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Are residents actually happy?

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I think you'll find happy and unhappy residents just like you'll find happy and unhappy medical students. People also have good and bad days, good and back weeks/months and so it really is hard to generalize. 

Residents work long hours yes, but at the same time, residents get to do the widest variety of things they will ever get to do in their careers and they also don't have that ultimate responsibility like staff do. 

Ultimately, there is no substitute for time put in, you'll notice that in many european countries, training is less split into residency and staff, and more split into a pyramid. Work hours may be mandated to be less, but training is often longer or progression isn't guaranteed and there are still places where the "contract" is broken regularly.

While I don't know which system is better, I do think that we should accept our privilege to be working a profession with a stable career, stable pay which is well respected and helps people. Especially with coronavirus, it made me think about how lucky we all are to have a stable career. 

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On 6/29/2020 at 5:41 PM, gogogo said:

Just came across the CMA National Physician Health Survey. It was done in 2018 and surveyed 400 residents and ~2500 attendings regarding wellbeing, burnout, depression, etc. The results are pretty damning. For instance, on page 10, they show data on residents vs. attendings. 48% of residents report having felt depressed on a screener and nearly 40% report high levels of burnout. 27% report suicidal ideation at least once, and 15% in the past year. On another page they show how these stats stratify according to years in practice. Lots of interesting data in there.

 

yeah it really is. 

For me personally I can say the residency experience particularly early on when the call shifts were near their maximum levels was simply so destructive that I barely got through that part. I like to think I am relatively hard working and smart but the depths of sleep deprivation, with the physical and mental burnout was crushing me to pieces. It was very hard to bring that up while in the middle of a program - particularly when anything done to reduce one persons call shifts just resulted in them being added to someone else. We lost people along the way in residency in various programs that just couldn't handle it (people that would have no problem doing this as staff under more normal shift situations). Good people, and I could have been one of them. 

Sounds stupid but I think it was really a relatively small number of call shifts over a personal limit that wiped me out. Once that fell down from 5-6 a month to 3-4 I got my brain back. I remember one day I could do math again - that was a good day. There was a year and a half or so there were I was in a complete mental fog - extremely frustrating. 

 

Edited by rmorelan

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6 minutes ago, rmorelan said:

yeah it really is. 

For me personally I can say the residency experience particularly early on when the call shifts were near their maximum levels was simply so destructive that I barely got through that part. I like to think I am relatively hard working and smart but the depths of sleep deprivation, with the physical and mental burnout was crushing me to pieces. It was very hard to bring that up while in the middle of a program - particularly when anything done to reduce one persons call shifts just resulted in them being added to someone else. We lost people along the way in residency in various programs that just couldn't handle it (people that would have no problem doing this as staff under more normal shift situations). Good people, and I could have been one of them. 

Sounds stupid but I think it was really a relatively small number of call shifts over a personal limit that wiped me out. Once that feel done from 5-6 a month to 3-4 I got my brain back. I remember one day I could do math again - that was a good day. There was a year and a half or so there were I was in a complete mental fog - extremely frustrating. 

 

If you feel very burnt out. Is there no way to reschedule call? Or take some time off ? Do they penalize you for this ?

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2 minutes ago, dooogs said:

If you feel very burnt out. Is there no way to reschedule call? Or take some time off ? Do they penalize you for this ?

the only way to reschedule call is to have someone else do it - but that doesn't work because then you just owe them a call shift. It isn't that a particular shift is annoyingly in the wrong place - it is just that the shear number of them didn't allow for recovery (for me personally - I should point out that the issue in part is that as a particular individual late nights are not much of an issue but early mornings are. The flipping around from days to nights to days constantly was the issue. with a different call structure - say a week of night float - I could have been just fine). 

You have vacation time - and you can use that to recover (and should) but often that seems to result in call shifts pushed closer together in many cases, you only have 4 weeks a year, and often you use that time to study for important milestones. 

So it isn't really penalized directly at all - the system just doesn't let you really escape things. even if you could you would have the wonderful knowledge you are just dumping onto your friends basically. Each call shift must be covered - it is a zero sum game. 

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1 minute ago, rmorelan said:

the only way to reschedule call is to have someone else do it - but that doesn't work because then you just owe them a call shift. It isn't that a particular shift is annoyingly in the wrong place - it is just that the shear number of them didn't allow for recovery (for me personally - I should point out that the issue in part is that as a particular individual late nights are not much of an issue but early mornings are. The flipping around from days to nights to days constantly was the issue. with a different call structure - say a week of night float - I could have been just fine). 

