Career satisfaction in family medicine

[gogogo]

I'm still early in med school, but it seems that the bread and butter of family medicine is chronic diseases with little tangible evidence of benefit (e.g., HTN meds, diabetes management) or tenuous symptom management  (e.g., autoimmune conditions). Combining this with patients who may not always be grateful or questioning/not listening to your recommendations (e.g., lifestyle modification), I am wondering where you derive satisfaction? I don't mean to ask this in a critical way, and I also recognize that I'm probably painting a caricatured picture of the specialty. In fact, I am strongly considering family medicine and want to expand my awareness on what makes other family doctors excited and satisfied with their work.

[Intrepid86]

To best answer your question, it requires a better understanding of what family medicine really is. The following is my perspective. Others may disagree, but to each their own.

The hallmark of specialists is knowledge. The hallmark of family physicians is communication. As a family doctor, a large part of the job is providing empathy and patient education. The medicine is important, but almost secondary. Your greatest asset is the strength and trust of the therapeutic relationship you have with patients as their primary care provider. When a patient is sick, they will want to see you. After a patient consults a specialist, they will still want your opinion on the recommended course of action. When a patient is dying and nothing more can be done, they and their loved ones will want your sympathy and guidance to feel like they aren't alone. This therapeutic relationship is your privilege, your wheelhouse, and ultimately, a significant part of where your job satisfaction comes from.

On a very practical level, family medicine is about improving patients through incremental change, the sum of which over time leads to improved quality of life. Let's say this is a game of baseball. As a family doctor, you probably won't be the star batter hitting home runs. You will be hitting singles all day. Is it sexy? no. Is it progress? yes. Is it needed? yes.

You are correct; FM can be a grind. Feeling under appreciated at some point is common. There are patients who will not be grateful despite your best efforts. There will be vague complaints for which you will have no clear idea what is going on. 20% of your patients will feel like 80% of your work. These and other daily challenges will all demand your care and attention. Family medicine not suitable for everyone, but like every other field of medicine, it has both its satisfying and less than satisfying aspects.

I hope this helps.

Good luck in your future studies.

[medigeek]

14 minutes ago, Intrepid86 said:

To best answer your question, it requires a better understanding of what family medicine really is. The following is my perspective. Others may disagree, but to each their own.

The hallmark of specialists is knowledge. The hallmark of family physicians is communication. As a family doctor, a large part of the job is providing empathy and patient education. The medicine is important, but almost secondary. Your greatest asset is the strength and trust of the therapeutic relationship you have with patients as their primary care provider. When a patient is sick, they will want to see you. After a patient consults a specialist, they will still want your opinion on the recommended course of action. When a patient is dying and nothing more can be done, they and their loved ones will want your sympathy and guidance to feel like they aren't alone. This therapeutic relationship is your privilege, your wheelhouse, and ultimately, a significant part of where your job satisfaction comes from.

On a very practical level, family medicine is about improving patients through incremental change, the sum of which over time leads to improved quality of life. Let's say this is a game of baseball. As a family doctor, you probably won't be the star batter hitting home runs. You will be hitting singles all day. Is it sexy? no. Is it progress? yes. Is it needed? yes.

You are correct; FM can be a grind. Feeling under appreciated at some point is common. There are patients who will not be grateful despite your best efforts. There will be vague complaints for which you will have no clear idea what is going on. 20% of your patients will feel like 80% of your work. These and other daily challenges will all demand your care and attention. Family medicine not suitable for everyone, but like every other field of medicine, it has both its satisfying and less than satisfying aspects.

I hope this helps.

Good luck in your future studies.

As I posted in another thread - you can do additional things (inpatient, ER, Ob, a large variety of random things etc.) in family medicine. You can also carry very in-depth knowledge in certain niches as well.

[Intrepid86]

8 minutes ago, medigeek said:

As I posted in another thread - you can do additional things (inpatient, ER, Ob, a large variety of random things etc.) in family medicine. You can also carry very in-depth knowledge in certain niches as well.

