If you like FM, is there any point in exploring other specialties?

[insomnias]

I guess this is a corollary of the whole "if you enjoy anything other than surgery do that." I like family medicine overall and am confident I could find a niche I'd enjoy spending the rest of my life doing. I also like various aspects of various other specialties, and I could enjoy doing those specialties for the rest of my life as well. Given the training time difference and flexibility in hours, location and scope of practice that's pretty much unparalleled by any other specialty, why pursue the RC specialties over family medicine? Financially, it doesn't seem to make sense. From a mental health perspective (call sucks) it doesn't seem to make sense. Am I missing something?

[frenchpress]

13 minutes ago, insomnias said:

I guess this is a corollary of the whole "if you enjoy anything other than surgery do that." I like family medicine overall and am confident I could find a niche I'd enjoy spending the rest of my life doing. I also like various aspects of various other specialties, and I could enjoy doing those specialties for the rest of my life as well. Given the training time difference and flexibility in hours, location and scope of practice that's pretty much unparalleled by any other specialty, why pursue the RC specialties over family medicine? Financially, it doesn't seem to make sense. From a mental health perspective (call sucks) it doesn't seem to make sense. Am I missing something?

I guess it depends what you mean by ‘exploring’. My thoughts as someone pursuing family medicine... There’s a lot to learn when on core and elective rotations that can be useful for when you’re a family doctor. For example, understanding what sorts of referrals you can make to what specialties, what sorts of things you can work up in the community or get started while waiting for a referral, more familiarity with patients’ experiences, etc. It’s also helpful for some specialized areas of family medicine. For example, if you want to do family obstetrics, gyne and general surgery experience I have found helpful exposure for becoming a better assist in sections. And family medicine programs vary a lot, so getting that sort of exposure may help you decide what sort of family residency you want to do - e.g. one with lots of acuity and hospital work vs.one with more call flexibility and longitudinal care, etc etc. 

[insomnias]

1 hour ago, frenchpress said:

I guess it depends what you mean by ‘exploring’. My thoughts as someone pursuing family medicine... There’s a lot to learn when on core and elective rotations that can be useful for when you’re a family doctor. For example, understanding what sorts of referrals you can make to what specialties, what sorts of things you can work up in the community or get started while waiting for a referral, more familiarity with patients’ experiences, etc. It’s also helpful for some specialized areas of family medicine. For example, if you want to do family obstetrics, gyne and general surgery experience I have found helpful exposure for becoming a better assist in sections. And family medicine programs vary a lot, so getting that sort of exposure may help you decide what sort of family residency you want to do - e.g. one with lots of acuity and hospital work vs.one with more call flexibility and longitudinal care, etc etc. 

You're absolutely right. By exploring I guess I actually meant considering. What's the argument for considering a 5 year RC specialty which may require a fellowship and limit you to certain locations versus family med which allows you to work pretty much anywhere if you already like family med and X specialty pretty much equally.

[frenchpress]

24 minutes ago, insomnias said:

You're absolutely right. By exploring I guess I actually meant considering. What's the argument for considering a 5 year RC specialty which may require a fellowship and limit you to certain locations versus family med which allows you to work pretty much anywhere if you already like family med and X specialty pretty much equally.

Ah yeah, in that case, I think there’s a lot fewer reasons. The only one that has really resonated with me is the increasing competitiveness of family medicine programs, and having a backup plan. If you’re willing to go absolutely anywhere then you can probably stick to just family. But particularly for people who have a strong preference/reasons to do residency in a particular city/province, they may want to parallel plan or back up with some R5 specialities (IM, Psych, Peds) that compliment their interests. Some people are willing to do IM if it means staying in an urban center, for example. 

Edited August 4, 2020 by frenchpress

[offmychestplease]

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[bruh]

1 hour ago, offmychestplease said:

There are almost no reasons to choose anything over than FM.

Training time - 2 years in FM, and you're done that's it. For almost all specialties,  you need to do a fellowship/graduate degree to get a job anywhere/desirable location after so you're comparing 2 years VS 6-7+ years 

Jobs- Everywhere, plentiful and flexible to move. You don't have to worry about being restricted to where you can live, or live somewhere away from family/friends which many people underestimate. You don't have to worry about being underemployed.