You have vacation time - and you can use that to recover (and should) but often that seems to result in call shifts pushed closer together in many cases, you only have 4 weeks a year, and often you use that time to study for important milestones. 

So it isn't really penalized directly at all - the system just doesn't let you really escape things. even if you could you would have the wonderful knowledge you are just dumping onto your friends basically. Each call shift must be covered - it is a zero sum game. 

I guess the nice part is that you are usually not by yourself so that if you are worried about making a mistake due to being tired it would get picked up?

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42 minutes ago, dooogs said:

I guess the nice part is that you are usually not by yourself so that if you are worried about making a mistake due to being tired it would get picked up?

as a rad resident I was by myself reading as a sole radiologist for about 8 hours every call shift :) Those hours were all through the night when you are max tired, and having read already for 16+ hours and much more likely to make a mistake. I would joke that you must study until you can do it in your sleep - because well you basically will be doing in your sleep - but that would hit too close to home. 

Now at many centres that isn't the case for some things - some have gone 24/7 staff in areas and in particular for rads at big centres. Others (most) are still as residents by themselves for at least a long part of the night. Ottawa was pretty good and had staff until 11 for many things. If you ever get into extreme trouble you can call staff but that is a very rare thing to do - in my case done exactly 2 twice and both times because a surg staff insisted on it (didn't trust any residents reads prior to the OR for complex things - fair enough). I should say that in many places where the staff are there 24/7 it is also quite busy - and that staff may not always be there to help with the full range of imaging you are reading for instance in rads  (like they only do the ER cases, and you have in patients to read as well). This is rad specific but most residents are operating for long periods of time with only other residents or just themselves (but at least with another resident you still have someone to discuss things with). 

This isn't all doom or gloom but I think you do have to have these open conversations about what residency is like and how we can collectively get through it. 

Edited by rmorelan

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On 6/28/2020 at 6:50 PM, Intrepid86 said:

Residency is temporary. I suggest you focus on what area of medicine you ultimately want to practice in, rather than the quality of life during your training program. That being said, it would be hard to beat a Family Medicine residency for work life balance.

 

On 6/28/2020 at 6:41 PM, offmychestplease said:

FM

This is strictly for family med - but given the duration (2 years), if it's an "easier" residency then how in the world are you supposed to become competent? There's just no way to train someone to do full scope if the 2 years are not very intense. And even if someone is dead set on doing strictly outpatient 100% of the time (minds can change though), you can't build competency with an easy 2 years. It's a good way to train a referologist who can't start and manage insulin for diabetes.

I fully agree that being very intense for 5 years is just not a good. But 2 years? You get scammed out of your training. 

3 hours ago, unmatch said:

Because I don't feel there's a lot of learning to be had after M4. The focus of the FM residency is instilling independence and practice management skills, you've learned 90%+ of the content by the time you're done med school. I think  you need to think about whether you enjoy the academic drive of the Royal College specialties and the need to learn a topic very in-depth. Family medicine is not about the medicine, it's about following preventative guidelines, reassuring the worried-well, and triaging to other services. You need to decide if you feel happy enough being a doctor regardless of what patients you're seeing or if you really want to be an expert on a topic. There's also a cost-benefit analysis that I think most FM-prospectives go through where you'll make nearly as much as most of the Royal College specialists (excluding surgeons, cardiologists, and GI) while doing an easy and short residency. 

Because in the end, if you are not seeing patients on whatever you read there's no satisfaction from having that knowledge, and you won't retain it either. Family doctors don't have the time or training to be seeing complex patients. You could spend 30-60 minutes counselling a liver cirrhosis patient and treating all their comorbidities, but you could also just refer to GI or GIM who will be far more experienced in treating something like that. You also bill the same amount for seeing a patient for a rash for 3 minutes so there's no incentive to see complex patients.

And this is how you waste the system money and lengthen wait times for people who actually need a specialist. Why exactly are you unable to treat a cirrhotic patient? You should know what diuretics to use, how much and how to manage their other (bread and butter) comorbidities. Same goes for every similar patient. CHF, COPD etc. really do not need referrals unless they're out of control and you don't know what to do. If I don't need a procedure (ex. a scope), starting things like biologics, or I'm not needing something like an insulin pump etc. then there's no reason to refer. 