That's true. Family doctors can certainly niche their practices into something more specialized, but I feel it's not really answering the question that was posed. The OP is largely referring to career satisfaction derived from family medicine in its most traditional, comprehensive care form.

[medigeek]

2 minutes ago, Intrepid86 said:

That's true. Family doctors can certainly niche their practices into something more specialized, but I feel it's not really answering the question that was posed. The OP is largely referring to career satisfaction derived from family medicine in its most traditional, comprehensive care form.

Doesn't traditional and comprehensive kind of reference what I said though? Broad scope that goes well beyond just a clinic practice. 

[Arztin]

On 6/4/2020 at 10:35 PM, gogogo said:

I'm still early in med school, but it seems that the bread and butter of family medicine is chronic diseases with little tangible evidence of benefit (e.g., HTN meds, diabetes management) or tenuous symptom management  (e.g., autoimmune conditions). Combining this with patients who may not always be grateful or questioning/not listening to your recommendations (e.g., lifestyle modification), I am wondering where you derive satisfaction? I don't mean to ask this in a critical way, and I also recognize that I'm probably painting a caricatured picture of the specialty. In fact, I am strongly considering family medicine and want to expand my awareness on what makes other family doctors excited and satisfied with their work.

Hey there

I would say that a lot of what you said is partially true.

It's true that managing chronic conditions might seem boring. However, that can be a very good sign. e.g. your diabetic and hypertensive patient has never been admitted to the hospital for a massive STEMI since his diabetes and hypertension are well managed ? Well that's certainly a good sign. Plus you managed to help them quit smoking? even better!

The bread and butter of most fields is repetitive. The nephrologist who follows CKD, well there aren't any magical therapy in that regard. The cardiologist who follows the vasovagal syncope patient who has 20 syncopes per week? Not sure they have magical treatments in that regard neither. The ophthalmologist doing the 20th cataract surgery the same day? Not sure what they like about that.

Family medicine isn't the only place where you will see patients who won't be grateful, or non compliant patients. Emerg physicians get unpleasant, verbally abusive patients all the time. As a hospitalist, you might be admitting the same patient the 5th time this year for DKA because they refuse to take their insulin as prescribed. As a psychiatrist, you might get the psychotic patient who stopped taking their medications, and now readmitted for psychosis once more. As a vascular surgeon, you might see the critical limb ischaemia patient who kept smoking, and now you have no choice but to perform a limb amputation. As a respirologist, you might get the 120 pack-year end stage COPD patient who still smokes 2 packs a day. As a transplant surgeon, you might get a liver transplant patient who restarted drinking, and now cirrhotic again. Trust me, non compliance is not just in family medicine.

Now consider the following:

FM = true generalist. You know a bit of everything. The internists will manage complex medical conditions much better than you, but you know how to repair a laceration much better than the internist. The orthopod will know MSK much better than you, but you know how to manage medical conditions better than the orthopod etc...

Flexibility and mobility: It's not something you can get with most specialties. You can do palliative care, rural medicine, hospital medicine, emerg, etc...

Long-term relations with patients: as the main physician following your patients for 20 years, you will get to know them, and most patients will appreciate you for your job. Contrast this with the orthopedic surgeon who in 1 day saw 50 patients in their fracture clinics.

Variety: something you won't get with most other specialties

When it comes to your job satisfaction, it really depends on how you perceive things. Some derive it from the work-life balance they get from FM, others from the impact they have on patients, some from the bonds they form with their patients etc...

Anyways, it's getting late. I'm out. Don't rule out family medicine just yet. It has a lot to offer! Feel free to PM me if you have questions!

 

[whatisgoingon]

5 minutes ago, Arztin said:

The ophthalmologist doing the 20th cataract surgery the same day? Not sure what they like about that.

I think I have an idea what they like about that...

[Arztin]

22 hours ago, whatisgoingon said:

I think I have an idea what they like about that...

wink wink ;)

[Lactic Folly]

22 hours ago, Arztin said:

The ophthalmologist doing the 20th cataract surgery the same day? Not sure what they like about that.

