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Jaeger

Why not family med?

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I'm only entering M1 this September, but family medicine seems like the best career for me. I find so many aspects of the job appealing including making long-term relationships with patients and their families, and predictable work hours. However, several people I know who are also entering M1 this september, as well as some in pre-clerkship, have already completely ruled out family. 

For those who completely ruled out family med, why? I'm just curious what many of you don't like about family med.. was it your experience or are you simply drawn to another speciality? Is the fact that family med makes less money relative to other doctors a factor? I grew up in a family that always struggled financially so I personally cannot see myself letting go of family med just because of pay, but perhaps others do (which is totally fine!) 

Very interested in what you all have to say :)

 

 

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Great questions. I think it comes down to values and what someone finds most rewarding in a career *personally* - eliciting these different views can really clarify your own decision-making process, although it sounds like you've already done quite a bit of self-reflection.

I was one of those who never really considered family medicine (as embodied by the urban practices we were assigned to in first year medical school, as our subsequent rural rotations were obviously quite different) for the following reasons:

- Patient population: I enjoy a certain level of acuity. Not necessarily airway crashing type stuff, but I find it rewarding to be involved in the care of sick people who have come into hospital with acute abdominal pain - to set their care on the right course by determining whether or not they have a surgical problem, and giving the team the information they need to manage the patient appropriately - whether that's at 8 p.m. or 3 a.m. I did not experience the same level of satisfaction when dealing with primarily well patients for checkups, prescription refills, ambulatory care issues, etc. even when I went home at 4:30 p.m. every day. When more complex psychosocial issues presented, I didn't feel I had enough time (nor training) to deal with them properly within the space of an office visit. As above, this does not mean dealing with these patient concerns is of any less value - just that the work is less suited to me.

- Duration of patient contact: for me, it's about quality, not quantity. I find it rewarding to have performed a biopsy in such a manner that the patient says that it wasn't as bad as they had thought it would be, responding in such a way to indicate they felt they were cared for and their needs attended to during that time. Although I continue to take an interest in their care afterwards and follow up on the results, outcome, etc., I do not feel that something is missing if I do not personally see the patient again, knowing I have done my best for them. Evidently, long-term patient relationships are a big draw of traditional family medicine, but this factor is simply not important to me. Doing rural family medicine would also lead one to be much more immersed in a community, even outside of work.

- Generalization vs specialization: I have heard generalists say they wouldn't feel like a "real doctor" if they couldn't deal with issues across the spectrum of health. The breadth of knowledge and skill would simply be too daunting for me, though (especially in a rural setting). To boot, many serious conditions seem to have such nonspecific presentations in the beginning - stress/fatigue vs malignancy? Yet, it would be undesirable and harmful to over-investigate every common complaint. To me, it is satisfying to develop at least some level of expertise in a small area, in order to be able to act as a consultant and provide some guidance, if not answers, to other physicians. Therefore, branching out into GP-assist type work holds less appeal for me. I've come to peace with my lack of utility in an airplane crisis :)

I'm not sure what comparative pay works out to be on an hourly basis, but given the above factors, I can say that financial reasons did not really enter into my decision not to pursue family medicine. Hope this helps.

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I'm entering the 2nd year of my Family Medicine Residency. From others I've spoken to, the main reason is the nature of the job itself. Being an undifferentiated, generalist physician is not easy. It is broad. You are the primary care provider for patients of every demographic. All of their labs, imaging, consult reports etc, all go to you. Your scope of practice makes you the first point of contact for any medical query, and that can be challenging if symptoms are vague, or your patient is complex. There is also a lot of grunt work and handling of things like insurance forms, work notes, sick notes, as well as addressing psychosocial issues like domestic abuse, poverty, and all manner of other situations that specialists don't want to deal with. Family medicine is a great field, but it's not for everyone.

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There's the whole issue of being looked down upon as well. Family docs are unfairly given less credit or recognition than many of their specialist counterparts. 

I'm in path and find it difficult to tolerate the lack of respect pathologists deal with on a systemic basis. I imagine family doctors have a similar feeling, especially when you see how the government of ontario is clawing at them.

