Why not family med?

[NLengr]

On June 29, 2017 at 1:42 PM, #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.

That's nuts. More than the majority of Ontario specialists. 

I'm surprised the ON government didn't make the family docs in the FHO's go salaried in order to work in them. Seems like an easier way to control FHO costs vs restricting geographical regions. 

[Snowmen]

16 hours ago, JohnGrisham said:

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

It is widespread but rather shallow. You can't really manage complex conditions independantly whereas a specialist can. By limited, I didn't mean that the practices you could cover were few but that your habilities in these scopes were limited. If GPs could handle complex cases, there wouldn't be specialists.

Now, before you bring up rural FM as being completely different, my conclusions are based on observing GPs in rural clinics or doing hospitalization in rural community hospital. I know they can do more, and that still isn't enough for me.

15 hours ago, 1997 said:

 

What's your point?

[ralk]

11 hours ago, codebar said:

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.

I completely agree that prestige is part of the typical M1 resistance to FM. However, I think there's a practical argument for the initial aversion to FM as well. It's comparatively easy to make a late switch to FM, but harder to make a late switch away from FM. As students can get type-casted based on their preferences early on, it's probably advantageous to publicly lean towards something more competitive (and typically prestigious), while keeping FM as a real option privately, than to advertise a desire for FM while harboring ambitions for another, more competitive specialty. In that sense, I don't think it's maturity that's lacking for M1s in avoiding FM, but experience and certainty about what would be the best option for them - in the face of doubt, better to aim "high" (ie more competitive) than "low".

1 hour ago, Snowmen said:

It is widespread but rather shallow. You can't really manage complex conditions independantly whereas a specialist can. By limited, I didn't mean that the practices you could cover were few but that your habilities in these scopes were limited. If GPs could handle complex cases, there wouldn't be specialists.

Now, before you bring up rural FM as being completely different, my conclusions are based on observing GPs in rural clinics or doing hospitalization in rural community hospital. I know they can do more, and that still isn't enough for me.

What's your point?

It's fair to say you want depth rather than breadth as a reason not to choose FM, but if you're talking about being limited by your specialty's scope overall, that's not really a fair criticism of FM. Every specialty has limits on what they can or should do, and FM arguably has less of those restrictions than specialists, because of the breadth of being a generalist. FPs essentially get to choose which cases they keep and for how long, while specialists are limited by what's in their field. While referrals are often recommended at certain stages, FPs can handle complex cases if they feel comfortable doing so, and often that does happen. Where referrals are often done, it's a much a matter of resources as it is expertise - specialists typically have equipment, supplies, and supports that FM docs don't. It's also worth pointing out that few specialists handle truly complex cases independently - they very often refer these patients out for help from other specialists, in addition to calling on the patients' FPs for help on aspects of care.

[#YOLO]

On 6/30/2017 at 2:24 PM, Borborygmi said:

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!

I find you distasteful. people need to realize money matters.

[MarsRover]

On 7/2/2017 at 1:48 PM, Snowmen said:

It is widespread but rather shallow. You can't really manage complex conditions independantly whereas a specialist can. By limited, I didn't mean that the practices you could cover were few but that your habilities in these scopes were limited. If GPs could handle complex cases, there wouldn't be specialists.

Now, before you bring up rural FM as being completely different, my conclusions are based on observing GPs in rural clinics or doing hospitalization in rural community hospital. I know they can do more, and that still isn't enough for me.

What's your point?

I think that what people are saying is that family doctors handle a lot of the chronic care, and even fairly in depth stuff. Specialists do not have that much scope and breadth like you talked about wanting to avoid. It is knowing a lot a lot about one field, and in fact within most specialties there is a handful of same cases that will make up most of your case load on a daily/weekly basis. A lot of incoming patients to a specialists should have at least good enough write ups from family doctors that it is at least possible to make a fairly good list of differential diagnosis and test for it (probably reason family physician didn't is because they can't or dont have time to). Specialists are often glorified by incoming students as searching for and determining all these complex and unknown diseases within their field, but thats really not the reality. Not to shit on specialists, they are very important. Just it by nature is limited to a handful of a few routine cases and some unknown, and then refering for anything outside your field 

[GrouchoMarx]

Whenever I was on the wards, and the patient started asking my attending about a bunch of unrelated, often hippy-dippy stuff, the attending would reply "You should talk about that with your family doctor" Then I imagined being the family doctor, and how difficult it would be trying to address all of that. That's when I decided I'd never do FM.