Lifestyle- You have a chill 2 years in residency, Vs 6-7 years of much more difficult residency for everything else. And even when you're staff your lifestyle is better than pretty much all specialities. 

Income- After 2 years, you will be making 300K after overhead in AB (50th percentile). If you want to really work hard, and are business minded/want to maximize potential 90th percentile income is 650K after overhead, 95th percentile is 750K after overhead, 99th percentile after overhead income is 1.1 million. Since you are done so much earlier than other fields, you can also invest money much earlier.

Scope - There are sooo many niches in FM like sports med, rural ER, OB, hospitalist, cosmetic medicine, etc. You can work in these areas without further training and move around in your career. You aren't limited to a very specific field for the rest of your life. You also have many opportunities to do various +1's

Matching- You can take it easy in medical school compared to peers who have to grind to research, CV boosting, etc and most likely get first choice location which again, people underestimate the value of that. 

 

I will never understand how interest in a field takes priority over job opportunities + training time length + difficulty of training + location restriction + lifestyle etc for some people. I have to respect those people but I can't understand it. 

If you woke up every day knowing you literally hate what you do for a living, would you still do it just because it offers good money and lifestyle? 

There is a lot more to life than making good money and having home/work balance. At the end of your life, you want to be happy knowing you did things in your life that you actually enjoyed and had a passion for. 

Going into FM won't necessarily bring you happiness or satisfaction in life or work. In fact, FM never ranks at the top in terms of happiness or self-esteem at or outside work. According to the CMA, more general surgeons are satisfied with the work/life balance AND their professional life, compared to family physicians. Also more FM docs are dissatisfied with their work/life balance AND their professional life, compared to general surgeons. Now, I'm not saying you should go into surgery to be happier, I'm just saying there is more to life than money and length of training. 

FM: https://www.cma.ca/sites/default/files/2019-01/family-e.pdf

General Surgery https://www.cma.ca/sites/default/files/2019-01/general-surgery-e.pdf

Medscape data for the US https://www.medscape.com/slideshow/2019-lifestyle-happiness-6011057#3

[offmychestplease]

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[DrOtter]

10 minutes ago, offmychestplease said:

you're assuming that FM doctors wake up everyday hating their jobs lol. Have you ever considered that many people enjoy the lifestyle, short training time, flexibility etc AND the actual job of being a FM doctor?

I'm just saying that you must realllllly like the field (hence the common phrase, only choose surgery if it is the ONLY thing you can imagine yourself doing) because you will be compromising MANY areas of life mentioned earlier that most people value. 

I think bruh has a point. They're clearly not saying that all FM doctors are unhappy with their careers, but a measurable portion are. Hence, money and lifestyle are not the sole basis for choosing a specialty. If you're deeply interested in an IM subspecialty say Oncology, I'd imagine it would suck to wake up every day to deal with patients with general malaise and rashes.

Also not everyone wants to practice in AB, where you keep pulling your data from. Not everyone can have both practicing in AB or other well-paying provinces and living close to their families and support network. 

[MDinCanada]

32 minutes ago, DrOtter said:

I think bruh has a point. They're clearly not saying that all FM doctors are unhappy with their careers, but a measurable portion are. Hence, money and lifestyle are not the sole basis for choosing a specialty. If you're deeply interested in an IM subspecialty say Oncology, I'd imagine it would suck to wake up every day to deal with patients with general malaise and rashes.

Also not everyone wants to practice in AB, where you keep pulling your data from. Not everyone can have both practicing in AB or other well-paying provinces and living close to their families and support network. 

I would argue that a good portion of the FM doctors who are unhappy would also be unhappy in any other specialty. 

Probably a big portion of the people who chose FM are those who realized that medicine isn't what they expected, they became burnt out towards the end, etc,

I also noticed that surgeons are happy being surgeons even while being bullied by their seniors, working awful hours, etc., not because they find the job itself fun, but just because they have intrinsic "happy" personalities or it's a cemented defense mechanism to prevent them from having an existential crisis/dropping out of residency.

