate, with dedicated breaks etc. Even when I was a late in year MS3, I saw more patients than the NP in one outpatient specialty clinic (of course reviewing with staff) during a full day. Granted they were a relatively newish NP 1 year into practice...but I was a lowly and below average ms3. 

Other NPs I've worked with generally operate at an r1 level with a bit more independence, and once they are in the same role for a few years, at an r2 level for that specific role. Its simply just a different training model they receive.

What does a GP cost the government? Like 300-400k a year? An NP is what 120-150? So 2 NPs is often cheaper than 1 doc

[rmorelan]

5 minutes ago, Raptors905 said:

What does a GP cost the government? Like 300-400k a year? An NP is what 120-150? So 2 NPs is often cheaper than 1 doc

well to follow up JG's point - you have to consider cost per patient rather than cost per year. 

Still they are or at least have the potential to be cheaper in many ways. 

They are also much much cheaper to train - and we have to remember the government spends a very large sum of money on that as well. 

[JohnGrisham]

3 hours ago, Raptors905 said:

What does a GP cost the government? Like 300-400k a year? An NP is what 120-150? So 2 NPs is often cheaper than 1 doc

Yes but like rmorelan stated, its much more nuanced than that. If you exclude training costs, NPs on a per patient basis cost more because they see less patients but have a salary. Most GPs are fee for service, so unless they see patients, they aren't getting paid. For the same income level of 125k, a GP will have seen more patients and done much more unpaid work. Not to mention GPs dont often get retirement or benenefits.

I have yet to see a good cost analysis when you factor in training costs in addition to costs to see patients and then benefits/retirement.

And missing from this whole conversation is "cost control". Its in the govts interest to have less patients seen by GPs and less patients seen overall, because then it costs them less healthcare dollars. At some mid point there is a sweet spot, enough patients are being seen that they aren't in an uproar and political suicide, and not too many are being seen that its costing the system crippling amounts and again political uproar.

 

[rmorelan]

4 hours ago, JohnGrisham said:

Yes but like rmorelan stated, its much more nuanced than that. If you exclude training costs, NPs on a per patient basis cost more because they see less patients but have a salary. Most GPs are fee for service, so unless they see patients, they aren't getting paid. For the same income level of 125k, a GP will have seen more patients and done much more unpaid work. Not to mention GPs dont often get retirement or benenefits.

I have yet to see a good cost analysis when you factor in training costs in addition to costs to see patients and then benefits/retirement.

And missing from this whole conversation is "cost control". Its in the govts interest to have less patients seen by GPs and less patients seen overall, because then it costs them less healthcare dollars. At some mid point there is a sweet spot, enough patients are being seen that they aren't in an uproar and political suicide, and not too many are being seen that its costing the system crippling amounts and again political uproar.

 

Only minor nuiance I would add - I am not sure in Ontario at least that most are fee for service anymore. Last time I looked at this the majority have now switched to the Capitation model for payment so flat rate per patient rather than visit. That model also blocks many of the additional uncontrollable or at least unpredictable costs for the government with visits. 

[medigeek]

On 1/4/2020 at 8:30 AM, Raptors905 said:

It’s irrelevant what you think. It saves the government money to pay doctors to see the complex patients and mid levels to see the easier ones. 
 

hiring one doc and 2 NPs is better than 2 docs doing the same work from a cost effective standpoint 

Completely false. They order more tests and send off more referrals which leads to more total costs. They're also way slower than doctors. 

[Raptors905]

8 hours ago, medigeek said:

Completely false. They order more tests and send off more referrals which leads to more total costs. They're also way slower than doctors. 

Im not sure anyone has done a full analysis including training costs etc. I do know they use them and PAs a lot in the US and they are starting to crop up here as well in clinics and ERs. Why would TGH for instance have a bunch of PAs in the ER Then?

[medigeek]

14 hours ago, Raptors905 said:

Im not sure anyone has done a full analysis including training costs etc. I do know they use them and PAs a lot in the US and they are starting to crop up here as well in clinics and ERs. Why would TGH for instance have a bunch of PAs in the ER Then?

Better question is why staff docs at TGH let PAs work under them.

