Challenges of Family Medicine

[brady23]

Hey guys,

I've been thinking of family medicine - I really like that you tend to see healthy patients, minimal acuity, and really enjoy the disease management and prevention aspect of it, and that there are minimal physical procedures.

However, I was wondering what are the challenging aspects of family medicine? 

1) Physical Exams - I know I'm just a first year student, but I feel like it's so easy to miss something (ex: not being confident in doing a cardiac exam or respiratory exam properly - and as a family physician, you'd have to be able to recognize murmurs and pathological lung sounds or even recognizing carcinomas from a skin exam) 

2) Feeling like a referologist - if I'm not sure of whether this heart sound is pathological or this skin lesion is cancerous, I might refer them to a specialist.   

3) Recognizing high emergency situations - ex: someone walking into your office with sudden loss of hearing and knowing it's an emergency and not something that can wait.

4) Having to look things up frequently - I was shadowing someone, and a patient mentioned how their family doctor is always looking things up which made them uncomfortable in the care they were receiving. But with the vast information that family docs are supposed to know, I can kind of understand this, but at the same time, I can also understand the patient's perspective. 

[JohnGrisham]

Chronically I'll patients make up a good chunk of FM patients.

[Mithril]

44 minutes ago, brady23 said:

I really like that you tend to see healthy patients, minimal acuity, and really enjoy the disease management and prevention aspect of it, and that there are minimal physical procedures.

Well, that entirely depends upon your practice. A good chunk of my patients I would consider to be not healthy. Obesity and obesity-related conditions plague the general population. I can agree with you though that most of my patients are of minimal acuity, i.e., they are not on the verge of serious complications and death at that instant in time, but I still see 10-20 patients a week I would consider high acuity, and many patients who are just a Big Mac away from an MI. Physical procedures I am not entirely sure what you mean, but I still do a lot of procedures such as intra-articular injections, suturing, biopsies, wedge resections, and cautery.

 

44 minutes ago, brady23 said:

1) Physical Exams - I know I'm just a first year student, but I feel like it's so easy to miss something (ex: not being confident in doing a cardiac exam or respiratory exam properly - and as a family physician, you'd have to be able to recognize murmurs and pathological lung sounds or even recognizing carcinomas from a skin exam) 

You have to recognise murmurs and pathological lung sounds, sure, but you don't necessarily need to know what specific disease entity correlates with a particular abnormal finding. If you can recognise that something is abnormal, then read up on what it could be or talk to a colleague. You have lots of tools, such as imaging, lab tests, or specialists to narrow down the specific diagnosis, but by the time you are done residency you should know when a finding is bad and warrants further investigation and when a finding is innocuous or inconsequential.

44 minutes ago, brady23 said:

2) Feeling like a referologist - if I'm not sure of whether this heart sound is pathological or this skin lesion is cancerous, I might refer them to a specialist.  

You could refer them to a specialist, but like I said above you also have other things at your disposal such as imaging or other tests. An abnormal heart sound could always be checked with an echo or an ECG. A skin lesion can always be sent for a biopsy. These are things that you can do as a family physician and residency programs should be training you to be relatively autonomous within the scope of family medicine. It is important to recognise the limits of your knowledge and there's no shame in that, but I would say I am comfortable handling 95% of what comes through my office without needing to refer to a specialist.

44 minutes ago, brady23 said:

3) Recognizing high emergency situations - ex: someone walking into your office with sudden loss of hearing and knowing it's an emergency and not something that can wait.

This can be challenging and not always obvious, that's true. I had an elderly patient once who came in with vague bilateral calf pain after hiking a few days prior, thought it was muscle strain, but ordered a d-dimer anyway because he had a prior history of clots. His Well's score was low. A few hours later he ended up in the ER with a PE. Seems like he did have a clot in one of his legs whereas the other leg was just a muscle strain. Sometimes you just can't know what is truly high acuity, but residency programs in family medicine do train you to recognise obvious high emergency situations.

44 minutes ago, brady23 said:

4) Having to look things up frequently - I was shadowing someone, and a patient mentioned how their family doctor is always looking things up which made them uncomfortable in the care they were receiving. But with the vast information that family docs are supposed to know, I can kind of understand this, but at the same time, I can also understand the patient's perspective. 

I still look things up a lot. I can't possibly know what to treat with for a guy who drank a bunch of dirty water in Nicaragua and ended up with a Blastocystis hominis infection. I mean, I know now, but for the most part my patients have appreciated after I told them I need to research more about their condition, or more about how to properly manage their kid's catch-up schedule for vaccines, than trying to fake knowledge you don't have, which is both dangerous and unethical.

[brady23]

^Amazing @Mithril

thanks for your response - definitely agree with what you're saying.