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I think many incoming medical students also overlook family medicine as well! Family medicine is an AMAZING speciality for the following reasons (few of many):

1. You have to know a lot:

As a family doc, you are the gatekeeper of the health and taking care of patients cradle to grave (although this is becoming rarer). That means you have to know how to assess, diagnose, and treat new borns, paediatrics, adolescents, pregnant mothers, and geriatrics. Just like Intrepid86 said, you really have to know enough about everything. I've had family docs who are honestly super lazy and are super quick to refer you to a specialist based on patient reported symptoms (not even clinical signs or on physical assessment or basic blood work). But I've also had family docs who do prenatal care, pelvic exams, ingrown toe-nail removals, varicose veins, and even home calls. The latter are the type of family physicians we NEED in our country. 

2. You can really branch out and refine your practice:

In Canada you can do a 2+1 or even other unaccredited fellowships where you can refine your practice towards: Anesthesia, ER, Obs/Gyn, first assist in the OR, Derm, Oncology, Geriatrics, Palliative care, Sports medicine, and so much more I'm probably not remembering. Many also work as hospitalists! So if you aren't GUNG-HO on a specialty, and had a very positive experience on your FM rotation, Family Medicine as a residency is an AMAZING option.

3. Life style factor:

The residency is 2 years, and 2 years goes by real fast (i.e. it's basically half the length of high school, undergrad, and most medical schools). You also have more autonomy over your clinic hours, who you work with, where you decide to work (in comparison to all other specialities). I also imagine that with changes to health care, GPs will take on more and more administrative aspects of primary care (FHN's and FHO's).

Like I said, these are just a few of many reason why many medical students shouldn't rule out FM wayyyy too early in the game!

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For me, I always knew I wanted to do psychiatry, but going into medical school I thought family would be a second choice or back up plan. 

But when I did my family rotation, I quickly realized that wasn't going to happen. I liked the staff, the clinic setting, and the relationship aspect, but I didn't like the work. I find the bread and butter (diabetes checks, hypertension, blood work) boring, I hated not being the expert and being responsible for implementing others' recommendations, and with 15 minute appointments, I constantly felt rushed and like I didn't have time to explore things in the detail I wanted to in order to feel comfortable. 

So I guess for me it's a matter of personality. I like being able to take my time and being the expert. 

I have a wonderful family doctor who I respect the hell out of but I could never do it. 

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14 hours ago, Jaeger said:

I'm only entering M1 this September, but family medicine seems like the best career for me. I find so many aspects of the job appealing including making long-term relationships with patients and their families, and predictable work hours. However, several people I know who are also entering M1 this september, as well as some in pre-clerkship, have already completely ruled out family. 

For those who completely ruled out family med, why? I'm just curious what many of you don't like about family med.. was it your experience or are you simply drawn to another speciality? Is the fact that family med makes less money relative to other doctors a factor? I grew up in a family that always struggled financially so I personally cannot see myself letting go of family med just because of pay, but perhaps others do (which is totally fine!) 

Very interested in what you all have to say :)

Starting my PGY-1 in FM in just a few days - here's where FM gave me pause:

1) Minimal opportunities for research or education. Some specialties are focused on the academic side of medicine, sometimes to a point where you can't avoid it even if you want to. Most others have ample opportunities to get involved in research and/or education. Not Family Medicine. Don't get me wrong, there are still opportunities to get involved in these aspects of medicine, but the default is to be in clinical practice only and so the options in FM-based research or education are less apparent and usually less-well compensated compared to clinical practice. This is something I was hoping to keep in my practice moving forward and may have to give up or lessen in FM.

2) Time constraints. Current standard in FM is 4-6 patients per hour, leaving only 10-15 minutes per patient. That can turn off a lot of people, especially as other specialties can have an hour or more per patient, depending on the setting. Now, more is demanded of specialists during their visits, so I'll say that with the exception of pediatrics, I felt at least as rushed on rotations in other specialties as I did in FM, but it's hard to say that time is plentiful in FM.

3) Pay. Income for FM is better in Canada than pretty much anywhere in the world, while hours are better both in quantity and quality than most other specialties in Canada and training times are shorter. Yet, total take-home is less that most specialties. I likely could have doubled my expected income doing something else, at least how things currently stand. I'll still make more than enough for my own needs and that of my family, but it's still hard to pass that kind of money up.

There are other aspects that I know classmates have felt to be drawbacks - lots of paperwork, significant routine care, lack of acuity - that I should mention as well. However, I either didn't mind these aspects or felt them to be over-stated (every specialty has paperwork and work that becomes routine, for example).

So why did I go into FM despite these drawbacks? In a word: flexibility.