[Lactic Folly]

Loss of Saudi residents has had a significant impact in academic hospitals.

[Wachaa]

38 minutes ago, medigeek said:

Better question is why staff docs at TGH let PAs work under them.

It's nice if it's not at additional cost to the staff. I get that it's additional cost to the system. But that issue aside, do you mean if you had the option (at no additional cost to you), you would decline additional nursing / PA support?

At some clinics the nurse can work in a separate room in the clinic for the GP, doing injections, etc, etc and the GP can bill for those services.

[medigeek]

1 minute ago, Wachaa said:

It's nice if it's not at additional cost to the staff. I get that it's additional cost to the system. But that issue aside, do you mean if you had the option (at no additional cost to you), you would decline additional nursing / PA support?

At some clinics the nurses can work with GPs to do injections, etc and the GP can bill for those services.

Of course I'd decline. Why in the world would I facilitate giving a lifting hand to my replacement? 

[Raptors905]

8 hours ago, medigeek said:

Of course I'd decline. Why in the world would I facilitate giving a lifting hand to my replacement? 

Missing Forrest for the trees my friend. Short sighted on their part

[magneto]

On 12/29/2019 at 5:39 PM, blueskyguy said:

Hello all,

I am a current 3rd year med student interested in pursuing a career in FM. I am interested in working in an outpatient clinic/walk-in clinic setting.

Family medicine is a great specialty and we need more people who are genuinely interested in it. Thanks for choosing family medicine and I am sure if you keep up the hard work then you will become an excellent doctor.

 

On 12/29/2019 at 5:39 PM, blueskyguy said:

I have read online about other fields (nurse practitioners, etc.) possibly encroaching on FM in Canada. Is there any truth to this? Are FM salaries affected by this in any way, etc.?

There are other health care workers (such as nurse practitioners, pharmacists, physician assistants, optometrists) who are increasing their scope and overlapping with family medicine. I don't believe that family medicine salaries are affected by this in any way. There is a true shortage of family physicians across Canada and even greater shortage of family physicians who practice good medicine. My advice is to not get distracted by what other professions are doing. At the end of the day, you can only control what you can do.

 

On 12/29/2019 at 5:39 PM, blueskyguy said:

Will FM ever be replaced by other fields, etc.? Will FM continue to be a solid and safe career choice in Canada for the future?

(What about FM in the U.S.?)

I love this field, I just want to be clear on its reliability and job security.

Thanks for the input!

I don't think family medicine will be replace by these other fields. Optometrists can only deal with eyes. Pharmacist can prescribe and follow chronic diseases (such as diabetes) but there are still limitations on scope. They can deal with single complaints and stable patients only. Nurse practitioners can usually only practice within their training scope. For example, many NPs train to work in ED where they can only see low and mid acuity things and they need MD approval for certain things. They are very independent which is good but MD has to see all sick patients in the ED. Therefore, NPs are not replacing MDs. They are one of many professions in the ED who are part of the team to provide health care. Other NPs who work in OB office are part of the team that includes MD, NP, RN etc.

As a family physician, you are a generalist who is able to work in any setting and can see both stable and unstable patients. Family medicine is becoming more sub-specialized (R3s in most things now exist) but no one should stop you from being a good generalist family physician.

In my opinion, family medicine will continue to be solid and safe career choice in Canada. I would advice that you develop some sort of interest/expertise in one area (either through R3 or just through practice) so that you can both be a generalist and also a sub-specialist within FM.

 

On 12/29/2019 at 5:39 PM, blueskyguy said:

(What about FM in the U.S.?)
 

Family medicine still exists in USA even though the scope of practice for NPs, PAs is greater in USA than Canada. In addition, many specialists (OBs, IMs, EMs, Peds etc.) also do primary level care in USA - but still Family medicine physicians are not running out of patients any time soon.

On 12/29/2019 at 5:39 PM, blueskyguy said:

I love this field, I just want to be clear on its reliability and job security.

 

Continue to have a good attitude and you will do great. Family medicine is a great career. And one day you will realize how amazing it is that random strangers will come to you and share with you their life experiences and make you an important part of their life. As a family doctor, you will get a chance to make a difference in someone's life every single day.

If you have any other questions, feel free to ask.