[katakari]

On 3/11/2018 at 0:39 AM, brady23 said:

Hey guys,

I've been thinking of family medicine - I really like that you tend to see healthy patients, minimal acuity, and really enjoy the disease management and prevention aspect of it, and that there are minimal physical procedures.

However, I was wondering what are the challenging aspects of family medicine? 

1) Physical Exams - I know I'm just a first year student, but I feel like it's so easy to miss something (ex: not being confident in doing a cardiac exam or respiratory exam properly - and as a family physician, you'd have to be able to recognize murmurs and pathological lung sounds or even recognizing carcinomas from a skin exam) 

2) Feeling like a referologist - if I'm not sure of whether this heart sound is pathological or this skin lesion is cancerous, I might refer them to a specialist.   

3) Recognizing high emergency situations - ex: someone walking into your office with sudden loss of hearing and knowing it's an emergency and not something that can wait.

4) Having to look things up frequently - I was shadowing someone, and a patient mentioned how their family doctor is always looking things up which made them uncomfortable in the care they were receiving. But with the vast information that family docs are supposed to know, I can kind of understand this, but at the same time, I can also understand the patient's perspective. 

I don't find any of these to be challenging aspects of family medicine. Most of my management is based on history, if you have a concerning undifferentiated finding, you can always get an echo, get a chest x-ray, or do a biopsy.

In a community family medicine site, often you don't have the opportunity to refer due to limited resources. This gives you the opportunity and impetus to manage a lot on your own. In all the patient's I see in a week, I would say I refer less than 5% of the time, and even then would be a likely overestimate.

Often the longitudinal relationship can benefit you in high stakes situations. I remember one patient walked in on 9L of O2 and looked terrible. I sent him home because he had a restrictive lung disease and no further management could be offered him. I was able to say this comfortably because of the longitudinal relationship we had with him. His family disagreed with me and sent him to the hospital. Well of course, someone who doesn't know this guy, is going to admit him to the ICU, begin workup of this idiopathic disease and he found himself with 3 organs severely damaged due to iatrogenic investigations/management, transported inbetween several hospitals for different management of the varying iatrogenic comorbidities, and I saw him in rehab a few weeks later with no difference to his management or diagnosis.

Patients seem to not mind that I look things up, especially when I am open about it.

Now, for the challenges I face in family medicine:

1) Being the coordinator of care. You are responsible for everything and often have to tie together poor communication from various health fields, records, notes etc. You also can't turf your patient back to family medicine when you're at a loss for what to do or when it doesn't fit your specialty's area of expertise

2) Diversity of knowledge required. The specialists I work with often have reductionist views of disease because they see things that are already worked up. You have to begin from the ground and consider so many various possiblities, choose the right tests without choosing too many, etc. You're often admonished for not having specialist expertise in every specialty. It takes a lot of work to find a balance

3) Chronic disease. Chronic disease can often be frustrating when patient's don't get better and you have to manage their investigations, tell them why they can't have another MRI or more opioids, and this can upset people

4) Benign disease. On the same spectrum, having to tell people why they don't need antibiotics for a small cough. It's also really easy to miss something severe at the same time. Anyone can manage a STEMI - there's a basic protocol for it. But that low risk chest pain that comes into your office with a few almost-red flags, deciding what to do there is where medicine gets very nuanced.

That being said, you need to shadow some family doctors. It's a great field, but it's not for everyone.

[shikimate]

FM is easy and hard. Many good points raised above. From my point of view they have to synthesize so much information from different sources, and unfortunately sometimes it's a mess trying to sort out different reports from different specialists and labs. If you have read crappy discharge summaries you know what I mean. Also personally I find it difficult to retain the patience for chronic disease management. A lot of times it's not hard to diagnose things or prescribe a treatment, but things like compliance is what drives me impatient, not to mention socioeconomic factors. In the same vein I find the treatment aspect of psychiatry very annoying. Imagine treating someone with SSRI for like 6 weeks and they report no or little bit of response.

The other thing is I find it difficult to switch my mind from one area to another quickly as you have to do in most FM practices. Some people like it though, but not myself.

I wouldn't worry about the looking up aspect, because everyone does, sometimes you just don't realize it. A world renowned dermatopathologist (who has an authoritative dermatopathology textbook named after him) even admits publicly being unsure about certain cases and appreciate when someone brings up literature with information that he doesn't know about.

[brady23]

3 hours ago, kanakari said:

I don't find any of these to be challenging aspects of family medicine. Most of my management is based on history, if you have a concerning undifferentiated finding, you can always get an echo, get a chest x-ray, or do a biopsy.

In a community family medicine site, often you don't have the opportunity to refer due to limited resources. This gives you the opportunity and impetus to manage a lot on your own. In all the patient's I see in a week, I would say I refer less than 5% of the time, and even then would be a likely overestimate.