I also strongly think that family doctors should be working up and ordering more specialized tests to diagnose the lesser common conditions prior to referral. This also saves the system money because then the specialist can focus on treating rather than starting from scratch. It also saves the patient time in getting treated quicker. 

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1 hour ago, rmorelan said:

yeah it really is. 

For me personally I can say the residency experience particularly early on when the call shifts were near their maximum levels was simply so destructive that I barely got through that part. I like to think I am relatively hard working and smart but the depths of sleep deprivation, with the physical and mental burnout was crushing me to pieces. It was very hard to bring that up while in the middle of a program - particularly when anything done to reduce one persons call shifts just resulted in them being added to someone else. We lost people along the way in residency in various programs that just couldn't handle it (people that would have no problem doing this as staff under more normal shift situations). Good people, and I could have been one of them. 

Sounds stupid but I think it was really a relatively small number of call shifts over a personal limit that wiped me out. Once that feel done from 5-6 a month to 3-4 I got my brain back. I remember one day I could do math again - that was a good day. There was a year and a half or so there were I was in a complete mental fog - extremely frustrating. 

 

What would happen to the call schedule if this happened? Just spread the load to the remaining residents?

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2 minutes ago, piperacillin said:

What would happen to the call schedule if this happened? Just spread the load to the remaining residents?

when we lose residents (transfer to another program/school, long term illness, mat/pat leave...........) the remaining call shifts are just redistributed yeah. For most people they are not actually doing the max allowed call (which is insane and quite often only there for most to handle extremely busy rotations on a shorter term interval), which means things can be increased at least by the rules. When you have full resident roaster the increase can be evenly distributed, and ideally there is already some buffer can in some programs you cannot expect everyone to always complete things - things happen etc. Still it can be a bit draining when you are already in the mud as it were, and someone leaves for whatever reason and now there is a bit more to do. 

 

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10 minutes ago, medigeek said:

And this is how you waste the system money and lengthen wait times for people who actually need a specialist. Why exactly are you unable to treat a cirrhotic patient? You should know what diuretics to use, how much and how to manage their other (bread and butter) comorbidities. Same goes for every similar patient. CHF, COPD etc. really do not need referrals unless they're out of control and you don't know what to do. If I don't need a procedure (ex. a scope), starting things like biologics, or I'm not needing something like an insulin pump etc. then there's no reason to refer. 

I also strongly think that family doctors should be working up and ordering more specialized tests to diagnose the lesser common conditions prior to referral. This also saves the system money because then the specialist can focus on treating rather than starting from scratch. It also saves the patient time in getting treated quicker. 

Thanks for presenting the other side. As someone strongly considering FM, I find that there are very contrasting views on what it means to be a family physician. Some boil it down to patient communication and referrals. Others say they can manage around 90% of what they see and only refer for the last 10%.

How can one become the more comprehensive family physician you describe? I want to be a good family physician. Does practicing family medicine more comprehensively mean sacrifices in other areas, as sometimes implied (e.g., longer hours, lower pay, etc.)?

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10 minutes ago, gogogo said:

Thanks for presenting the other side. As someone strongly considering FM, I find that there are very contrasting views on what it means to be a family physician. Some boil it down to patient communication and referrals. Others say they can manage around 90% of what they see and only refer for the last 10%.

How can one become the more comprehensive family physician you describe? I want to be a good family physician. Does practicing family medicine more comprehensively mean sacrifices in other areas, as sometimes implied (e.g., longer hours, lower pay, etc.)?

some people like medigeek are just salty that FM is a chill 2 year residency where you can practice right away, anywhere with no additional fellowships/graduate degrees. FM is really a no brainer...why someone wants to slave away in 5-6 (+) years since many FRCPC fields you need to do a fellowship(s) to get a job in a desirable city is beyond me... 

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2 minutes ago, gogogo said:

Thanks for presenting the other side. As someone strongly considering FM, I find that there are very contrasting views on what it means to be a family physician. Some boil it down to patient communication and referrals. Others say they can manage around 90% of what they see and only refer for the last 10%.

How can one become the more comprehensive family physician you describe? I want to be a good family physician. Does practicing family medicine more comprehensively mean sacrifices in other areas, as sometimes implied (e.g., longer hours, lower pay, etc.)?