[ellorie]

20 minutes ago, Cain said:

Whenever I was on the wards, and the patient started asking my attending about a bunch of unrelated, often hippy-dippy stuff, the attending would reply "You should talk about that with your family doctor" Then I imagined being the family doctor, and how difficult it would be trying to address all of that. That's when I decided I'd never do FM.

Admittedly, I have used that line myself on several occasions and breathed a sigh of relief.  Thank God for family doctors.

[ralk]

13 hours ago, Cain said:

Whenever I was on the wards, and the patient started asking my attending about a bunch of unrelated, often hippy-dippy stuff, the attending would reply "You should talk about that with your family doctor" Then I imagined being the family doctor, and how difficult it would be trying to address all of that. That's when I decided I'd never do FM.

Ha! It was those events that sold me on Family Medicine. I hated pushing patient concerns - even the trivial ones - off on someone else, sometime in the future, when I was perfectly capable of helping them. 

[Lactic Folly]

Patient: I have this rash (lifts up shirt).

Me: (looks at it, quizzical) 

Attending family doctor: (comes in room) Oh, that is just a pregnancy-related rash!

Me: (??all these things I never heard tell of in medical school!)

[LoneStar]

On 7/1/2017 at 4:32 PM, 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.

.

[JohnGrisham]

5 minutes ago, ItsBeenReal said:

I'm not trying to start an argument but to say that PT is a limited field is just wrong. Ortho (inpatient, outpatient, post-op LE & UE, sports injury) Neuro (post stroke rehab, CP rehab,pakinsons, CNS tumours and so much more), Cardio resp (COPD patients, lung and heart transplants, bypass surgeries etc.), Burns, amputees, pelvic floor rehab, cancer rehab, etc. I don't care about why you left PT after a year, but to reduce the entire field as being limited is just wrong.

Agreed - its mostly just reimbursement being far less, for often times equally as gruelling/time consuming work.  PT makes a huge difference.

[ralk]

1 hour ago, ItsBeenReal said:

I'm not trying to start an argument but to say that PT is a limited field is just wrong. Ortho (inpatient, outpatient, post-op LE & UE, sports injury) Neuro (post stroke rehab, CP rehab,pakinsons, CNS tumours and so much more), Cardio resp (COPD patients, lung and heart transplants, bypass surgeries etc.), Burns, amputees, pelvic floor rehab, cancer rehab, etc. I don't care about why you left PT after a year, but to reduce the entire field as being limited is just wrong.

I read that point from Snowmen's post very differently. Scope of practice can refer to variety in conditions and patients treated, as you've listed, but it can also refer to what you're allowed to do with those patients under the law. I think they were referring to the latter. While physicians' legal scope of practice is virtually unconstrained, those in other healthcare professions, including PT, cannot perform certain actions or provide certain services for their patients, even when they have the requisite knowledge and experience to do so safely. It can be extremely frustrating to know the right thing to do for your patient, but to be barred from doing it because of your profession and in that sense, PT (and most other healthcare professions) can be quite limited in their scope of practice.

[justwannabeadoc]

1 hour ago, ralk said:

I read that point from Snowmen's post very differently. Scope of practice can refer to variety in conditions and patients treated, as you've listed, but it can also refer to what you're allowed to do with those patients under the law. I think they were referring to the latter. While physicians' legal scope of practice is virtually unconstrained, those in other healthcare professions, including PT, cannot perform certain actions or provide certain services for their patients, even when they have the requisite knowledge and experience to do so safely. It can be extremely frustrating to know the right thing to do for your patient, but to be barred from doing it because of your profession and in that sense, PT (and most other healthcare professions) can be quite limited in their scope of practice.