Going for FM, I got to choose the electives I wanted to in medical school, without worrying whether they were the right choices. I got a lot more say about where I ended up for residency, because it's a less competitive field. I'll get to choose whether or not to do a +1 and can choose that +1 without having to worry about the job market much. Once I start working, I should be able to get work fairly easily and get a lot more choice over where I get to work. With some small restrictions depending on practice type, I'll get to work the hours I want to work, at the pace I want to work. If I want to take longer with patients - while it would cost me money to do so - I can. Since my scope of practice is whatever I have the training, comfort level, and tools for, I get to decide whether it's best to refer a patient or handle their issues on my own. In short, I have a lot of latitude to decide my own mix of personal and professional priorities. There are restrictions and trade-offs on these choices, of course, but it's a degree of freedom that's hard to duplicate in medicine outside of Family practice.

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Too broad, has to deal with too many issues. Yes you can consult other people but I prefer to be an expert in a few things which others can consult me about.

 

However there are many things about FM that I loved. Friendly, relaxed people, many jobs, variety of work settings, flexible schedule. If I could be an elective medical student forever I would do my electives in FM in cool places.

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I personally hesitated a long time between internal and family medicine. I ultimately ranked FM first, as the same reasons mentionned by Ralk: flexiblity, lifestyle, freedom.

I personally came from a disadvantaged socio-economic background, I went through medical school with scholarships, governmental loans, while trying not to get into too much debt. I want to make sure that when I finish residency, I would be able to work WHERE I want, and how I want. I can`t afford being an internist working part-time after 5 years, 2 years of fellowship, and a master later, while trying desperately to come back and practice in urban area. I have a family who depends on me. 

I guess that you should always pick what you love the most, but the job market aspect is one important factor, at least for me :)

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Job market played a big role. 

One of my FM staff was actually going for GI until trasnfering out of IM. 

Like said above, I don't want to spend my mid 30s racking up part time work, with no stability. 

Much rather start making real income in my late 20s. FM pay in Canada is really nice, especially with FHOs, 45k a month, plus bonus, and shadow billing is nice.

More control, plus greater business aspect is appealing too.

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4 minutes ago, #YOLO said:

Job market played a big role. 

One of my FM staff was actually going for GI until trasnfering out of IM. 

Like said above, I don't want to spend my mid 30s racking up part time work, with no stability. 

Much rather start making real income in my late 20s. FM pay in Canada is really nice, especially with FHOs, 45k a month, plus bonus, and shadow billing is nice.

More control, plus greater business aspect is appealing too.

FHO and FHTs are pretty limited in Ontario nowadays, mostly offered at rural areas. The Ontario government has taken steps to RESTRICT new FM grads to join FHO, FHTS.

For pay, I figure that each specialty of medicine pays pretty well. :) Do what you love, and if job market is important to you, and you like the breadth of knowledge in FM, it is an awesome job!

I don't want to mislead the OP, there are still jobs in 5 year- specialties, but not where you necessarily want, and perhaps not full-time permanent at the beginning. You have to be willing to do locums around the country, for example, as an newly graduated anesthesiologist or general surgeon, GI or Cardiologist...It really depends how much you are willing to sacrifice and your passion for your field of interest!

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32 minutes ago, LittleDaisy said:

FHO and FHTs are pretty limited in Ontario nowadays, mostly offered at rural areas. The Ontario government has taken steps to RESTRICT new FM grads to join FHO, FHTS.

How are they being restricted? I've heard this a lot and am curious.

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Hey google it in the news, you will find a lot of interesting articles :)

Basically, it is pretty hard for new grads to join FHO, FHTS, with more interdisplinary support and more lucrative remuneration method.. The Ontario government restricts the number of new GPS who could join those networks, and those positions are nowadays only offered in rural area...So not in Toronto, not in Ottawa; which disadvantages the patients..Wouldn`t it be nice to have dietitian, physiotherapist, psychologist, nurses under the same roof?

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3 hours ago, #YOLO said:

Job market played a big role. 

One of my FM staff was actually going for GI until trasnfering out of IM. 

Like said above, I don't want to spend my mid 30s racking up part time work, with no stability. 

Much rather start making real income in my late 20s. FM pay in Canada is really nice, especially with FHOs, 45k a month, plus bonus, and shadow billing is nice.

More control, plus greater business aspect is appealing too.

45k a month sounds a bit off to me, unless FHO were that damn lucrative before they cut off access to it.

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31 minutes ago, JohnGrisham said:

45k a month sounds a bit off to me, unless FHO were that damn lucrative before they cut off access to it.