 

[bruh]

1 hour ago, offmychestplease said:

you're assuming that FM doctors wake up everyday hating their jobs lol. Have you ever considered that many people enjoy the lifestyle, short training time, flexibility etc AND the actual job of being a FM doctor?

I'm just saying that you must realllllly like the field (hence the common phrase, only choose surgery if it is the ONLY thing you can imagine yourself doing) because you will be compromising MANY areas of life mentioned earlier that most people value. 

Oh I am definitely NOT saying that all FM docs wake up hating their job! I am sure many FM docs are very happy and satisfied! The stats I posted show more than half of FM docs are happy with their work and their work/life balance. 
 

If you enjoy FM, then there is a very very strong case to be made for you to pursue it. I’ll agree that if you like both FM and surgery, then sway towards FM because of all the things you have mentioned. But if you do not enjoy the work of a family physician (I know many who are in this category) don’t go into the field - regardless of what perks it offers. 

[bearded frog]

3 hours ago, offmychestplease said:

There are almost no reasons to choose anything over than FM.

Except, you know, actually having to practice family medicine.

[gogogo]

I am very interested in FM and definitely recognize its benefits, but it is important to be critical of any specialty so that we can understand what we are getting into. It's important to remember that all specialties will exaggerate their pros and downplay their negatives; it's marketing just like anything else. So, for the sake of being a devil's advocate, let me give a different perspective on the benefits of FM:

Jobs

It's true, FM has jobs everywhere. But let's be realistic: How many job openings do you actually need? It's not as if you're going to switch your clinic every year. You'll find a clinic you like and stay there, in all likelihood. I also think that the tight job market in at least some of the other specialties might be overplayed. Speaking to people in certain specialties, they seem to be confident about the job market, even in specialties that, from the outside, I'm told have a tight job market. Of course, if you want to work downtown Toronto, then it'll be difficult to get a job. But if you're okay with working in the suburbs/community, it seems there are jobs available. I think it's important to talk to people in the field, especially residents in their final year, to get a different perspective.

Lifestyle

FM has the best lifestyle, but other specialties have it pretty good as well, like dermatology, ophthalmology, and outpatient IM specialties. I've also been told that you have a lot of control over your hours as a staff even in the more demanding specialties. I also check the hours of FM clinics in my area, and there definitely are FM doctors who are working 50-60 hours a week, including on weekends, and pretty late into the evening. Residency lifestyle seems awful for any specialty and is temporary, so probably not worth thinking about.

Income

I'm still learning about FM salaries, but it seems AB is an outlier (isn't AB in the news now for trying to unilaterally slash funding?). In ON, it seems reasonable that, on average, you'll make ~200-250k as an FM working 40-50 hours/week. Some are efficient and can do more, but some are not as efficient and work more hours for less (especially when you include the time they spend doing paperwork outside of clinic hours). And being efficient to make more money might not be enjoyable for some people because it requires faster appointments. 

Of course, 200-250k is a good salary, but your colleagues, who only put in ~3 years more than you, are making 100-200k more (or even 2-3x more in specialties like ophthalmology or dermatology, with an equally good lifestyle). I know this shouldn't matter, but as med students with type A personalities, it's hard not to allow comparison to be thief of joy. And to elaborate, you have to be in the 80th percentile of FM in ON to make 320k after overhead (see here). It's good to be ambitious and be inspired by these numbers, but there is a reason that only 20% of FM in ON are billing that high. We can't just say that 80% of FM in ON are lazy or inefficient doctors. If so, then perhaps be prepared to be like them, because by definition, we can't all be in the top 20%.

Scope

There are niches in FM, but again, there is probably a reason most don't do them. For example, to be a cosmetic FM, you have to build a clientele and compete against other specialties doing cosmetics, like derm, ENT, and plastics. Splitting your time between regular FM and a niche could also prove to be difficult, because the days you spend doing the niche (e.g., cosmetics) are days that you're not giving time to your regular FM patients. The latter patients will then be angry with you. ER has a rough lifestyle, OB has a rough lifestyle and probably requires that you work outside of the city, etc.