NPs can do patient communication and referrals just as well as we can. I mean, if you're not offering much more than an NP - how do we justify our pay compared to them? Doctors are being displaced by NPs and PAs in the American system and they're competing with doctors in Canada too now. Also, in my experience, doctors who do very little for the patient in terms of workup/management tend to also be weaker on the communication side as well. 

I think you become a much better trained FM doc if you go to a very intense residency that has great inpatient exposure and culturally relies less on referrals (this sometimes is due to lack of access too lol). Part of it is also how much develop you can develop on your own time/how much reading and studying you do yourself. And lastly, how patient oriented you are. If you have a patient with transaminitis without a clear cause - are you ordering all the ceruloplasmin and autoimmune and a1 trypsin labs or are you just doing a hepatitis panel then referring out? As the patient, I want a doctor who will actually work something up properly to save me time. Excellent communication skills do not compensate for delayed diagnosis.

As for the money issue, I diagnosed a case of pheo a few weeks ago. Took me an extra 2 minutes to order a full comprehensive set of labs to workup the refractory hypertension. You might make marginally less money (maybe, probably not), but it's much better for the patient. 

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1 minute ago, offmychestplease said:

some people like medigeek are just salty that FM is a chill 2 year residency where you can practice right away, anywhere with no additional fellowships/graduate degrees. FM is really a no brainer...why someone wants to slave away in 5-6 (+) years since many FRCPC fields you need to do a fellowship(s) to get a job in a desirable city is beyond me... 

Except I'm in FM. Not sure how you can be salty in my situation. I'm not in a (remotely) chill residency though. 

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1 minute ago, offmychestplease said:

oh sorry, I thought you were talking down on FM lol

I just don't think the FM people should want an easy residency when it is only 2 years. Should in fact strive to do more during that time length. There's way too much to know. Otherwise I strongly agree that 5 year programs often don't need to be 5 years and can be lighter in intensity. 

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20 minutes ago, offmychestplease said:

some people like medigeek are just salty that FM is a chill 2 year residency where you can practice right away, anywhere with no additional fellowships/graduate degrees. FM is really a no brainer...why someone wants to slave away in 5-6 (+) years since many FRCPC fields you need to do a fellowship(s) to get a job in a desirable city is beyond me... 

I've noticed a trend of you being extremely hostile in these threads. In fact, you accused me of propagating lies and speaking about things I don't know about in a thread about how Western utilizes GPA - until another user confirmed my story.

We're all pre-meds, med students, or residents/physicians just trying to find some support, information, and advice in these threads. We're all on the same team here. I really think you should work on using them for their intended purpose rather than immediately becoming combative 

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1 hour ago, medigeek said:

NPs can do patient communication and referrals just as well as we can. I mean, if you're not offering much more than an NP - how do we justify our pay compared to them? Doctors are being displaced by NPs and PAs in the American system and they're competing with doctors in Canada too now. Also, in my experience, doctors who do very little for the patient in terms of workup/management tend to also be weaker on the communication side as well. 

I think you become a much better trained FM doc if you go to a very intense residency that has great inpatient exposure and culturally relies less on referrals (this sometimes is due to lack of access too lol). Part of it is also how much develop you can develop on your own time/how much reading and studying you do yourself. And lastly, how patient oriented you are. If you have a patient with transaminitis without a clear cause - are you ordering all the ceruloplasmin and autoimmune and a1 trypsin labs or are you just doing a hepatitis panel then referring out? As the patient, I want a doctor who will actually work something up properly to save me time. Excellent communication skills do not compensate for delayed diagnosis.

As for the money issue, I diagnosed a case of pheo a few weeks ago. Took me an extra 2 minutes to order a full comprehensive set of labs to workup the refractory hypertension. You might make marginally less money (maybe, probably not), but it's much better for the patient. 

Agreed. 

For reference, I believe medigeek is doing FM in the US, where it is 3 years, and generally more in-patient heavy. And they sound like an individual who is up for a challenge and wants to be competent in a broad scope of FM, and not just an Urban-FM doc who refers out when things get tough.

You can find many Canadian 2 year FM residency programs that also train you to a strong extent like this, in many mid-sized, semi-urban/smaller centres. Where its only FM residents. 