Often the longitudinal relationship can benefit you in high stakes situations. I remember one patient walked in on 9L of O2 and looked terrible. I sent him home because he had a restrictive lung disease and no further management could be offered him. I was able to say this comfortably because of the longitudinal relationship we had with him. His family disagreed with me and sent him to the hospital. Well of course, someone who doesn't know this guy, is going to admit him to the ICU, begin workup of this idiopathic disease and he found himself with 3 organs severely damaged due to iatrogenic investigations/management, transported inbetween several hospitals for different management of the varying iatrogenic comorbidities, and I saw him in rehab a few weeks later with no difference to his management or diagnosis.

Patients seem to not mind that I look things up, especially when I am open about it.

Now, for the challenges I face in family medicine:

1) Being the coordinator of care. You are responsible for everything and often have to tie together poor communication from various health fields, records, notes etc. You also can't turf your patient back to family medicine when you're at a loss for what to do or when it doesn't fit your specialty's area of expertise

2) Diversity of knowledge required. The specialists I work with often have reductionist views of disease because they see things that are already worked up. You have to begin from the ground and consider so many various possiblities, choose the right tests without choosing too many, etc. You're often admonished for not having specialist expertise in every specialty. It takes a lot of work to find a balance

3) Chronic disease. Chronic disease can often be frustrating when patient's don't get better and you have to manage their investigations, tell them why they can't have another MRI or more opioids, and this can upset people

4) Benign disease. On the same spectrum, having to tell people why they don't need antibiotics for a small cough. It's also really easy to miss something severe at the same time. Anyone can manage a STEMI - there's a basic protocol for it. But that low risk chest pain that comes into your office with a few almost-red flags, deciding what to do there is where medicine gets very nuanced.

That being said, you need to shadow some family doctors. It's a great field, but it's not for everyone.

Thank you for your amazing perspective! 

In terms of sending patients for echos and biopsies - that's not something you can do in a family physician's office correct? You'd have to send them out somewhere to do it and wait until the results get back to you?

I've heard of some family physician offices having echos which could be very helpful but very costly as well.

[Mithril]

7 hours ago, brady23 said:

Thank you for your amazing perspective! 

In terms of sending patients for echos and biopsies - that's not something you can do in a family physician's office correct? You'd have to send them out somewhere to do it and wait until the results get back to you?

I've heard of some family physician offices having echos which could be very helpful but very costly as well.

Some family practice offices are joined with internal medicine specialist offices and sometimes they may be able to do an echo there. If I need an echo I refer out to the hospital's radiology department.

You can do biopsies in the family practice office yourself. They will then be sent to a lab for review by a pathologist.

[goleafsgochris]

On ‎2018‎-‎03‎-‎11 at 1:22 AM, Mithril said:

Well, that entirely depends upon your practice. A good chunk of my patients I would consider to be not healthy. Obesity and obesity-related conditions plague the general population. I can agree with you though that most of my patients are of minimal acuity, i.e., they are not on the verge of serious complications and death at that instant in time, but I still see 10-20 patients a week I would consider high acuity, and many patients who are just a Big Mac away from an MI. Physical procedures I am not entirely sure what you mean, but I still do a lot of procedures such as intra-articular injections, suturing, biopsies, wedge resections, and cautery.

 

You have to recognise murmurs and pathological lung sounds, sure, but you don't necessarily need to know what specific disease entity correlates with a particular abnormal finding. If you can recognise that something is abnormal, then read up on what it could be or talk to a colleague. You have lots of tools, such as imaging, lab tests, or specialists to narrow down the specific diagnosis, but by the time you are done residency you should know when a finding is bad and warrants further investigation and when a finding is innocuous or inconsequential.

You could refer them to a specialist, but like I said above you also have other things at your disposal such as imaging or other tests. An abnormal heart sound could always be checked with an echo or an ECG. A skin lesion can always be sent for a biopsy. These are things that you can do as a family physician and residency programs should be training you to be relatively autonomous within the scope of family medicine. It is important to recognise the limits of your knowledge and there's no shame in that, but I would say I am comfortable handling 95% of what comes through my office without needing to refer to a specialist.

This can be challenging and not always obvious, that's true. I had an elderly patient once who came in with vague bilateral calf pain after hiking a few days prior, thought it was muscle strain, but ordered a d-dimer anyway because he had a prior history of clots. His Well's score was low. A few hours later he ended up in the ER with a PE. Seems like he did have a clot in one of his legs whereas the other leg was just a muscle strain. Sometimes you just can't know what is truly high acuity, but residency programs in family medicine do train you to recognise obvious high emergency situations.

I still look things up a lot. I can't possibly know what to treat with for a guy who drank a bunch of dirty water in Nicaragua and ended up with a Blastocystis hominis infection. I mean, I know now, but for the most part my patients have appreciated after I told them I need to research more about their condition, or more about how to properly manage their kid's catch-up schedule for vaccines, than trying to fake knowledge you don't have, which is both dangerous and unethical.