How about restoring people's sight and significantly improving their quality of life with a single procedure?

Is that such a far fetched possibility?

[Edict]

On top of what others have said, which I fully agree with, Family medicine offers career flexibility and a better lifestyle. I think that is what really appeals to people. 

[bearded frog]

17 hours ago, Lactic Folly said:

How about restoring people's sight and significantly improving their quality of life with a single procedure?

Is that such a far fetched possibility?

Implying that other things doctors do don't improve quality of life...

[unmatch]

Most people I know in family chose it because they were satisfied enough with being a doctor regardless of specialty. Short residency, free job market, flexible lifestyle, and a short cut to emerg were all common reasons my friends/co-residents chose family. People choose other specialties when they have a desire to be the expert in a topic, be the endpoint of treatment for patients, and divulge in academia. 

[Lactic Folly]

3 hours ago, bearded frog said:

Implying that other things doctors do don't improve quality of life...

There is absolutely zero implication of that in my post. I am very surprised to see such a response and have no idea why you would say that.

Did you see my post in the other thread here?

 

[bearded frog]

If you took Arztin's sarcastic comment at face value and thought he was actually confused why ophthalmologists like doing 20 of the same procedures in a row, and are not aware of the context, and you were genuinely, if naively, trying to helpfully suggest a reason why someone might want to do the same procedure over and over again, then I apologize.

However, doing the same procedure 20 times in a row over and over would be pretty bad for most people, the reason they do it, that Arztin was commenting about above, is that they are overpaid for the procedure, and are receiving payment schedules that were established when the procedure took hours, and they can now bill the same amount for less time and effort, and is one of the most egregious examples of physician overcompensation. I'm sure they also enjoy helping people's eyesight, but if not for the profits, I'm sure they would vary their practice to mix their days up like other specialties.

[Wachaa]

19 hours ago, bearded frog said:

If you took Arztin's sarcastic comment at face value and thought he was actually confused why ophthalmologists like doing 20 of the same procedures in a row, and are not aware of the context, and you were genuinely, if naively, trying to helpfully suggest a reason why someone might want to do the same procedure over and over again, then I apologize.

However, doing the same procedure 20 times in a row over and over would be pretty bad for most people, the reason they do it, that Arztin was commenting about above, is that they are overpaid for the procedure, and are receiving payment schedules that were established when the procedure took hours, and they can now bill the same amount for less time and effort, and is one of the most egregious examples of physician overcompensation. I'm sure they also enjoy helping people's eyesight, but if not for the profits, I'm sure they would vary their practice to mix their days up like other specialties.

 

From my interpretation, @Arztin was just pointing out that a lot of things are repetitive, not exclusive to family medicine. I agree.

The need to have "variety" every single day in your daily practice is grossly overrated and I would go as far as arguing that most people, whether they are doctors or any other profession, do a ton of repetitive work because that's where they are the most efficient. In the case of ophthalmology, if they don't perform those surgeries, then the waiting lists continue to grow. Plus, surgery is just one of the days of the week and I don't see a problem where they try to maximize their efficiency on that given day. The rest of the time they can do other things. It just so happens that surgeries in general, are lucrative if they don't take a lot of time.

By the way, since I've been out in practice, I realize the reason ophthalmologists make more is not simply because of a certain procedure they can do over and over. But rather the sheer volume of EVERYTHING, including 60-100 of new referrals a day in the office. Similarly for other specialists like ortho, where they round on 20+ people in the AM, see 40-50 in cast clinic, and then be paid for being on call. People are working hard for the money and they deserve to get paid. This is, after all, "work". i.e. we do it to make a living, and compensation is part of that.

[bearded frog]

I don't think anybody disagrees that if you work hard then you shouldn't be compensated for such. I don't have a problem with ortho or ENT etc who can see a patient every 8 minutes, if everyone agrees that $X is a reasonable compensation for that visit. The issue is when the billing agrees that $X compensation is reasonable for something that takes 6 hours and is a certain amount difficult, and then due to technology, now that something takes 30 minutes and less difficult, the billing should be adjusted to fairly compensate for the current situation.

