Going into FM without liking the core aspects of the program?

[CrazyRay]

Hi Everyone,

Current MS3 here thinking about pursuing FM. I'm leaning towards family medicine, but I realized that I like family medicine more for the things that I could do with the training outside the core responsibility of a GP. For example, I don't particularly like managing the elderly with chronic conditions but I'm more interested in potentially working as an emerg doc, working with peds/doing deliveries, and possibly some procedures/cosmetics on the side.

I'm wondering if anyone could provide some insight regarding this issue - does it sound ludicrous to go into a program in which you don't particularly enjoy the bread-and-butter cases but more enjoy other aspects of it (including lifestyle and flexibility)? Would love to hear your thoughts.

[callmeswags]

I don't think it's outrageous, lots of others are in the same boat and end up in family. It might require some flexibility on your end though, e.g. if you want to work in emerg or do deliveries, you might need to be willing to work in a rural or smaller setting. 

[1D7]

The bulk of your practice will typically be doing the normal 'boring' FM stuff. If you can tolerate it, you'll be fine. A lot of people enter FM for the lifestyle and flexibility and even if not solely for that, it still a big selling point of FM.

[shikimate]

It's 2/3 year residency, so bit of a grind, but afterwards you basically have freedom to do whatever you want, so could be worth the grind.

There are family docs who only does surgical assist, or only ER, or only walk in clinic, or cosmetics or whatever other stuff you can think of. You gotta find that niche you are passionate about, it's out there, it may require some work and some time, but it's out there. I remember reading about this Michigan med grad who did 1 year internship and was confused, have no interest in clinical medicine whatsoever. Then he founded a chain of medical marijuana stores and now he's successful businessman, multimillionaire. He literally carved out his own way, which is quire admirable.

I am sure every resident will find something about their residency that they don't like. Even someone I know who's fanatical about their specialty, like he probably can't sleep without thinking about his cases, tells me there are certain cases he wouldn't want to do as a staff. Just goes to show you it's a give and take game.

[frenchpress]

Not outrageous, lots of people do FM and find niches like Emerg, hospitalist, obstetrics, to do full time instead. You’ll likely have more options depending on where you live (more opportunities for gp anesthesia outside of major centres, for example) but it is doable. Even if you think you are going to go this route though, be careful about saying so on residency applications - saying you only want to pursue fm for a +1 (especially Emerg) seems to be a red flag for some programs. 

[blah1234]

Tons of people in the community across specialties only focus on the niches they enjoy. Just don't be too honest on applications. You're not free from the system yet.

[1029384756md]

Most of my cohort are now practicing full time hospitalist or ER or another plus one with some walkin clinics on the side. Very few are actually doing office based family medicine - too many cons incompatible with what recent grads want in life. A few have left medicine including myself. All that to say, there are many possibilities to develop your career outside of office family medicine. But don't let anyone know your interests until you're out of the system, seriously. For carms, just say you enjoy full scope FM. Who knows, you might actually end up liking it.

[gogogo]

8 hours ago, 1029384756md said:

Most of my cohort are now practicing full time hospitalist or ER or another plus one with some walkin clinics on the side. Very few are actually doing office based family medicine - too many cons incompatible with what recent grads want in life. A few have left medicine including myself. All that to say, there are many possibilities to develop your career outside of office family medicine. But don't let anyone know your interests until you're out of the system, seriously. For carms, just say you enjoy full scope FM. Who knows, you might actually end up liking it.

Of the ~10 recent FM grads I’ve spoken to, all but one are doing something other than office-based FM. I’m starting to reconsider FM because of it.

Can you elaborate on why office FM is incompatible with grads’ life goals? What about FHOs? And what are you and the others who left medicine doing now?

 

[shikimate]

I don't practice FM but I feel how painful pure office FM is nowadays.

Basically they deal with a lot of paper pushing, and because of subspecialization, a lot of problems are referred out, then the specialist dumps the patient back, sometimes with unclear instructions, so you gotta clean up their mess sometimes. 

You are also first line for patients, so if they aren't happy more likely than not they'll dump their anger on FM. Also your choice is patients is somewhat limited. Specialists can refuse a consult or discharge their patients back to FMD, but if you are a FMD stuck with an incompatible patient, it's very hard to discharge them.

Lastly it's a big job managing your practice, prof corp and whatever other admin duties you have. You don't get paid for those lol. So unless you have a business mind and like these type of stuff, I can clearly see why people would prefer to do ER or surg assist, just get paid by the hour and walk out after shift is done.

Academic FM is very different because they're likely salaried physicians with a lot more support and less crap to deal with than your community person. That's why you see such a big disconnect between what academics think someone's practice should be and what most 'real life" practice actually do.

You'll see that disconnect on certifying exams, which are written by academics. Some of the stuff they think on exams which demonstrate " core competencies are laughable.  

[JohnGrisham]

3 hours ago, gogogo said:

Of the ~10 recent FM grads I’ve spoken to, all but one are doing something other than office-based FM. I’m starting to reconsider FM because of it.

Can you elaborate on why office FM is incompatible with grads’ life goals? What about FHOs? And what are you and the others who left medicine doing now?

 

Remember a lot of this is province specific, even region specific. Take everything in this thread with a grain of salt, and do your own research to see how it *may* apply to your own situation. 

But i do agree with alot of the sentiments, but even then FM is still a very good compromise for many, versus some 5-7 year programs. Its not always greener on the other side as a royal college specialist either.

[offmychestplease]

25 minutes ago, JohnGrisham said:

Remember a lot of this is province specific, even region specific. Take everything in this thread with a grain of salt, and do your own research to see how it *may* apply to your own situation. 