To OP: it sounds like Mithril is an excellent family doctor.  But doing biopsies, intraarticular injections etc is not the norm and is not expected, certainly not in major cities.  Just wanted to add that haha the rest of the post is great.  

Also: everyone in every specialty looks stuff up.  Some are apt enough to do it in such a way that its not obvious to the patient that youre going to look stuff up.  You will figure this out with time

[NutritionRunner]

14 hours ago, goleafsgochris said:

To OP: it sounds like Mithril is an excellent family doctor.  But doing biopsies, intraarticular injections etc is not the norm and is not expected, certainly not in major cities.  Just wanted to add that haha the rest of the post is great.  

Also: everyone in every specialty looks stuff up.  Some are apt enough to do it in such a way that its not obvious to the patient that youre going to look stuff up.  You will figure this out with time

I work in a Community Health Centre.  The family physicians I work with regularly do biopsies and intra-articular injections.  How do I know this?  Well, I see it on the patient’s charts when they are referred to me.  It’s quicker and easier for our patients, who may otherwise have to wait months to see a specialist, and who may have difficulties getting to an appointment at another location.  They like that they have so many health services available to them in our centre: family physicians, nurse practitioners, a pharmacist, occupational therapy, dietitian services, social work, kinesiologist services, a certified diabetes educator, a foot care nurse, OTN access to specialists that are hard to access in our community, practical assistance, pre- and post-natal care, etc. They also have access to fitness classes, cooking classes, parenting classes, can have their blood work drawn by our RPNs, just to name a few things that make it easier on our clients.  Granted, this is a community health centre, where many of our clients are very complex, living in poverty, belong to traditionally underserved and marginalized populations, and have mental or physical disabilities. Making access to health care services as smooth as possible for them is a huge benefit in terms of positive outcomes.

[psychiatry2017]

In family medicine, we regularly do procedures, be it simple or complex. As a PGY1, I do intra-articular injections (under supervision of course), skin biopsies for suspicious melanoma, suturing & I&D & casts in ED (the ED physicians would expect a FM resident to be quite comfortable with basic procedures), vaginal deliveries and vaginal repairs in OBS & GYN (required rotation in all FM residencies). Not to mention that some FM residency require gen surgery rotation, and you will be constantly required to be the surgical assists. 

Simple procedures involve ear syringing, vaccinations injections and preparations, liquid nitrogen, pap smear and bi-manual pelvic examination, cyst aspiration, etc.

You have to love to do some basic procedures, or try to be proficient in the majority of procedures, regardless of kind of FM practice you want to have  

I think that if you don't like working with your hands at all, perhaps psychiatry & public health is the way to go!

[mm88]

On 3/13/2018 at 4:13 PM, goleafsgochris said:

To OP: it sounds like Mithril is an excellent family doctor.  But doing biopsies, intraarticular injections etc is not the norm and is not expected, certainly not in major cities.  Just wanted to add that haha the rest of the post is great.  

Agree with this.

On 3/14/2018 at 6:33 AM, NutritionRunner said:

I work in a Community Health Centre.  The family physicians I work with regularly do biopsies and intra-articular injections.  How do I know this?  Well, I see it on the patient’s charts when they are referred to me.  It’s quicker and easier for our patients, who may otherwise have to wait months to see a specialist, and who may have difficulties getting to an appointment at another location.  They like that they have so many health services available to them in our centre: family physicians, nurse practitioners, a pharmacist, occupational therapy, dietitian services, social work, kinesiologist services, a certified diabetes educator, a foot care nurse, OTN access to specialists that are hard to access in our community, practical assistance, pre- and post-natal care, etc. They also have access to fitness classes, cooking classes, parenting classes, can have their blood work drawn by our RPNs, just to name a few things that make it easier on our clients.  Granted, this is a community health centre, where many of our clients are very complex, living in poverty, belong to traditionally underserved and marginalized populations, and have mental or physical disabilities. Making access to health care services as smooth as possible for them is a huge benefit in terms of positive outcomes.

This is a rarity in most urban centres and this kind of community health centre likely is well funded by the government. I did my FM residency at a teaching clinic where this was all possible and paid for by the local health authority and physicians are salaried. I experienced other clinics through rotations and after doing so, I feel that the time and monetary costs of doing this just isn't worth it for the average GP in their own clinic - you have to buy disposable trays or pay to sterilise your trays, stock all the disposable items. Some provincial billing codes come with an automatic tray fee built in when you bill a procedure from the community, but some provinces don't. How do you justify the cost of spending 35$ on a disposable tray when the biopsy/excision pays 40$ (can't bill a visit with it) and you still have other overhead to pay? 
I'm a GP on an alternate payment arrangement don't worry about overhead costs but crunching the numbers certainly makes me wonder what I would do if I ever left my current practice.  As you correctly identified, easy access is key to positive outcomes. Most privately owned urban family practices are sustainable because of throughput, not because they provide comprehensive service which is really very sad!