PTs can't diagnose, order tests, or prescribe.

[Snowmen]

17 hours ago, ralk said:

I read that point from Snowmen's post very differently. Scope of practice can refer to variety in conditions and patients treated, as you've listed, but it can also refer to what you're allowed to do with those patients under the law. I think they were referring to the latter. While physicians' legal scope of practice is virtually unconstrained, those in other healthcare professions, including PT, cannot perform certain actions or provide certain services for their patients, even when they have the requisite knowledge and experience to do so safely. It can be extremely frustrating to know the right thing to do for your patient, but to be barred from doing it because of your profession and in that sense, PT (and most other healthcare professions) can be quite limited in their scope of practice.

Exactly what I meant to say!

[MDwannabe02]

23 hours ago, justwannabeadoc said:

PTs can't diagnose, order tests, or prescribe.

PTs can diagnose in Ontario. It's a controlled act PTs are allowed to right out of school. They can't diagnose EVERYTHING (i.e. conditions that you can't make a clinical diagnosis with such as MS or an acute MI), but physios can diagnose within their scope. This is pretty limited to MSK things like mechanical low back pain, tendinopathies, and sprains, but these are still diagnoses. 

[rogerroger]

Why not family med? A very person to person specific question. 

Personally, I found the issues family MDs dealt with uninteresting. I also found other specialties equally uninteresting. I do not find the process of managing chronic diseases intellectually stimulating. Making long-term connections with patients over years was also not something I personally found greatly rewarding in of itself. I can appreciate how some might enjoy these things. But for me, I just do not find enough career satisfaction in these aspects to make family med rewarding. 

I went into medicine to diagnose, to solve problems and to use my brain to solve these problems to do some good. It is the process of being presented a novel problem, figuring out the problem, and implementing a solution to this problem that makes getting up to go to work enjoyable. The more critical the problem (sicker the patient), and the more rapid these mentioned things occur in succession, the bigger I find the satisfaction. That's me and how I'm wired. Family med and many other specialties don't have these elements with my desired frequency.

[rogerroger]

On 7/9/2017 at 5:30 PM, justwannabeadoc said:

PTs can't diagnose, order tests, or prescribe.

I give a talk to med students semi-regularly on the role of the Colleges and regulation of the health professions. 

FYI

In Ontario the RHPA regulates the following professions;

Audiologist, Speech Pathologist, Chiropractors, Chiropodist, Podiatrist, Dietitians, Dental Hygienists, Dental Technicians, Denturists, Massage Therapists, Medical Lab Technicians, Medical Radiation Technologists, Midwifes , Nurses, Occupational Therapists, Opticians, Optometrists, Physicians & Surgeons, Psychologists, Physiotherapists, Respiratory Therapists, Pharmacists, and Dental Surgeons

There are 13 Controlled Acts in the RHPA, together this defines the legal bounds of “Medicine”. Only RHPs can do these controlled acts (or be delegated by RHPs to others in limited cases).

These acts are;

i. Communicating a diagnosis

ii. Performing a procedure below the dermis

iii. Setting or casting a fracture of a bone or dislocation of a joint

iv. Moving the joints of the spine beyond the usual physiological range of motion

v. Administering a substance by injection or inhalation

vi. Putting an instrument, hand or finger:

  1)   Beyond the external ear canal,

  2)    Beyond the point in the nasal passage where they normally narrow,

  3)   Beyond the larynx,

  4)   Beyond the opening of the urethra,

  5)    Beyond the labia majora,

  6)   Beyond the anal verge,

  7)  or into an artificial opening in the body

vii. Applying or ordering the application of a form of energy.

viii. Prescribing, dispensing, selling or compounding a drug.

ix. Prescribing or dispensing vision devices, contact lenses or eye glasses.

x. Prescribing a hearing aid for a hearing impaired person.

xi. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance.

xii. Managing labor or conducting the delivery of a baby.

xiii. Allergy challenge testing.

