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Challenges of Family Medicine

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Also it's much more convenient for the patient if they could get their joint infiltration or biopsy done at that appointment, instead of having to miss another day of work to get a 5min infiltration at another clinic..

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@JohnGrisham and @F508

For sure, you guys aren't wrong. Just saying that when you're a practicing doc, you are free to do as you feel comfortable and depending on your interests.

Many med students seem to think that having variety means doing many different things, even if it sacrifices time/ money in your practice. Personally, I feel that even if I just do clinic, I get enough variety from seeing the many interesting medical cases throughout the day, and being very satisfied by how I'm compensated.

One thing to point out is that many clinic owners/ managers are not physicians. They are business people whose priorities are not if you have variety or not. What they know is that procedures cost the clinic more money and some would rather not stock those supplies or have a procedure room. Why have a room that nobody uses when you can utilize the space for hiring another physician. Or why buy reusable speculums, brushes etc when you don't break even with the tray fees (you lose money per pap test because the visit billing fee is lower, and the tray fee is $5). Or why do childhood vaccinations for $5 when it causes screaming children in the clinic, needing extra MOA staffs' time to weight/ measure the baby, chart the vaccine lot/expiry number, stock vaccines and send records to public health on a regular basis...when you can just refer to Public Health (already paid by Government to have this resource).

Secondly, if you do live in a resourceful community, you have to realize that there are people who do things better than you and are worth referring to, even if you are technically able to do the procedure yourself. If you're a male physician, a lot of females are a heck of a lot more comfortable if you would give them the telephone/ address of a women's health clinic for them to go do their paps every 1-5 years, or to put in an IUD. The first visit might be a "referral" quick visit, but you've actually given them important information and in the future they'll know where to go. Another example, you could do a non-urgent biopsy off someone's face, but no doubt a plastic surgeon is more capable of producing a cosmetically-favorable result and the patient will forever be grateful to you.

And as a sidenote, re: "costs" to the system or being a "referral-machine" - these procedures are seldom and is nowhere near the cost of a re-referral every 6 months to the specialist for a chronic condition. For example in BC, patients are requested by their ophthalmologists to get a re-referral from their GP every 6 months for "repeat diabetes eye exam", "IOP check", "visual field exam", etc.

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7 minutes ago, Wachaa said:

And as a sidenote, re: "costs" to the system or being a "referral-machine" - these procedures are seldom and is nowhere near the cost of a re-referral every 6 months to the specialist for a chronic condition. For example in BC, patients are requested by their ophthalmologists to get a re-referral from their GP every 6 months for "repeat diabetes eye exam", "IOP check", "visual field exam", etc.

This should not be allowed. It is a chronic condition so it should be considered a F/U visit and not a re-referral. This is stealing money from the government. Ophthalmologists already make enough money.

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10 minutes ago, DermJuly2018PGY1 said:

This should not be allowed. It is a chronic condition so it should be considered a F/U visit and not a re-referral. This is stealing money from the government. Ophthalmologists already make enough money.

That's just the way the system is. Using derm as an example (from your username), there's every 6 monthly psoriasis/ eczema/ mole check up. As a GP, if the specialist requests it, and booked the pt an appointment already, the patient comes to you for a re-referral letter...are you going to say no? You get a consult letter back that's literally 3 lines long....Thank you for your referral for: rash. Diagnosis: Psoriasis. Plan: Clobetasol ung BID PRN. Review in 6 months.

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29 minutes ago, Wachaa said:

@JohnGrisham and @F508

For sure, you guys aren't wrong. Just saying that when you're a practicing doc, you are free to do as you feel comfortable and depending on your interests.

Many med students seem to think that having variety means doing many different things, even if it sacrifices time/ money in your practice. Personally, I feel that even if I just do clinic, I get enough variety from seeing the many interesting medical cases throughout the day, and being very satisfied by how I'm compensated.

One thing to point out is that many clinic owners/ managers are not physicians. They are business people whose priorities are not if you have variety or not. What they know is that procedures cost the clinic more money and some would rather not stock those supplies or have a procedure room. Why have a room that nobody uses when you can utilize the space for hiring another physician. Or why buy reusable speculums, brushes etc when you don't break even with the tray fees (you lose money per pap test because the visit billing fee is lower, and the tray fee is $5). Or why do childhood vaccinations for $5 when it causes screaming children in the clinic, needing extra MOA staffs' time to weight/ measure the baby, chart the vaccine lot/expiry number, stock vaccines and send records to public health on a regular basis...when you can just refer to Public Health (already paid by Government to have this resource).