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

And to answer OP's question: the medicine part of it can be hard but with knowledge and specialists at our disposal to consult, you very quickly become comfortable with looking things up, asking questions, and calling your patients to follow up if you're really concerned. If you're able to come up with a reasonable follow up plan with clear indications to return or visit the ED, and can clearly communicate this with your patients, this solves most hard "medicine" uncertainties in family practice. There will always be something you don't know, teaching med students and residents will force you to stay up to date, they will often be reading and studying and teach you new things! Recognition of the abnormal will come with examining lots of "normal", it will just come with time.

What I find most challenging about being a practising family physician is managing patient expectations and the mountains of paperwork that consume your life (results to review, forms to fill out - none of which pays). Many docs I know finish charting at the end of the day and go home to continue to work from their remote EMR reviewing results and such. Of course, if you practice niche family medicine like hospitalist, low risk obs, sport med this can be a complete different story.

Don't be afraid of family medicine because of the breadth of knowledge you feel like you must have to be good at your job - all of us are always still learning!

[psychiatry2017]

5 hours ago, mm88 said:

Agree with this.

This is a rarity in most urban centres and this kind of community health centre likely is well funded by the government. I did my FM residency at a teaching clinic where this was all possible and paid for by the local health authority and physicians are salaried. I experienced other clinics through rotations and after doing so, I feel that the time and monetary costs of doing this just isn't worth it for the average GP in their own clinic - you have to buy disposable trays or pay to sterilise your trays, stock all the disposable items. Some provincial billing codes come with an automatic tray fee built in when you bill a procedure from the community, but some provinces don't. How do you justify the cost of spending 35$ on a disposable tray when the biopsy/excision pays 40$ (can't bill a visit with it) and you still have other overhead to pay? 
I'm a GP on an alternate payment arrangement don't worry about overhead costs but crunching the numbers certainly makes me wonder what I would do if I ever left my current practice.  As you correctly identified, easy access is key to positive outcomes. Most privately owned urban family practices are sustainable because of throughput, not because they provide comprehensive service which is really very sad!

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

And to answer OP's question: the medicine part of it can be hard but with knowledge and specialists at our disposal to consult, you very quickly become comfortable with looking things up, asking questions, and calling your patients to follow up if you're really concerned. If you're able to come up with a reasonable follow up plan with clear indications to return or visit the ED, and can clearly communicate this with your patients, this solves most hard "medicine" uncertainties in family practice. There will always be something you don't know, teaching med students and residents will force you to stay up to date, they will often be reading and studying and teach you new things! Recognition of the abnormal will come with examining lots of "normal", it will just come with time.

What I find most challenging about being a practising family physician is managing patient expectations and the mountains of paperwork that consume your life (results to review, forms to fill out - none of which pays). Many docs I know finish charting at the end of the day and go home to continue to work from their remote EMR reviewing results and such. Of course, if you practice niche family medicine like hospitalist, low risk obs, sport med this can be a complete different story.

Don't be afraid of family medicine because of the breadth of knowledge you feel like you must have to be good at your job - all of us are always still learning!

I think for GP-hospitalist in a rural hospital or small community hospital, they do 24 hour coverage for their own patients, and will get paged by nurses for decompensating patients and are expected to come round on their patients the next morning . Also, some hospitalists do overnight ED& morning consults, I don't think that their lifestyle is 9-5 Monday-Friday, as one sick patient could take a big chunk of your morning, just my two cents. 

[mm88]

1 hour ago, psychiatry2017 said:

I think for GP-hospitalist in a rural hospital or small community hospital, they do 24 hour coverage for their own patients, and will get paged by nurses for decompensating patients and are expected to come round on their patients the next morning . Also, some hospitalists do overnight ED& morning consults, I don't think that their lifestyle is 9-5 Monday-Friday, as one sick patient could take a big chunk of your morning, just my two cents. 

I was specifically talking about urban family practice in my post above. Rural practice varies, you can be on call for a whole week at a time as a hospitalist, or 72hrs at a time covering both ED and inpatients and the payment will be different depending what province you work in. Having done rural locums, I can tell you that it can drastically different from urban family practice. 

Most people really aren't thinking about rural family medicine esp like OP when mentions the following:

On 3/10/2018 at 10:39 PM, brady23 said:

I really like that you tend to see healthy patients, minimal acuity, and really enjoy the disease management and prevention aspect of it, and that there are minimal physical procedures.

^ none of those things are really prominent aspects of hospitalist or rural medicine, lol. In fact its quite the opposite: people are sick, high acuity often with traumas rolling into a 1 of 1 emerg, and you are often managing acute exacerbation rather than doing disease prevent. Hospital work is definitely not everyone's cup of tea and that is perfectly ok in family practice. No one HAS to practice rurally or do hospitalist, don't scare the OP like that, please.  There is plenty of urban office only family medicine work!

