Ask questions about family medicine here

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On 6/5/2020 at 3:08 AM, gogogo said:

I asked this in a separate post, but maybe it'll get more traction here: 

 

I'm still early in med school, but it seems that the bread and butter of family medicine is chronic diseases with little tangible evidence of benefit (e.g., HTN meds, diabetes management) or tenuous symptom management  (e.g., autoimmune conditions). Combining this with patients who may not always be grateful or questioning/not listening to your recommendations (e.g., lifestyle modification), I am wondering where you derive satisfaction? I don't mean to ask this in a critical way, and I also recognize that I'm probably painting a caricatured picture of the specialty. In fact, I am strongly considering family medicine and want to expand my awareness on what makes other family doctors excited and satisfied with their work.

 

Thanks!

I think it is all about having a positive attitude.

You can use a similar reasoning for any specialty in medicine and make it look boring.

Family medicine is about building a relationship with your patients. They come to you for help. They are looking up to you for guidance. I think that is very rewarding experience.

Let's take diabetes for an example. If you pick up a new diagnosis of diabetes through screening, you have the potential to significantly change a patient's life.

Let's say no one picked up that this patient had diabetes. It is possible that he/she could present one day to hospital in severe hyperglycemia state with sepsis that could potentially be life threatening. Or he/she can lose vision one day all of a sudden due to diabetic retinopathy. Or he/she can develop chronic kidney disease requiring life long dialysis.

As a family doctor, you are in a position to screen for morbid diseases like diabetes and then connect patients with the right resources (e.g., optometrist for diabetic eye check up).

Will you be successful 100% of time? NO. But just because you will fail sometimes that does not mean that it is not worth a try.

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On 6/6/2020 at 1:19 AM, gogogo said:

Thanks for answering. I completely understand that satisfaction may emerge from the relationship building (trust, connection, respect, etc.), but what about the care? I suppose you could argue that developing a relationship is in itself therapeutic. But besides that, do family doctors find satisfaction in making incremental decreases to HbA1c or BP? Do patients appreciate that? I guess I'm trying to understand whether any of the satisfaction in family medicine comes from the medicine/disease side, or if it is exclusively on the communication/relationship/patient side of things. 

It is not only incremental decreases in HbA1c. It is about looking out of your patient.

A 50 year old male can come to your clinic because he has blood in his stool. You can refer him for colonoscopy and potentially pick up an early cancer.

Many people don't feel comfortable sharing their embarrassing problems to new people such as a physician at walk-in-clinic or emergency doctor unless they are anxious or super unwell. However, they trust their family doctor because they believe that their family doctor is their quarterback.

Let's take another example. A patient has a small mole on his skin. He/she is worried that she has cancer. You can do a skin biopsy or small resection under local anesthetic and send it to pathologist for diagnosis. Within a week, you have the ability to potentially diagnose (and even treat) a skin cancer OR give good news that the mole is benign and nothing to worry about. You can possibly pick up an early melanoma and save a patient's life.

There are not that many things in life where you can play such a crucial role in another person's life.

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On 6/29/2020 at 12:59 AM, medigeek said:

What's wrong with an FM applicant wanting to be a hospitalist? Society of hospital med in USA is co-sponsored by the internal med and family med boards. 

If anything, we should be encouraging more inpatient practice.

Nothing wrong with an FM applicant wanting to be a hospitalist. But I would advice to not make that the highlight of the interview. They are interviewing applicants for family medicine program (and not hospitalist program). The goal of family medicine program is to pick up applicants to train to become family medicine doctors. If you want to be a hospitalist, once you get into family medicine program then you can start advertising. Hope that helps.

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On 6/29/2020 at 5:44 AM, chateau22 said:

What about if you said palliative care? Does it get treated the same as saying you want to do a +1 in EM?

If asked about subspecialty interest during the interview, you can say palliative care. But overall your message should be that you want to become a family doctor first. And you will explore special interests once you are in the residency.

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Thank you to all the forum members who have contributed to this thread and answered questions and advocated for family medicine. I am looking for your help going forward. 

I did not log in for several weeks and couldn't answer the questions right away as I was busy finishing my residency and then finding a job. I am hopeful that I will be able to check more often from now on.

[Meds2022 0]

Do family physicians who do pain clinics get remunerated the same as an anesthetist would doing a pain clinic? Ie are the billing codes the same? 

[CaRMS2021 109]

1 hour ago, Meds2022 said:

Do family physicians who do pain clinics get remunerated the same as an anesthetist would doing a pain clinic? Ie are the billing codes the same? 