[Wachaa]

42 minutes ago, bearded frog said:

I don't think anybody disagrees that if you work hard then you shouldn't be compensated for such. I don't have a problem with ortho or ENT etc who can see a patient every 8 minutes, if everyone agrees that $X is a reasonable compensation for that visit. The issue is when the billing agrees that $X compensation is reasonable for something that takes 6 hours and is a certain amount difficult, and then due to technology, now that something takes 30 minutes and less difficult, the billing should be adjusted to fairly compensate for the current situation.

 

I agree that the billing schedules aren't always adjusted accordingly. And unfortunately when fee cuts are made, they tend to be made across the board. Sadly, the public already thinks that doctors as a whole are overpaid.

 

Off topic Re: cataracts/ ophtho billing

I'm not an expert. Just referencing to the fee guides.

A cataract surgery, despite billing ~$400 (depending on which province you are, this has been cut by 10-25%), still takes around 15-30 minutes (including all the set up, etc). In the office, they could have seen patients and billed twice as much in the same amount of time. I'm not sure how much more they can cut the fees though. A colonoscopy is comparable to the amount of time to do a cataract surgery and billings are similar (well, I guess it depends how many polyps you also remove).

I think the income disparity is created when offices are run like factories. The specialists aren't personally seeing all the patients coming into the office that day. They're being seen by trained assistants, doing  OCT/ perimetry/ etc. Imagine an internist or cardiologist who is having an office with stress test visits, ECG/ Holter visits, and private consultations. This leads to high volumes. But again, this is work that needs to be done and compensated for. If they don't do it, someone else will, and perhaps in a less efficient manner.

[bearded frog]

I am not an expert in these matters, however this has been discussed by those more knowledgeable than I. I refer to https://cmajnews.com/2019/10/08/are-fees-for-cataract-surgery-still-too-high/ for a brief discussion of the issue and allow others to draw their own conclusions.

[Lactic Folly]

On 6/8/2020 at 2:50 AM, bearded frog said:

If you took Arztin's sarcastic comment at face value and thought he was actually confused why ophthalmologists like doing 20 of the same procedures in a row, and are not aware of the context, and you were genuinely, if naively, trying to helpfully suggest a reason why someone might want to do the same procedure over and over again, then I apologize.

Thank you for clarifying that extrinsic and intrinsic motivators can coexist. I don't disagree that pay obviously influences behaviour, but when I responded to Arztin's comment, I was thinking of my friend in ophtho who, as a student, expressed his awe about the gratitude from patients after their surgeries. Now with a young family, he continues to provide volunteer services and teach in the developing world (before this year, anyway). I'm sure he enjoys his income too, but wouldn't presume to state that pay is his only motivation. It's a bit of a harsh judgment to make about the character of a stranger (unless you agree with my undergrad science prof who openly stated all doctors are in it for money, since even a junior resident does much better than a postdoc for what he sees as less intellectual and mostly mechanistic work... and I can't really dispute that).  

You know, I do get it. The hidden curriculum is extremely strong. As a student, I absorbed all these attitudes and even parroted them myself. At that stage, the talk wasn't so much about money (probably because to students, any staff physician income is a great improvement). However, certain fields were known as "lifestyle" fields. So, if someone entered one of these fields, it must be because they are primarily motivated by lifestyle, and don't have the same work ethic as others... right?

Then, a family member had a brief health scare. We received excellent care, and I realized how ignorant my assumptions were, as they were only based on others' comments and no firsthand knowledge. I still remember the resident's grimace as I thanked him for "coming in early on the weekend" when he had already been working in the hospital for some time prior to coming to clinic. I was ashamed for the microaggressions I had previously unthinkingly expressed in conversations about other people I was barely acquainted with, based on their "lifestyle" specialty.