Secondly, if you do live in a resourceful community, you have to realize that there are people who do things better than you and are worth referring to, even if you are technically able to do the procedure yourself. If you're a male physician, a lot of females are a heck of a lot more comfortable if you would give them the telephone/ address of a women's health clinic for them to go do their paps every 1-5 years, or to put in an IUD. The first visit might be a "referral" quick visit, but you've actually given them important information and in the future they'll know where to go. Another example, you could do a non-urgent biopsy off someone's face, but no doubt a plastic surgeon is more capable of producing a cosmetically-favorable result and the patient will forever be grateful to you.

And as a sidenote, re: "costs" to the system or being a "referral-machine" - these procedures are seldom and is nowhere near the cost of a re-referral every 6 months to the specialist for a chronic condition. For example in BC, patients are requested by their ophthalmologists to get a re-referral from their GP every 6 months for "repeat diabetes eye exam", "IOP check", "visual field exam", etc.

In my experience i've seen many FPs doing procedures and larger clinics with dedicated procedure rooms. Perhaps its just a provincial variance, as tray fees are not bad in my province.  Even the busiest GP ive seen (who regularly bills >500k in a big city) still does procedures, but as a business-minded individual, he ONLY does them on Fridays. All his patients know that is his procedure day, and the MOAs book. Sure if its emergent and simple, he will fit them in as a walk-in..otherwise the patients are directed to urgent care and ER.  

BUT with that said, I fully agree it is up to the GP to decide for themselves what is worth it or not (as long as the patient has alternative recourse that is! Which usually is the case in a big city).  Just saying that billing well and doing procedures is not necessarily mutually exclusive. However, this very well may be a Provincial variance,  as tray fees seem to have wide variance in reimbursement fees. 

My point with the "referral-machine" comment, was that it costs the system far more, to have the GP refer to a specialist who will do the same procedure, but now you have extra costs of the specialist referral, time off work to the patient, etc.  

Your point about the opthalmologist is essentially a similiar point im trying to make, except a bit more on the extreme: Why are opthos (or many other specialties that do this) allowed to ask for a re-referral from their GP for what essentially is a follow up visit for a chronic problem? It's not only Optho.  I've seen the same happen in outpatient ENT clinics and GI.  Of course not all physicians are doing that, but it happens.   A GP should be able to do a simple eye exam, and shouldnt feel the need to refer because it takes them too long and they arent able to bill for it enough. Of course this is assuming its in their scope. Obviously if its more serious and comorbid, you need to refer to the best level of care.  But for simple things. instead of paying the GP for 5 mins of work to quickly refer out and then pay the optho their referral fees etc(who is also likely not spending very much time), we should pay the GP a bit more to make it worth their time to do a proper job.  [To this last point, it may seem that some provinces do, hence why there are more practitioners who are offering these proecedural services..as you said not everyone is motivated by variety, and still are in it from a business sense first and foremost, so if even those are doing procedures, it must make financial sense]

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6 minutes ago, Wachaa said:

That's just the way the system is. Using derm as an example (from your username), there's every 6 monthly psoriasis/ eczema/ mole check up. As a GP, if the specialist requests it, and booked the pt an appointment already, the patient comes to you for a re-referral letter...are you going to say no? You get a consult letter back that's literally 3 lines long....Thank you for your referral for: rash. Diagnosis: Psoriasis. Plan: Clobetasol ung BID PRN. Review in 6 months.

Well, that shouldn't be allowed, and is an abuse of the system.

4 minutes ago, JohnGrisham said:

 A GP should be able to do a simple eye exam, and shouldnt feel the need to refer because it takes them too long and they arent able to bill for it enough.  Instead of paying the GP for 5 mins of work and then pay the optho their referral fees etc, we should pay the GP a bit more to make it worth their time to do a proper job.  

I agree. This is the cost-benefit way of doing things. Unfortunately, there aren't many health services researchers in Canada to guide our decisions.

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I was hoping the topic wouldn't go off topic to be just about money.

Focusing on just why sometimes procedures or cases get referred out.

There are simply some procedures that even if they paid well enough, GPs would probably still refer out because of practice niche, interest, personal comfort, time constraint, or that someone else can do a better job since they have different training. Some specialists clinic are just better equipped.