Not all RHPs can do all these acts. Out of the 13 controlled acts, MDs are entitled to perform 12, the exception is number 11 which is a dental procedure.

There are slight differences between provinces but the major elements are consistent. 

 

[justwannabeadoc]

@MDwannabe02 @rogerroger thanks for clarifying!

[ellorie]

Psychotherapy is also a controlled act, is it not?

[Jaeger]

14 hours ago, rogerroger said:

Why not family med? A very person to person specific question. 

Personally, I found the issues family MDs dealt with uninteresting. I also found other specialties equally uninteresting. I do not find the process of managing chronic diseases intellectually stimulating. Making long-term connections with patients over years was also not something I personally found greatly rewarding in of itself. I can appreciate how some might enjoy these things. But for me, I just do not find enough career satisfaction in these aspects to make family med rewarding. 

I went into medicine to diagnose, to solve problems and to use my brain to solve these problems to do some good. It is the process of being presented a novel problem, figuring out the problem, and implementing a solution to this problem that makes getting up to go to work enjoyable. The more critical the problem (sicker the patient), and the more rapid these mentioned things occur in succession, the bigger I find the satisfaction. That's me and how I'm wired. Family med and many other specialties don't have these elements with my desired frequency.

interesting  Do you mind sharing what speciality you pursued or are planning to pursue? 

[la marzocco]

On 7/10/2017 at 7:46 PM, rogerroger said:

Why not family med? A very person to person specific question. 

Personally, I found the issues family MDs dealt with uninteresting. I also found other specialties equally uninteresting. I do not find the process of managing chronic diseases intellectually stimulating. Making long-term connections with patients over years was also not something I personally found greatly rewarding in of itself. I can appreciate how some might enjoy these things. But for me, I just do not find enough career satisfaction in these aspects to make family med rewarding. 

I went into medicine to diagnose, to solve problems and to use my brain to solve these problems to do some good. It is the process of being presented a novel problem, figuring out the problem, and implementing a solution to this problem that makes getting up to go to work enjoyable. The more critical the problem (sicker the patient), and the more rapid these mentioned things occur in succession, the bigger I find the satisfaction. That's me and how I'm wired. Family med and many other specialties don't have these elements with my desired frequency.

.

[Lactic Folly]

Not really. I believe rogerroger is in emergency medicine, so it makes sense. Although I had not really considered EM before my clerkship rotation, I ended up enjoying it quite a bit for the same reason (satisfaction of solving problems and making a diagnosis - you can really make a difference for a patient who comes in with a new presentation by setting the rest of their management on the right track). Main difference is that I prefer moderate instead of critical acuity 

[la marzocco]

On 7/11/2017 at 11:31 AM, Lactic Folly said:

Not really. I believe rogerroger is in emergency medicine, so it makes sense. Although I had not really considered EM before my clerkship rotation, I ended up enjoying it quite a bit for the same reason (satisfaction of solving problems and making a diagnosis - you can really make a difference for a patient who comes in with a new presentation by setting the rest of their management on the right track). Main difference is that I prefer moderate instead of critical acuity 

.

 

[Lactic Folly]

I'm not sure how a preference for working with critical, sick patients, and a fast pace of work translates into "god complex."

Some people like working in the ambulatory setting dealing with chronic conditions, and others prefer the ICU/ER/OR with potentially unstable patients. That is all I can glean.

You might be reading too much into rogerroger's statement, since nowhere do I find anything to suggest an inflated sense of ability/privilege as you seem to be implying with your psychological label.

Given rates of burnout, I'm glad to see physicians who find intrinsic satisfaction in their work.

[ellorie]

I don't think it has to do with a God complex. That would imply more being obsessed with power.  Some people just like a fast pace, thinking quickly, and a bit of adrenaline. It's really a personal preference.