The niche stuff I'm talking about is being like a GP specialist in the city (usually with an extra year of training) - like GP derm, sport med, low risk obs, addictions where you're essentially a consultant for other family docs. You can always punt them back to the referring GP, the onus of managing those complex or difficult patients is not on you as a consultant, you just contribute your bit and say "adios!".

[psychiatry2017]

3 hours ago, mm88 said:

I was specifically talking about urban family practice in my post above. Rural practice varies, you can be on call for a whole week at a time as a hospitalist, or 72hrs at a time covering both ED and inpatients and the payment will be different depending what province you work in. Having done rural locums, I can tell you that it can drastically different from urban family practice. 

Most people really aren't thinking about rural family medicine esp like OP when mentions the following:

^ none of those things are really prominent aspects of hospitalist or rural medicine, lol. In fact its quite the opposite: people are sick, high acuity often with traumas rolling into a 1 of 1 emerg, and you are often managing acute exacerbation rather than doing disease prevent. Hospital work is definitely not everyone's cup of tea and that is perfectly ok in family practice. No one HAS to practice rurally or do hospitalist, don't scare the OP like that, please.  There is plenty of urban office only family medicine work!

The niche stuff I'm talking about is being like a GP specialist in the city (usually with an extra year of training) - like GP derm, sport med, low risk obs, addictions where you're essentially a consultant for other family docs. You can always punt them back to the referring GP, the onus of managing those complex or difficult patients is not on you as a consultant, you just contribute your bit and say "adios!".

You are right about being a GP specialist in the city, as GP derm, sports med, low risks obs, and addictions, etc. The thing about being a GP specialist in a big city like Montreal, Vancouver, Toronto, there are so many specialists eager to take on new consults, that you can't do 100% of your practice as FM-obs. The majority of FM obs in urban areas, do part-time FM obs (on call once per day) with low volumes 1-3 delivers per day or sometimes none. I have a few prenatal patients in my family practice with no risks, who specifically ask for obs-gyn for deliveries. I think that being trained 1 year extra is great, but you will still end up doing some <<bread and butter>> and comprehensive family medicine practice. 

To OP, if you really like healthy patients with minimal acuity, and no physical procedures, I would suggest outpatient psychiatry & or public health

[brady23]

32 minutes ago, psychiatry2017 said:

You are right about being a GP specialist in the city, as GP derm, sports med, low risks obs, and addictions, etc. The thing about being a GP specialist in a big city like Montreal, Vancouver, Toronto, there are so many specialists eager to take on new consults, that you can't do 100% of your practice as FM-obs. The majority of FM obs in urban areas, do part-time FM obs (on call once per day) with low volumes 1-3 delivers per day or sometimes none. I have a few prenatal patients in my family practice with no risks, who specifically ask for obs-gyn for deliveries. I think that being trained 1 year extra is great, but you will still end up doing some <<bread and butter>> and comprehensive family medicine practice. 

To OP, if you really like healthy patients with minimal acuity, and no physical procedures, I would suggest outpatient psychiatry & or public health

Thanks! Psychiatry and Public Health don't really interest me for other reasons.

I'm open to doing procedures, but I don't want that to be a major part of my job - definitely thinking about something more interdisciplinary like FM or IM, but leaning towards FM because of the lower acuity and primary care aspect.  

[psychiatry2017]

7 minutes ago, brady23 said:

Thanks! Psychiatry and Public Health don't really interest me for other reasons.

I'm open to doing procedures, but I don't want that to be a major part of my job - definitely thinking about something more interdisciplinary like FM or IM, but leaning towards FM because of the lower acuity and primary care aspect.  

ahahah I think that in IM, you definitely have to do procedures unless you opt for endocrinology, or allergy & immunology. 

I think that you will have to do obs-gyn, emergency medicine, and general surgery in clerkship, I will definitely overcome the fear of working with your hands, and try to be more hands-on and jump in the occasion to do procedures!

Also, in urban family medicine, the low acuity patients don't present to your office much. It's often the elderly patients with complex medical history who presents more often, the acuity is not high, but you do have to be comfortable knowing when it's urgent to refer to ED, prompt f-u, or benign conditions, etc. 

[brady23]

1 hour ago, psychiatry2017 said:

ahahah I think that in IM, you definitely have to do procedures unless you opt for endocrinology, or allergy & immunology. 

I think that you will have to do obs-gyn, emergency medicine, and general surgery in clerkship, I will definitely overcome the fear of working with your hands, and try to be more hands-on and jump in the occasion to do procedures!

Also, in urban family medicine, the low acuity patients don't present to your office much. It's often the elderly patients with complex medical history who presents more often, the acuity is not high, but you do have to be comfortable knowing when it's urgent to refer to ED, prompt f-u, or benign conditions, etc. 