Since you do mention about compensating GPs more, they would have to pay equal to what the specialists are making and in the view of the system, there would be no point. From the view of the patient, sure, it's more convenient. But you'd have to pay GPs  a lot more to manage diabetes by compensating them for diabetic nurse education, insulin teaching, etc...all of which now often gets done by specialists. There are all these facilities set up by the health authorities and paid for already, so why not utilize them rather than trying to make GPs do everything.

Secondly, if you have the GPs do everything, then on a daily basis they can't see as many patients. Regarding that example where the doctor spends a whole day doing procedures. Where are all these doctor-less patients going to go when they need to see a primary care provider and you're not "available" on a Friday?

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2 hours ago, F508 said:

Also it's much more convenient for the patient if they could get their joint infiltration or biopsy done at that appointment, instead of having to miss another day of work to get a 5min infiltration at another clinic..

Exactly!  Not to mention, in the setting where I work, a community health centre, many of our patients have enormous difficulty getting to specialist appointments, for a whole variety of reasons, including not being able to pay for the taxi there (if it‘s not on a bus route), having major anxiety over meeting new practitioners (with many CHC clients it can take a while to build up trust and establish rapport), having difficulty getting to new and unfamiliar places, or not being able to afford and extra trip on the access bus that week or month.  Our physicians are all on salary, so they aren‘t earning anything extra for the procedures they do.  The ones who do low risk OB do earn extra for deliveries, but they don‘t for pre- and post-natal care, or for IUD insertions, etc.

It‘s sad that so many physicians, medical students, and residents posting here are focused on the amount of money they earn for a procedure, instead of on what is best for the patient.

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13 minutes ago, NutritionRunner said:

 

It‘s sad that so many physicians, medical students, and residents posting here are focused on the amount of money they earn for a procedure, instead of on what is best for the patient.

Most of us are explaining WHY family docs typically don't do procedures.  Not placing a value judgement on it.  Also not to be harsh but people come on here to get information, not to hear constant re-affirmations of our commitment to patients (which for the record is often a given)--so I don't appreciate the judgment tbh 

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1 hour ago, Wachaa said:

I was hoping the topic wouldn't go off topic to be just about money.

Focusing on just why sometimes procedures or cases get referred out.

There are simply some procedures that even if they paid well enough, GPs would probably still refer out because of practice niche, interest, personal comfort, time constraint, or that someone else can do a better job since they have different training. Some specialists clinic are just better equipped.

Since you do mention about compensating GPs more, they would have to pay equal to what the specialists are making and in the view of the system, there would be no point. From the view of the patient, sure, it's more convenient. But you'd have to pay GPs  a lot more to manage diabetes by compensating them for diabetic nurse education, insulin teaching, etc...all of which now often gets done by specialists. There are all these facilities set up by the health authorities and paid for already, so why not utilize them rather than trying to make GPs do everything.

Secondly, if you have the GPs do everything, then on a daily basis they can't see as many patients. Regarding that example where the doctor spends a whole day doing procedures. Where are all these doctor-less patients going to go when they need to see a primary care provider and you're not "available" on a Friday?

Not sure what FM docs you've worked with...but I have yet to meet one who refers out for DM counselling? That is what, 10-20% of a GPs job dealing with chronic care diabetes patients.  Which is why you spread things out over multiple visits, and as well as have complex care codes etc.  Yes many get referred to endo, but alot of the day to day mgmt is still done by the GPs. And if there is still confusion, GPs can(and often do) let the patient know to make sure to talk to the dispensing pharmacist, who will more often than not happily explain proper dosing and administration etc a second time. (Especially given they often have their own MSP billing codes for such services).   

As for the argument about spending a whole day doing procedures, and now there are doctor less patients...what? The doctor is SEEING his patients and providing care.  I'm not sure the exact name of the fallacy, but im pretty sure that is one of them ha.  You are being available and providing them services. There is no functional difference if those same patients were spread out throughout the week. He would see the same number of patients at minimum, but based on his rationale he is able to see MORE patients by having majority of procedures on one day, so that way things can be more stream-lined and efficient. 

Anyways, i think we've gotten a bit off topic! 