Seeing how a decent % of the Ontario over $1million billers are family physicians doing pain clinic, I would assume so? I personally know someone on the list who is family medicine trained doing pain clinic

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3 hours ago, Meds2022 said:

Do family physicians who do pain clinics get remunerated the same as an anesthetist would doing a pain clinic? Ie are the billing codes the same? 

Depends, like if its a standard H&P visit with prescriptions then probably, but there may be some procedural stuff that on anaesthetists may bill for.

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6 hours ago, Meds2022 said:

Do family physicians who do pain clinics get remunerated the same as an anesthetist would doing a pain clinic? Ie are the billing codes the same? 

FM doctors doing pain clinic vs anesthesiologists doing pain clinic are two very different things. FM pain=joint injections. Anesthesia pain=nerve blocks, stimulators, etc. 

[JohnGrisham 1,798]

Not to mention "pain clinics" are very province specific in connotation. Ontario for some reason or other has an abundance of them compared to other provinces, where it is really not as prevalent. 

[yesmedman 9]

How much could a family doctor make doing locums in rural areas? For example in one of the rural locum programs in Alberta or BC? What would be the best strategy to maximize earnings in these cases?

[AB.Med. 3]

On 2/6/2021 at 5:51 PM, yesmedman said:

How much could a family doctor make doing locums in rural areas? For example in one of the rural locum programs in Alberta or BC? What would be the best strategy to maximize earnings in these cases?

To add to this question, how long do you usually stay in a locum position? Do you rent a place there or can you commute sometimes? I don’t know much about the logistics. 

[jadawo 1]

What is the realistic scope of a rural FM doctor? Is it possible to do a combination of some general peds/adult outpatient, some OB call/deliveries, some hospitalist work, and some emerg work? Maybe not all four, that is a lot...maybe 3 out of 4?Or do most rural doctors need to focus on one niche? I know FM doctors have OB, peds, adult, inpatient and outpatient training, but I am curious if it is actually common for FM doctors to utilize this full skill-set in a rural area.

For context, I am an American medical student who is considering doing a FM medicine residency in the US and then moving to Canada as an attending. Our FM residency is 3 years and full recognized by the CFPC. Because it is 3 years instead of 2, I think we get a little more exposure to the various fields of FM in residency than Canadian graduates. At a good unopposed program (unopposed means no other residencies, just FM residents and the attendings in the hospital), it is common to get 100+ vaginal deliveries, 50+ intubations and central lines/art lines, 10 months inpatient adult, 5-6 months inpatient peds, 3-4 months ICU (have to be a bit of a masochist and do some ICU months as an elective), plus all the standard FM rotations like sports ortho, general surgery, etc. Not sure how this compares to a 2-year Canadian residency.

[JohnGrisham 1,798]

4 minutes ago, jadawo said:

What is the realistic scope of a rural FM doctor? Is it possible to do a combination of some general peds/adult outpatient, some OB call/deliveries, some hospitalist work, and some emerg work? Maybe not all four, that is a lot...maybe 3 out of 4?Or do most rural doctors need to focus on one niche? I know FM doctors have OB, peds, adult, inpatient and outpatient training, but I am curious if it is actually common for FM doctors to utilize this full skill-set in a rural area.

Province dependent, but there are many rural communities where you can do all of that you asked for. Some communities you may be able to do all but OB/deliveries - as often you need specific infrastructure(i.e. RNs and backup OBGYN) to do planned maternity care. of course if a low-risk pregnant women ends up in your emerg, you can deliver them, if sending them out wont make logistical sense.

Most rural communities you can do outpatient clinic, in hospital work, and emerg with zero issues. And many where you can add on OB call coverage - but often very little volume. Bigger less rural but perhaps still remote communities will likely have some more volume for OB and infrastructure to allow planned deliveries/c-sections. You can get additional training in some provinces to do c-sections, but generally you still need to have a OBGYN available in the community for GPs to be allowed to offer this service(i.e. you cant be the only one offering c-section coverage, in case something hits the fan and you need to call in a royal college specialist OBGYN).

It is almost a necessity due to short staffing in many rural communities where FM docs HAVE to have that full scope coverage - i.e. many communities will mandate that if you want hospital privilege as a FM doc, you have to provide EM shift coverage too or if you want to work at all in that community on an alternate payment plan FM model, you must provide hospital services/coverage (i.e. you can't just work outpatient clinic work 9-5, while your other FM colleagues manage in patient and emerg). Every community is different, and province specific variations happen.

[jadawo 1]

2 minutes ago, JohnGrisham said:

Province dependent, but there are many rural communities where you can do all of that you asked for. Some communities you may be able to do all but OB/deliveries - as often you need specific infrastructure(i.e. RNs and backup OBGYN) to do planned maternity care. of course if a low-risk pregnant women ends up in your emerg, you can deliver them, if sending them out wont make logistical sense.