Thanks for the advice! It's not really a fear but more of a preference, but I agree! Just out of curiosity, do you know what typical procedures internists perform? (even as a GIM)

[Mithril]

12 hours ago, mm88 said:

Agree with this.

This is a rarity in most urban centres and this kind of community health centre likely is well funded by the government. I did my FM residency at a teaching clinic where this was all possible and paid for by the local health authority and physicians are salaried. I experienced other clinics through rotations and after doing so, I feel that the time and monetary costs of doing this just isn't worth it for the average GP in their own clinic - you have to buy disposable trays or pay to sterilise your trays, stock all the disposable items. Some provincial billing codes come with an automatic tray fee built in when you bill a procedure from the community, but some provinces don't. How do you justify the cost of spending 35$ on a disposable tray when the biopsy/excision pays 40$ (can't bill a visit with it) and you still have other overhead to pay? 
I'm a GP on an alternate payment arrangement don't worry about overhead costs but crunching the numbers certainly makes me wonder what I would do if I ever left my current practice.  As you correctly identified, easy access is key to positive outcomes. Most privately owned urban family practices are sustainable because of throughput, not because they provide comprehensive service which is really very sad!

 

What province do you work in? A biopsy here in BC pays $51. A major tray fee is another $31. That's $82 for something that takes probably 15-20 minutes in total to do. We can also bill a visit at half the rate if it's for an unrelated cause. Additionally, for lacerations up to 5 cm that pays $64 plus the major tray fee which is another $31 for $95 in total. For lacerations beyond 5 cm it's $13 per cm plus the tray fee. Seems like you aren't getting renumerated fairly for your hard work.

[NutritionRunner]

19 hours ago, mm88 said:

Agree with this.

This is a rarity in most urban centres and this kind of community health centre likely is well funded by the government. I did my FM residency at a teaching clinic where this was all possible and paid for by the local health authority and physicians are salaried. I experienced other clinics through rotations and after doing so, I feel that the time and monetary costs of doing this just isn't worth it for the average GP in their own clinic - you have to buy disposable trays or pay to sterilise your trays, stock all the disposable items. Some provincial billing codes come with an automatic tray fee built in when you bill a procedure from the community, but some provinces don't. How do you justify the cost of spending 35$ on a disposable tray when the biopsy/excision pays 40$ (can't bill a visit with it) and you still have other overhead to pay? 
I'm a GP on an alternate payment arrangement don't worry about overhead costs but crunching the numbers certainly makes me wonder what I would do if I ever left my current practice.  As you correctly identified, easy access is key to positive outcomes. Most privately owned urban family practices are sustainable because of throughput, not because they provide comprehensive service which is really very sad!

I suppose it depends on how you define “urban centre.”  I’m not in the GTA, Vancouver, or Montreal, but I currently work in a city that is home to a medical school, so I supervise medical students and work with residents all the time.  Our MDs do the minor procedures described, and two of our family physicians also do low risk OB. Previously I worked at a community health centre in another city (again, not any of the “big three” but certainly not rural either) and the MDs there did minor procedures, but no low risk OB.

It might be different in “traditional” family medicine practices, but certainly in CHCs, which serve traditionally underserved and marginalized populations, family physicians can do minor procedures as part of their practice.  It’s just far easier for our clients.  For that same reason, our RPNs do any blood draws for blood work and then send them to the lab for analysis.  Asking our clients to go elsewhere to get blood drawn would place an added burden on them, with the result that many simply wouldn’t have the needed blood work done as getting to a lab would be difficult for them.

[ACHQ]

10 hours ago, brady23 said:

Thanks for the advice! It's not really a fear but more of a preference, but I agree! Just out of curiosity, do you know what typical procedures internists perform? (even as a GIM)

For GIM you have to be comfortable doing bedside procedures that include:

- Arterial blood gas 

- Paracentesis

- Thoracentesis

- Lumbar Puncture

- Arthrocentesis (At least of the big joints)

- Central lines + Arterial lines

- Bone Marrow biopsies

If you do GIM call, you should be comfortable with emergent airway management (bag mask) and at least trying intubation (in a more straightforward patient) but usually in large community hospitals you have RT and Anesthesia on call to help you out. 

Certain specialties have to do more “specialized” procedures (GI- OGDs/C-Scopes, Resp- Bronchs, etc...)

[mm88]

22 hours ago, Mithril said:

What province do you work in? A biopsy here in BC pays $51. A major tray fee is another $31. That's $82 for something that takes probably 15-20 minutes in total to do. We can also bill a visit at half the rate if it's for an unrelated cause. Additionally, for lacerations up to 5 cm that pays $64 plus the major tray fee which is another $31 for $95 in total. For lacerations beyond 5 cm it's $13 per cm plus the tray fee. Seems like you aren't getting renumerated fairly for your hard work.