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5 minutes ago, JohnGrisham said:

Not sure what FM docs you've worked with...but I have yet to meet one who refers out for DM counselling? That is what, 10-20% of a GPs job dealing with chronic care diabetes patients.  Which is why you spread things out over multiple visits, and as well as have complex care codes etc.  Yes many get referred to endo, but alot of the day to day mgmt is still done by the GPs. And if there is still confusion, GPs can(and often do) let the patient know to make sure to talk to the dispensing pharmacist, who will more often than not happily explain proper dosing and administration etc a second time. (Especially given they often have their own MSP billing codes for such services).   

As for the argument about spending a whole day doing procedures, and now there are doctor less patients...what? The doctor is SEEING his patients and providing care.  I'm not sure the exact name of the fallacy, but im pretty sure that is one of them ha.  You are being available and providing them services. There is no functional difference if those same patients were spread out throughout the week. He would see the same number of patients at minimum, but based on his rationale he is able to see MORE patients by having majority of procedures on one day, so that way things can be more stream-lined and efficient. 

Anyways, i think we've gotten a bit off topic! 

1) Not saying we don't do any counselling re: chronic conditions, but patients are referred for DM counselling all the time. If the patients require a multidisciplinary approach then you make the referral for the good of the patient. Just to name a few resources that are already out there and the cost per patient visit is much higher than an endocrinologist's fee because you'll have the Endocrinologist's fee + fees for dietitian, nurse practitioner, etc.

https://www.fraserhealth.ca/health-info/health-topics/diabetes/

https://find.healthlinkbc.ca/ResourceView2.aspx?org=53965&agencynum=17646052

http://vch.eduhealth.ca/PDFs/FL/FL.802.D53.pdf

2) Once you start working you'll quickly realize that one of the challenges is that on any given day, you will constantly have patients who need to be seen in primary care on the same day. By doing an entire day of procedures, or any portion of the day, you are not available to see acutely sick patients during that time. That's the challenge when you start trying to have more "variety" in your practice. For example, if you do a day of nursing home visits, obstetrics, hospitalist, etc, when your patients want to be seen on that day/ time, your MOA will tell them you're "booked" or "unavailable". Then they'll go to Walk in clinics or ER.

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On 3/24/2018 at 10:49 AM, ACHQ said:

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...)

Thank you for this amazing list! Do FMs typically perform these procedures? (I would think not - but I've heard family medicine tends to more procedures than IM, but more simpler procedures)

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33 minutes ago, JohnGrisham said:

Not sure what FM docs you've worked with...but I have yet to meet one who refers out for DM counselling? That is what, 10-20% of a GPs job dealing with chronic care diabetes patients.  Which is why you spread things out over multiple visits, and as well as have complex care codes etc.  Yes many get referred to endo, but alot of the day to day mgmt is still done by the GPs. And if there is still confusion, GPs can(and often do) let the patient know to make sure to talk to the dispensing pharmacist, who will more often than not happily explain proper dosing and administration etc a second time. (Especially given they often have their own MSP billing codes for such services).   

As for the argument about spending a whole day doing procedures, and now there are doctor less patients...what? The doctor is SEEING his patients and providing care.  I'm not sure the exact name of the fallacy, but im pretty sure that is one of them ha.  You are being available and providing them services. There is no functional difference if those same patients were spread out throughout the week. He would see the same number of patients at minimum, but based on his rationale he is able to see MORE patients by having majority of procedures on one day, so that way things can be more stream-lined and efficient. 

Anyways, i think we've gotten a bit off topic! 

I'll give an idea of what my typical encounter with a newly diagnosed DM patient looks like

-Review of results, discussion about pharmacotherapy and nonpharmacotherapy. Option to attend DM education classes. Review prescription and give lab req for repeat blood test a1c

-See again in 3 months - review of a1c, discussion about meds, how much the patient is exercising, if they're following their lifestyle goals, etc. Renew prescription and see again in 3 months

-Targets not attained, or other difficulty. Review other resources available - do they need counseling (review option to return to clinic more often or refer to community resources) or something tricky with their meds (switch to alternate, or refer to internal medicine depending on complexity)

-Three months later, Internal medicine does a fantastic consult, convinced patient on the right track, transfer care back to GP.

 

What you will notice is that the more visits it takes for attaining the target or doing counseling for diet/ exercise can be achieved by a referral. This opens more time in your day, rather than doing exercise counseling, to seeing sick patients. If I have time I'll write a post about how one of the challenges in FM is that patients value your accessibility and ability to help them with acute illness much more than chronic illnesses.