Most rural communities you can do outpatient clinic, in hospital work, and emerg with zero issues. And many where you can add on OB call coverage - but often very little volume. Bigger less rural but perhaps still remote communities will likely have some more volume for OB and infrastructure to allow planned deliveries/c-sections. You can get additional training in some provinces to do c-sections, but generally you still need to have a OBGYN available in the community for GPs to be allowed to offer this service(i.e. you cant be the only one offering c-section coverage, in case something hits the fan and you need to call in a royal college specialist OBGYN).

It is almost a necessity due to short staffing in many rural communities where FM docs HAVE to have that full scope coverage - i.e. many communities will mandate that if you want hospital privilege as a FM doc, you have to provide EM shift coverage too or if you want to work at all in that community on an alternate payment plan FM model, you must provide hospital services/coverage (i.e. you can't just work outpatient clinic work 9-5, while your other FM colleagues manage in patient and emerg). Every community is different, and province specific variations happen.

Thanks for the great reply. That all makes sense, especially the OB stuff. Do you get well compensated for taking on the additional scope in a rural area (emerg and hospital plus/minus low-risk OB)? Or is the way to make the most money still to just be an outpatient machine that sees 40 patients/day?

[JohnGrisham 1,798]

10 minutes ago, jadawo said:

For context, I am an American medical student who is considering doing a FM medicine residency in the US and then moving to Canada as an attending. Our FM residency is 3 years and full recognized by the CFPC. Because it is 3 years instead of 2, I think we get a little more exposure to the various fields of FM in residency than Canadian graduates. At a good unopposed program (unopposed means no other residencies, just FM residents and the attendings in the hospital), it is common to get 100+ vaginal deliveries, 50+ intubations and central lines/art lines, 10 months inpatient adult, 5-6 months inpatient peds, 3-4 months ICU (have to be a bit of a masochist and do some ICU months as an elective), plus all the standard FM rotations like sports ortho, general surgery, etc. Not sure how this compares to a 2-year Canadian residency.

Yes, 3 years is longer than 2 - i have colleagues who are FM docs who trained in the US ..it somewhat evens out, and not everyone needs 3 years to become competent for independent practice...and even in Canada, some people feel ready to leave residency halfway through 2nd year too. Value add is very dependent on scope and training programs you participated in. Not all programs are created alike in the US, nor in Canada. Many FM residents in canada will likely never have done extra intubations/lines in residency - because most aren't going to ever do them afterwards anyways.  Even when you're rural, its unlikely you're going to be doing it on a regular basis in some settings - but in some you will do them maybe fairly often for emergency purposes.  Alot of rural places don't have real ICU capabilities, so again, maybe useful training but not always.   There is a fair amount of self-selection in Canada, if you're interested in emerg, or OB care, you seek out more experiences in those fields and do more rotations as electives. This model works quite well on average. Those who are only interested in outpatient clinic care, stop inpatient rotations after the required core rotations, and focus on outpatient medicine, and get complimentary outpatient services(cardio, endo, gastro clinics etc). 

100 svds is great if you get it, and feel comfortable offering those as services, but again, most FM docs in canada don't do deliveries, and the ones that are interested can always get a few extra rotations after residency if they feel they need more numbers to offer it as a service.

As a whole, i agree, 3 years of residency prepares people better than 2 years, but many people don't "need" the extra year, depending on their scope and type of training program they completed.   

[JohnGrisham 1,798]

3 minutes ago, jadawo said:

Thanks for the great reply. That all makes sense, especially the OB stuff. Do you get well compensated for taking on the additional scope in a rural area (emerg and hospital plus/minus low-risk OB)? Or is the way to make the most money still to just be an outpatient machine that sees 40 patients/day?

Rural in general compensates well, and you will compensated better by virtue of simply working alot in the various scopes(clinic, inpatient/emerg and deliveries). When you are doing all 3(or 4), you aren't only working 40hrs a week, you're doing lots of call coverage, and working lots of hours. Hence you get paid very well.  Many jurisdictions have special call stipend offerings that increase with rurality. So even if nothing comes through the door in your rural hospital on a given night, you're being paid X $s for being available, sleeping in your bed 5 mins away. Its a mixed bag, and you'll have some places where you can easily direct nursing staff over the phone, or t hey handle things overnight with protocols so they don't have to wake up the MD at 3am when they know they also have clinic at 8am etc. Some rural places are run well and have great support staff that make it possible to keep the MDs in town. Rural medicine is nothing without support staff who make it sustainable to practice the rough lifestyle for longer periods of time.

In a fee for service model, some provinces will pay premiums for delivering care in rural areas. Others will pay you alternate payment models. You need to look into where you want to work and practice.