I also find it almost self-denial to say you want to go into FM because of the +1 opportunities. It's basically saying that you want to go into FM so that you can *not* do FM. If you are interested in a niche, perhaps it's better to just go into a specialty that does that niche?

Matching

I agree with this. But there are negatives to everything. Instead of sucking up to staff and residents to get research opportunities, as an FM doctor, you have to "suck up" to patients by putting up with their vague complaints and frustrations with the healthcare system (because you are their primary care provider/their first exposure to healthcare). For example, dealing with a chronic back pain patient who says nothing works for them is a very frustrating experience for everyone involved.

 

Overall, despite everything I said above, based on my limited training thus far, I think FM is great. But I think it's important to critical. FM is not an easy waltz into a 300k salary and requires sacrifices just like any specialty. 

[JohnGrisham]

11 minutes ago, bearded frog said:

Except, you know, actually having to practice family medicine.

Exactly this. Many people can not stand Family Medicine in clinic setting, and that is reason enough to find something else. It is easy to be a mediocre family doc, it takes a lot of work and is difficult to be a great family doc.

[offmychestplease]

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[MDinCanada]

6 minutes ago, offmychestplease said:

Thank you for providing these points. I just want to add, though:

 

Jobs:

For some (many people), they want to only work in Toronto/Montreal/Vancouver/Calgary and not rural/smaller centres. Let's not kid ourselves. For many specialties (surgery for example), it is extremely difficult to land a position in these locations without connections + luck + further fellowships etc. Some people are not willing to compromise on location. With FM, this is an non-issue. 

Lifestyle:

To get the "cush" lifestyle of optho, you need to go through 6 years (residency + at least one fellowship) of very demanding surgical training in an age when most people are getting married/having kids. I understand that the lifestyle is different after, but for some people who already had to go through so much to get into medical school in the first place, then go through medical school, 6 years is not an insignificant amount of further time to grind to then be able to finally have a "better life." 2 years of FM VS 6 years of surgical training are nowhere near comparable in any way.

Income:

I agree with you here. It is harder to argue that many specialties will have significantly more. But again, the potential is there in FM to make a lot and having years of time to invest money does mitigate some of the difference. 

Scope:

I agree with you that there are pros/cons to all these niches but the whole point is that FM is flexible you can bounce around different ones or even have a practice where you do multiple at the same time. Few specialties allow you to do that without being hyper-focused on one area. 

Matching: 

You're right. Again, I guess you can't have it all. But I just think from an overall pro/con and cost-benefit analysis especially after the 8-10 years of education that medical students have under their belt on average after medical school, FM seems to be a great option.

Let's not forget that in order to work in a big center as a specialist, you usually have to do at least some research/teaching/other obligations

[Intrepid86]

Specialty training is longer, but if you're going to be practicing for 30 years anyways, then it shouldn't be a huge factor in your decision not to pursue it.

[1D7]

Generally I think if you hate FM you should not do it.

There are a lot of specialties that have no overlap at all with the workflow of a typical FM (e.g. operating, reading scans in the dark room, pushing glass under a microscope, intubating all day, cathing/scoping, running a critical care unit). There are other specialties that hyperfocus on one area of FM so they don't have to bother with general FM outpatient clinics (e.g. EM, OBGYN, psychiatry, paediatrics, hospitalist GIM, dermatology). On the surface there are a lot of different viable options.

Where I think the issue lies is when people kind of dislike FM and like something else more, but that 'something else' has a terrible job market that leads to them being unable to even do what they enjoy in the end (or needing to do it in an unreasonable location). Another common issue is people underestimating the difficulty of residency or not realizing that their priorities will shift in 5/10/15 years such that their career becomes less important.

E.g. An orthopaedic surgeon subspecialized in knee scopes & arthroplasty with a spouse & family in Vancouver, may be unhappy if he/she was forced to relocate to Winnipeg to practice general orthopaedics & take on loads of trauma call.

E.g. Or a interventional cardiology fellow realizing he/she just wants to enjoy raising their child with their spouse and not get called in for every person that needs a cath overnight.