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Thank you for the amazing discussion! I feel even more pushed towards FM but it's still early :P

I agree with many of the points. On one hand, referring to a dermatologist for a skin consult/biopsy may be another burden on the patient, but they're also getting someone with more knowledge/expertise in their circle of care which has benefits as well.

At the end of the day, I think it's realizing what you're comfortable with, and realizing what you're not comfortable doing, and having someone you can refer to who has more expertise in that field.   

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2 minutes ago, Wachaa said:

I'll give an idea of what my typical encounter with a newly diagnosed DM patient looks like

-Review of results, discussion about pharmacotherapy and nonpharmacotherapy. Option to attend DM education classes. Review prescription and give lab req for repeat blood test a1c

-See again in 3 months - review of a1c, discussion about meds, how much the patient is exercising, if they're following their lifestyle goals, etc. Renew prescription and see again in 3 months

-Targets not attained, or other difficulty. Review other resources available - do they need counseling (review option to return to clinic more often or refer to community resources) or something tricky with their meds (switch to alternate, or refer to internal medicine depending on complexity)

-Three months later, Internal medicine does a fantastic consult, convinced patient on the right track, transfer care back to GP.

When you say refer to internal medicine, do you mean endocrinology specifically?

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I have a question - let's say you're a FM and a patient walked into your clinic. 

He's experiencing typical cardiac symptoms such as chest pain, shortness of breath. But you don't hear any murmurs or abnormal heart sounds. Would it be okay to refer to a cardiologist for follow up? 

Or do the "let's wait a few weeks, and re-intervene" and if it continues, then refer to a cardiologist? 

 

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1 minute ago, brady23 said:

When you say refer to internal medicine, do you mean endocrinology specifically?

No, it's usually general internal medicine in the community - I feel they provide a very comprehensive approach to managing not only the sugars, but they'll be optimizing blood pressure/ LDL control and making appropriate recommendations for further testing as needed.

The internist also has excellent access to these testing facilities, eg. arranging Echos, MIBIs, exercise stress tests, as needed

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Just now, Wachaa said:

No, it's usually general internal medicine in the community - I feel they provide a very comprehensive approach to managing not only the sugars, but they'll be optimizing blood pressure/ LDL control and making appropriate recommendations for further testing as needed.

The internist also has excellent access to these testing facilities, eg. arranging Echos, MIBIs, exercise stress tests, as needed

What is a general internist? I thought those were the ones who consult patients on the hospital floors after they've been seen by ER?

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3 minutes ago, brady23 said:

I have a question - let's say you're a FM and a patient walked into your clinic. 

He's experiencing typical cardiac symptoms such as chest pain, shortness of breath. But you don't hear any murmurs or abnormal heart sounds. Would it be okay to refer to a cardiologist for follow up? 

Or do the "let's wait a few weeks, and re-intervene" and if it continues, then refer to a cardiologist? 

 

Absolutely not OK.

If emergent, you will refer the patient to go to Emergency.

If non-emergent, eg. their chest pain has resolved, they're not in acute distress, or if you think their chest pain is non-cardiac, you will arrange for some baseline testing, and I would refer them to an internist or cardiologist, who has excellent access to risk-stratifying the patient. Many specialists have in-house Holter, Echo, exercise stress test, and can also quickly arrange for MIBI as needed

 

Re: internist - there are many general internal medicine physicians in the community who consult on a wide range of conditions. They can make appropriate referrals to subspecialists as needed.

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Hey guys, just had some questions that I was wondering someone in FM could answer if they didn't mind. Thanks for all your help! 

1) What types of procedures do you typically perform in your office? Would you agree that FM tends to do more procedures but easier ones than IM?

2) I know this is a random question - but how often do you do physical exams like a cardiac, or skin or lung exam? I had an FM resident tell me that even though we're learning it in clinical skills, we don't use it as often in practice which I was surprised about.

3)  What proportion of your work is just talking to patients (ex: managing a chronic condition for them like diabetes, seeing if their blood glucose has improved, making referrals, counselling) vs. hands-on (physical exam like a cardiorespiratory exam, procedures like a TB skin test)?

4) How often would you say you come across emergency situations that require referral to the ER? I know chest pain that is not resolved as one of them, is there any others?

5) Did you ever have a debate between internal medicine and family medicine? If not, why weren't you into IM, and if you did have a debate, what made you decide on family?