Nowadays, I am trying to be a more conscious person. I don't disagree that the fee schedules need a lot of work. I will however not make statements about the personal motivations of someone solely based on their career choice, or how their field has evolved over decades. There are good and bad apples in every field of medicine, which I can attest to from personal experience. People who will go the extra mile for patients, and others who shuffle them out the door in literally less than one minute while building their cosmetic practice. So, when I see a hip/knee arthroplasty surgeon, who only does hip and knee surgeries, over and over again, I think... well that's their job and area of expertise, and patients need the surgeries... that's all.

[Lactic Folly]

On 6/8/2020 at 2:50 AM, bearded frog said:

However, doing the same procedure 20 times in a row over and over would be pretty bad for most people, the reason they do it, that Arztin was commenting about above, is that they are overpaid for the procedure, and are receiving payment schedules that were established when the procedure took hours, and they can now bill the same amount for less time and effort, and is one of the most egregious examples of physician overcompensation. I'm sure they also enjoy helping people's eyesight, but if not for the profits, I'm sure they would vary their practice to mix their days up like other specialties.

Since cataracts are a publicly funded medical procedure, if a claim is being made that someone is doing increased numbers of a procedure solely for profit, it would be helpful to elaborate on what other medically necessary care has been displaced as a result, or whether some patients actually do not require the procedure.

Given that most surgeries occur in publicly funded institutions, most of the decisions regarding number of procedures/day will be made at the administrative level. The wait times in each region of Ontario are constantly being tracked. With over 117k cataract surgeries per year in the province, each hospital needs to keep up. Hospitals are being scored on patient length of stay, in fractions of hours, and compared to their peers. Cataracts are funded as a Quality-Based Procedure, which means that instead of coming from the global hospital budget, these cases are paid separately according to patient volumes, and the cost per patient needs to come under a certain amount. 

Therefore, hospitals are putting significant emphasis on Lean processes and efficiency, and prioritizing standardization above individual physician preference. It's always more efficient to do multiple cases of the same procedure at once, instead of changing the room setup and having everyone shift gears, including allied health who are paid by the hospital. High-volume centres are also promoted as a way to improve outcomes, and for this reason, Cancer Care Ontario has recommended that patients not have Whipple resections done at lower volume centres, even if their surgeons would like to keep up doing a few per year. 

In this case, the result might align with physician incomes,  but in general a lack of involvement in administrative decisions is a major complaint that I hear from physicians. Maybe it's different where you are and physicians have more agency in directing hospital operations to suit their own agendas, I don't know. But the fee code is really a separate issue to the number of procedures performed per day.

I'm not going to change anyone's opinions but just wanted to offer more thoughts for others reading. These perceptions are certainly pervasive, and as said, many members of the public do feel all doctors are overpaid. In the future, you might get called for an urgent hospital case while in clinic. Your hectic day providing necessary coverage for the service may be interpreted by some of your patients as a choice to overextend yourself (for more $) at their expense. The extra time and effort you put into training the future generation of doctors at your clinic might be seen by some patients as sending a less qualified person in order to save time for the staff physician and help increase patient throughput/billings. These are opinions I've heard and read... no one is immune. 

[Lactic Folly]

On 6/9/2020 at 3:15 AM, bearded frog said:

I am not an expert in these matters, however this has been discussed by those more knowledgeable than I. I refer to https://cmajnews.com/2019/10/08/are-fees-for-cataract-surgery-still-too-high/ for a brief discussion of the issue and allow others to draw their own conclusions.

Reread Wachaa's last post carefully. I don't think it's saying that disparity isn't an issue (eta: many codes do not account for case complexity, leading to significant variance between practice settings in the same field, so it's not that straightforward to define their value). But perhaps advocating for increased supports, where needed, might be more helpful to the majority of medical practices.

As this thread has gone off-topic, I will circle back and say that one advantage of family medicine is the ability to conduct discussions like the thread below in a vastly different tone:

 

[whatisgoingon]

oh god what have i done