Frankly, you do more call, you have more responsibilities etc, you learn more.  If you want to just practice urban clinic, without any hospital work, you can get away with taking the easier path within residency...but its alot harder to upskill afterwards, when you aren't in a supported environment.   Do that extra CVC, spend that extra time with IM attendings managing complex patients, so that when you do work in a FM clinic, you'll be able to save time and pick things up quicker for subtle abnormalities, or subtle presenting complaints, that many would otherwise shrug off until they develop further. 

2 years isn't a long time, but it's really individual - some people feel like they have a good enough basis after 2 years and want to get going and learning more as they go. Others feel uncomfortable still handling 3am ward calls for post-op fluid abnormalities etc.  Which is fine, because not everyone in FM has to go into hospitalists, or inpatient fields that would necessitate handling those types of patient problems.

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3 minutes ago, JohnGrisham said:

Agreed. 

For reference, I believe medigeek is doing FM in the US, where it is 3 years, and generally more in-patient heavy. And they sound like an individual who is up for a challenge and wants to be competent in a broad scope of FM, and not just an Urban-FM doc who refers out when things get tough.

You can find many Canadian 2 year FM residency programs that also train you to a strong extent like this, in many mid-sized, semi-urban/smaller centres. Where its only FM residents. 

Frankly, you do more call, you have more responsibilities etc, you learn more.  If you want to just practice urban clinic, without any hospital work, you can get away with taking the easier path within residency...but its alot harder to upskill afterwards, when you aren't in a supported environment.   Do that extra CVC, spend that extra time with IM attendings managing complex patients, so that when you do work in a FM clinic, you'll be able to save time and pick things up quicker for subtle abnormalities, or subtle presenting complaints, that many would otherwise shrug off until they develop further. 

2 years isn't a long time, but it's really individual - some people feel like they have a good enough basis after 2 years and want to get going and learning more as they go. Others feel uncomfortable still handling 3am ward calls for post-op fluid abnormalities etc.  Which is fine, because not everyone in FM has to go into hospitalists, or inpatient fields that would necessitate handling those types of patient problems.

Just to add to this. 

I think it's just more fair for the patient too and gets the patient better and more timely care if their family doctor had the diagnosis promptly made. It also saves the system money as a whole and shortens specialist wait times. 

Of course, the more skilled you are - the less of a threat midlevels will be. 

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There's a saying I've come across before, along the lines of "at the attending level, if you feel threatened by NPs then you probably should be replaced by one" lol. Anyone who's actually worked with NPs will realize they don't even come close to a percentage of what we can do. This is my conclusion after having working with NPs in clinical and non-clinical settings. The threat is a purely political one - how do we show that we are safer and more cost-effective than midlevels? Even if we had such irrefutable evidence, how do we convince cash-strapped politicians and admin so? This midlevel fear speaks more of our profession's inability to successfully market our own value.

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7 hours ago, offmychestplease said:

some people like medigeek are just salty that FM is a chill 2 year residency where you can practice right away, anywhere with no additional fellowships/graduate degrees. FM is really a no brainer...why someone wants to slave away in 5-6 (+) years since many FRCPC fields you need to do a fellowship(s) to get a job in a desirable city is beyond me... 

because we just happen to like doing another field more - and enough so that you go a different route :) 

(and I have said over and over again on the forum how annoyed I am with myself that I didn't really like family medicine on a day to day basis - yet for many of the reasons you mention, plus the small fact that you can have a profoundly fulfilling career helping a lot of people that is sure an annoying fact. and yes it would have saved 5 years of time in my case).

 

 

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6 hours ago, JohnGrisham said:

Agreed. 

For reference, I believe medigeek is doing FM in the US, where it is 3 years, and generally more in-patient heavy. And they sound like an individual who is up for a challenge and wants to be competent in a broad scope of FM, and not just an Urban-FM doc who refers out when things get tough.

You can find many Canadian 2 year FM residency programs that also train you to a strong extent like this, in many mid-sized, semi-urban/smaller centres. Where its only FM residents. 

Frankly, you do more call, you have more responsibilities etc, you learn more.  If you want to just practice urban clinic, without any hospital work, you can get away with taking the easier path within residency...but its alot harder to upskill afterwards, when you aren't in a supported environment.   Do that extra CVC, spend that extra time with IM attendings managing complex patients, so that when you do work in a FM clinic, you'll be able to save time and pick things up quicker for subtle abnormalities, or subtle presenting complaints, that many would otherwise shrug off until they develop further. 