Current doc is retiring, and selling his spot. Thats what the recruiters shared as monthly revenues before bonus and shadows.

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Lots of Community Health Centres in Ontario advertising for family physicians (including the one where I work).  Of course, you have to have the right personality to deal with the type of clients we get at CHCs (i.e. Lots of complex cases, mental health conditions, low literacy, low socioeconomic status).  Not everyone enjoys working in that kind of setting, but for those who do, the work is incredibly rewarding.

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10 hours ago, #YOLO said:

Current doc is retiring, and selling his spot. Thats what the recruiters shared as monthly revenues before bonus and shadows.

Wow, if that was the norm for FHO..then no wonder they cut it. That is a stupid amount of salary. 500k+.  Were FHO docs also responsible for paying overhead like other FM docs, or was that factored in? That would be extra nutty.

I should really learn more about how the FHOs were implemented. I only have a vague understanding, since we dont have them in our province.

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Overhead is shared in a group with this one, and was pretty reasonable.
FHOs were crazy. The average FHO doc in 2012-2013 was bringing just over 400k. Some serious money, even after u deduct OH from that.
 Dudes house was a beautiful 1.5 million dollar estate.

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On 6/29/2017 at 11:42 AM, #YOLO said:

Overhead is shared in a group with this one, and was pretty reasonable.
FHOs were crazy. The average FHO doc in 2012-2013 was bringing just over 400k. Some serious money, even after u deduct OH from that.
 Dudes house was a beautiful 1.5 million dollar estate.

I find constant preoccupation about how much money you can make distasteful. The family docs I've worked with during med who are mostly concerned with raking in as much money as possible are not doctors I would ever want as my family physician. Rushed appointments and often point-blank refusal to see complex and underserved patients in their practice were the norm. That sort of mentality is an obvious disservice to patients.

RE: OP

I thought I was likely going to be pulled towards rural family when I entered med school. I realized it wasn't for me after the first year of school. The two main reasons for me not pursuing FM is that a large proportion of the presentations I saw were areas of medicine I found I just wasn't interested in (peds, obs, so many common cold presentations, doctor's notes, chronic pain) and many issues are only dealt with at a surface level (onc, psych, IM). Arguably, I could have gotten around these issues by pursuing a +1 or a hospitalist career path, but I felt I would rather do a 5 year specialty in that case. I also found that I could get the continuity of care piece that I liked in FM in other areas of medicine that I was more passionate about. I do think FM is a fantastic career path that has tons of flexibility and the ability to make an enormously positive impact on people's lives. I'm not sure you'll really know if it's for you until you dive into the work. Congrats on starting your journey!

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I think a lot of it for entering med students and M1's heading into M2 has less to do with the realities of family med, and more to do with perceived prestige and pay. In first year it seems most students spent their time talking about the pay rates of different specialties. Also it seems like the default is that a student will say they will do internal if they aren't sure yet, but a lot of students actively try to avoid they are going to do family med. I think it is stupid to look down on it, just it also does seem that a lot of entering students and M1 believe they are some how above that 

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For me, the decision was obvious: I left PT because I felt the scope of practice was too limited so why would I go into another field that is limited? That's why I decided to mainly pursue orthopedics or physiatry for now. As others have mentioned, I'd rather be a specialist in a narrow subject than a jack of all trade. Now, there's nothing wrong about being a GP, but it simply isn't for me.

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1 minute ago, Snowmen said:

For me, the decision was obvious: I left PT because I felt the scope of practice was too limited so why would I go into another field that is limited? That's why I decided to mainly pursue orthopedics or physiatry for now. As others have mentioned, I'd rather be a specialist in a narrow subject than a jack of all trade. Now, there's nothing wrong about being a GP, but it simply isn't for me.

How is  Family medicine "limited", there is such a wide variety of FM practices...especially if you leave the confines of typical urban FM.

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I remember in M1 that there were many people who REALLY DID NOT WANT to go into family medicine and were strongly defending their stance, as if it would help them in their prestigeous medical career. Looking back, I realize that few of their arguments actually made sense. I think it's the same mindset that leads people into medicine that guides them away from FM: shoot for the sky, always aim higher, etc. It's simple, to say that you want to go into family medicine is to admit that you are not aiming to reach your full, extraordinary potential. It is much more glamorous to present yourself as a future powerful cardiac surgeon than a small GP. Fortunately, most student mature (a bit) by the end of medschool and realize there is more to life than (professional) achievement.

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