Alberta pays great, simialr to BC but i am also salaried so it doesn't matter to me at all. OP is from UofT, from the ON billing codes I looked up it looks like Base fee is G700 $5.10 for a procedure, E542 $11.10 tray fee and skin biopsy Z133 or Z116 $29.90. Sorry I was 5$ off with my initial estimate, I forgot the 5$ base fee.

So if OP doesn't like procedures and they don't pay well, they really doesn't have to do them when they start their practice!

[Wachaa]

You don't have to do anything you don't like to do. Many family practices in BC (where I work) do not do any "extra" procedures. This is of course, assuming you live in a big city but even in cities with other GPs you can direct patients to your colleagues if they are more interested in doing certain procedures.

It's not uncommon that when procedures don't pay well or are time consuming, GPs stop doing them. Many practices in GVR will refer out biopsies (direct to derm to assess whether malignant or not), pap smears (refer to women's clinic), infant/ childhood vaccines (refer to public health clinics) or flu shots (refer to pharmacy flu clinics). I even refer out to podiatry, optometry, when the presenting complaint involves a procedure. Your practice is so busy seeing 1 patient per 10 minutes that you don't want to fit in something that takes 15-20 minutes.

(Flu shots - after spending 10 minutes with the patient on their main presenting complaint, they then ask for a flu shot, which takes an additional 5 minutes to draw up, sterilize, review side effects, and giving the shot)

So if you're not comfortable or don't want to do procedures, it's not a big deal at all. On one hand you can do many procedures, have variety in your practice, and be happy with it. Or, you can deal primarily with "medical" issues, without using your hands, seeing more patients and be happy that way.

[goleafsgochris]

4 hours ago, Wachaa said:

You don't have to do anything you don't like to do. Many family practices in BC (where I work) do not do any "extra" procedures. This is of course, assuming you live in a big city but even in cities with other GPs you can direct patients to your colleagues if they are more interested in doing certain procedures.

It's not uncommon that when procedures don't pay well or are time consuming, GPs stop doing them. Many practices in GVR will refer out biopsies (direct to derm to assess whether malignant or not), pap smears (refer to women's clinic), infant/ childhood vaccines (refer to public health clinics) or flu shots (refer to pharmacy flu clinics). I even refer out to podiatry, optometry, when the presenting complaint involves a procedure. Your practice is so busy seeing 1 patient per 10 minutes that you don't want to fit in something that takes 15-20 minutes.

(Flu shots - after spending 10 minutes with the patient on their main presenting complaint, they then ask for a flu shot, which takes an additional 5 minutes to draw up, sterilize, review side effects, and giving the shot)

So if you're not comfortable or don't want to do procedures, it's not a big deal at all. On one hand you can do many procedures, have variety in your practice, and be happy with it. Or, you can deal primarily with "medical" issues, without using your hands, seeing more patients and be happy that way.

For sure, this has been my experience in Toronto.  I'm guessing many GPs COULD do biopsies, joint injections, etc if they wanted to.  But it would be odd.  Maybe its done if youre a  more "academic" family dr with residents?  But in the community they tend to see 4-6 patients per hour (again, the ones I know in the GTA).  The set up, etc for a joint injection or biopsy is time consuming, not that well compensated, and to refer to derm/whatever takes 30 seconds and you still bill for the patient visit.  It probably makes sense if youre in a smaller centre where specialists are less accessible, but here it would honestly seem like you are just trying to prove something, against your own self interest haha

[JohnGrisham]

1 hour ago, goleafsgochris said:

For sure, this has been my experience in Toronto.  I'm guessing many GPs COULD do biopsies, joint injections, etc if they wanted to.  But it would be odd.  Maybe its done if youre a  more "academic" family dr with residents?  But in the community they tend to see 4-6 patients per hour (again, the ones I know in the GTA).  The set up, etc for a joint injection or biopsy is time consuming, not that well compensated, and to refer to derm/whatever takes 30 seconds and you still bill for the patient visit.  It probably makes sense if youre in a smaller centre where specialists are less accessible, but here it would honestly seem like you are just trying to prove something, against your own self interest haha

Alternatively... By not referring something that doesn't need to be, you are showing the system that GPs aren't just refferal.machines and you save the system money.  Likely that specialist is going to have  higher billing fee for even the simple joint injection etc too.

In clinics I've seen, many have separate procedure rooms that are well stocked. Some have a nurse(but this is only the bigger well run clinics) who can do any prep. Others have one of their MOAs quickly set up for you etc.  

Some docs dont mind the bit of slow down, as it adds variety and they are still remunerated decently enough(at least in some provinces as one poster above pointed out). Sure not as good as spending 2mins with a patient and sending a half hearted referral consult..but not at a debilitating loss.