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1 hour ago, brady23 said:

Thank you for the amazing discussion! I feel even more pushed towards FM but it's still early :P

I agree with many of the points. On one hand, referring to a dermatologist for a skin consult/biopsy may be another burden on the patient, but they're also getting someone with more knowledge/expertise in their circle of care which has benefits as well.

At the end of the day, I think it's realizing what you're comfortable with, and realizing what you're not comfortable doing, and having someone you can refer to who has more expertise in that field.   

You also have to realize that in some places, waiting lists for the patient to get in to see a dermatologist can be quite long.  In our clinic, our physicians do the simple skin biopsies, not only because it is easier for the patient, but also because the waiting list for dermatology is considerable (this despite being in a city that is home to a medical school).  We do have patients see a dermatologist via OTN (video-medicine facilitated by a nurse), but obviously the dermatologist can‘t take a biopsy via videoconference.  It‘s the same with numerous other specialities, including endocrinology and neurology - we use OTN not only because its more convenient and facilitates access for our patients, but also because waiting lists can be of considerable length.

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2 hours ago, JohnGrisham said:

Not sure what FM docs you've worked with...but I have yet to meet one who refers out for DM counselling? That is what, 10-20% of a GPs job dealing with chronic care diabetes patients.  Which is why you spread things out over multiple visits, and as well as have complex care codes etc.  Yes many get referred to endo, but alot of the day to day mgmt is still done by the GPs. And if there is still confusion, GPs can(and often do) let the patient know to make sure to talk to the dispensing pharmacist, who will more often than not happily explain proper dosing and administration etc a second time. (Especially given they often have their own MSP billing codes for such services).   
 

The family physicians at our clinic don‘t do a lot of diabetes counselling themselves, because they have me (the dietitian) and the Certified Diabetes Educator RN who do all of the diabetes education, and we have medical directives to do basal insulin starts and A1c blood work, and the RN CDE can also start bolus insulin and adjust basal and bolus insulin.  The family physicians, do, of course, prescribe and adjust medications, but they just don‘t have the time to do serious lifestyle intervention counselling. Either the RN CDE or myself also do the glucometre education and advise patients when and how often to test - again, the family physicians simply don‘t have time to go through all of that.  We consult with each other, of course, especially if there are any questions or if glucose control is extremely poor, but the bulk of the diabetes education is left to the RD and the RN CDE.

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3 hours ago, brady23 said:

Thank you for this amazing list! Do FMs typically perform these procedures? (I would think not - but I've heard family medicine tends to more procedures than IM, but more simpler procedures)

What is a general internist? I thought those were the ones who consult patients on the hospital floors after they've been seen by ER?

FM typically do not perform these procedures. That being said, I'm sure in a more rural setting, with less specialty/sub-specialty help available, they would have to end up doing them.

Most FM programs don't train their residents for competency in those procedures, but if someone was keen on doing it, they're not terribly hard to learn, but you do have get practice, and have enough done under your belt to be comfortable when/if things go wrong (and what to do), and in what circumstances to do and (especially) NOT do the procedure (aside from the basic indications and contra-indications). 

The thing is these procedures can take a little bit of time (especially if you're doing it all by yourself), and don't pay much, so most people wont bother and just refer or call GIM/sub-specialist to do it.

 

A general internist (or GIM) is someone who trained in internal medicine for 4 years (or 5 with the new GIM specialty program). They typically work in hospitals, in a wide variety of settings including inpatient hospitalists, inpatient consultant (usually for surgical and psychiatric services) and outpatient clinics. 

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5 hours ago, brady23 said:

Thank you for this amazing list! Do FMs typically perform these procedures? (I would think not - but I've heard family medicine tends to more procedures than IM, but more simpler procedures)

I think if you do rural emergency medicine as a family physician, or +1 in ER in urban areas, you will end up doing a lot of procedures that GIM does or even more...i.e: intubation, central lines, LP, paracentesis, etc. 

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8 hours ago, brady23 said:

I have a question - let's say you're a FM and a patient walked into your clinic. 

He's experiencing typical cardiac symptoms such as chest pain, shortness of breath. But you don't hear any murmurs or abnormal heart sounds. Would it be okay to refer to a cardiologist for follow up? 

Or do the "let's wait a few weeks, and re-intervene" and if it continues, then refer to a cardiologist? 

 

If they're having chest pain in the moment --> ER. 

If unspecified and vague / clearly not emergent --> do in-office EKG then send off for further tests. 

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