2 years isn't a long time, but it's really individual - some people feel like they have a good enough basis after 2 years and want to get going and learning more as they go. Others feel uncomfortable still handling 3am ward calls for post-op fluid abnormalities etc.  Which is fine, because not everyone in FM has to go into hospitalists, or inpatient fields that would necessitate handling those types of patient problems.

Where in Ontario or Canada would provide this sort of training during FM residency?

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2 hours ago, gogogo said:

Where in Ontario or Canada would provide this sort of training during FM residency?

Most mid-sized programs that put you into a hospital where you aren't required for solely service, like  big urban centre, and you are the first-dibs resident on site. That said, even motivated students in big urban centres can craft it for themself - just a bit harder when theres 20 other residents/fellows around.

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8 hours ago, 1029384756md said:

There's a saying I've come across before, along the lines of "at the attending level, if you feel threatened by NPs then you probably should be replaced by one" lol. Anyone who's actually worked with NPs will realize they don't even come close to a percentage of what we can do. This is my conclusion after having working with NPs in clinical and non-clinical settings. The threat is a purely political one - how do we show that we are safer and more cost-effective than midlevels? Even if we had such irrefutable evidence, how do we convince cash-strapped politicians and admin so? This midlevel fear speaks more of our profession's inability to successfully market our own value.

Yea it's political instead of clinical, but it's still something to acknowledge. Just look to the states and the rise of CRNAs. Yes, they provide a service to areas which may not otherwise be able to get anesthesia services, but interests of corporate medicine (or the government here) to save money don't always make decisions in the best interests of patients. It just needs to be 'good enough' as long as they are re-elected.

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7 hours ago, piperacillin said:

Yea it's political instead of clinical, but it's still something to acknowledge. Just look to the states and the rise of CRNAs. Yes, they provide a service to areas which may not otherwise be able to get anesthesia services, but interests of corporate medicine (or the government here) to save money don't always make decisions in the best interests of patients. It just needs to be 'good enough' as long as they are re-elected.

 

15 hours ago, 1029384756md said:

There's a saying I've come across before, along the lines of "at the attending level, if you feel threatened by NPs then you probably should be replaced by one" lol. Anyone who's actually worked with NPs will realize they don't even come close to a percentage of what we can do. This is my conclusion after having working with NPs in clinical and non-clinical settings. The threat is a purely political one - how do we show that we are safer and more cost-effective than midlevels? Even if we had such irrefutable evidence, how do we convince cash-strapped politicians and admin so? This midlevel fear speaks more of our profession's inability to successfully market our own value.

With the rise of technology and information more readily available - midlevels can absolutely be a huge threat to physicians who are just providing basic services. 

In the US, ICUs are often staffed solely by NPs or PAs at night time. CRNAs do solo cases with no anesthesiologist in house in most rural areas. Many consults are often just seen by a midlevel, and yes even the first time (not just follow ups). There are NP hospitalists. NICUs are run by NPs now. Derm is run by PAs. And there are midlevels who supervise residents in many places on specialty rotations. Some are being trained to do scopes. Some do bronchs. Many intubate independently. 

To say there's no threat is insane. 

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As one of my old FM preceptors put it, family medicine is as easy or difficult as you make it. As a practicing family doctor, I agree with that.

As with many other jobs, it's relatively easy to be adequate, harder to be good, and challenging to be excellent /exceptional. A two year FM residency is short. Everyone knows that. Like all other residencies, you get out what you put in. More effort up front usually means less needed later. Because there's an eventual range of interests, ability, and practice preferences, there also exists an abundance of clinical resources, transition advice (e.g., First five years of practice), mentorship networks etc. for those seeking it. By far the most important thing is to have a positive attitude towards self learning and improvement that will serve you well throughout your career, no matter what stage of career you're in.

As a family doctor, if a patient likes you, that is already more than half the battle, even if you did nothing else. That might sound dumb, perplexing, and possibly even wrong, but it's not. If your patient doesn't like you as their primary care provider, then the chance of them taking your preventative advice is low, as will be their engagement on any investigation and treatment plans proposed. Clearly, the more you can do for the patient on your own, the better. However, if you need to refer out, then refer out, because doing something that's not within your comfort or ability will be even worse. If you need to refer out all the time for something that most of your colleagues are not, then you might be falling below the standards of knowledge for your specialty, so the onus would be on you to rectify that.

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