But i do agree with alot of the sentiments, but even then FM is still a very good compromise for many, versus some 5-7 year programs. Its not always greener on the other side as a royal college specialist either.

this. Almost all FRCPC fields need at least one fellowship (1-2 years) +/- a grad degree to get a job in a large city (for some fields like surgery to get a job, period). So you are comparing 2 years of residency VS 6-7+. 

Talking pure numbers let's hypothetically that a FRCPC field will make 2x what an FM makes per year (just using this for argument's sake). There is 4-5 years of lost income the FRCPC has to make up. Assuming they get full-time employment right away, it would take the FRCPC an additional 4-5 years just to break even with the FM. This does not even take into account things like investments, etc. Let's put ages to these numbers. Let's say both people in the above example finish medical school at 28. The FM person would be done residency and start life at 30. While it would take the FRCPC person until they are 34-35 to be done residency/fellowship. And then, not until they are 39-40 until they finally break even with the FM (assuming they even got a job where they want to live). So, the FRCPC and FM won't even be on the same footing until age 40.

 

[gogogo]

12 hours ago, JohnGrisham said:

Remember a lot of this is province specific, even region specific. Take everything in this thread with a grain of salt, and do your own research to see how it *may* apply to your own situation. 

But i do agree with alot of the sentiments, but even then FM is still a very good compromise for many, versus some 5-7 year programs. Its not always greener on the other side as a royal college specialist either.

I agree, the opinions on this board are going to be biased because of the limited sample. But I'm starting to take them seriously because they align with what I'm hearing from FM grads that I've met/spoken to outside of the forum. All are from one of the bigger cities in Ontario.

12 hours ago, offmychestplease said:

this. Almost all FRCPC fields need at least one fellowship (1-2 years) +/- a grad degree to get a job in a large city (for some fields like surgery to get a job, period). So you are comparing 2 years of residency VS 6-7+. 

Talking pure numbers let's hypothetically that a FRCPC field will make 2x what an FM makes per year (just using this for argument's sake). There is 4-5 years of lost income the FRCPC has to make up. Assuming they get full-time employment right away, it would take the FRCPC an additional 4-5 years just to break even with the FM. This does not even take into account things like investments, etc. Let's put ages to these numbers. Let's say both people in the above example finish medical school at 28. The FM person would be done residency and start life at 30. While it would take the FRCPC person until they are 34-35 to be done residency/fellowship. And then, not until they are 39-40 until they finally break even with the FM (assuming they even got a job where they want to live). So, the FRCPC and FM won't even be on the same footing until age 40.

 

I completely agree with the financial analysis. In fact, I made the same argument in another thread comparing FM to PA or FM to FRCPC; when you consider the years of lost income, the higher earning option (i.e., FM > PA or FRCPC > FM) typically doesn't equal the lower earning option until 40s or 50s, and by that point, I don't think the extra money is worth it vs. having had more freedom in your 30s and early 40s.

But from a quality of career standpoint, it's becoming increasingly suspicious to me that 9/10 of FM grads I've spoken to are not practicing in the field they trained. Some are doing just derm, some palliative, some ER, some hospitalist, some only walk-ins, some cosmetics, some surgical assist, etc. But only one wants to do comprehensive office-based family med. And these are people from the bigger cities in Ontario (London, Hamilton, Toronto). That tells me there's likely something undesirable about family med that drives people away. I even know an older FM who used to have a practice and he quit and now only does walk-ins. He told me he'd never open a full practice again because of how demanding it is. The nice thing about FM is the flexibility to just turn away from the full scope of the field, but it doesn't look good and suggests to me that the path isn't as linear as we're promised as med students.

[offmychestplease]

I think we see eye to eye on many things, and I fully agree about the niches. 

[bearded frog]

I think if 9/10 residents don't want to do regular family med, that's either a relatively new thing which might see an overall shift in the field, or 9/10 have always said they wouldn't want to in residency and then end up doing it anyway for whatever reason, in that it's actually desirable from the staff perspective, or there wasn't the opportunity or ability to make that niche interest a financially viable career. If the later then I would be super hesitant to charge head first into family if you despise the bread and butter. (Which I can relate with, hence me not going into family)

[bellejolie]

I think the issue with not liking the core aspect isn't that it isn't possible to not do it (i.e if you don't like clinic it's possible to get away with that), but that you're in a profession where yes you are an independent contractor, and have freedoms and liberty and some sense of power, but we're are controlled by government mandates. In quebec for instance, a family physician told me in 5 years, they are going to have the greatest number of family doctors retire (she's on the family medicine cfpc equivalent in quebec) and it's going to be a huge crisis which will likely involve the government mandating clinic hours and having to see rosters of patients. I know Quebec is different than other provinces, but you can see even in Alberta, the government is changing the rules and family physicians tend to bear the brunt of these changes. It's already mandated in Quebec to have 2000 registered patients or something like that otherwise you lose 30% of your salary, and with the boomers retiring in the next 5-10 years, clinic may be something you will be mandated to do. it's just food for thought. 

At the end of the day though, you will make your practice what you want, and even if you dislike clinic, you can always balance it with other things. it's just good to be a bit foresighted and know sometimes we're at the mercy of the government and have to do things based on population needs which may include things you don't necessarily like. the bread and butter in fam med its office based clinic medicine, elderly populations with chronic conditions. for me, is it my favourite thing? no. but i love the continuous relationship and other parts of that side of medicine along with the potential to do ob, peds, er etc. it is unlikely you will be able to avoid entirely the bread and butter, but if you can tolerate it while balancing it with your interests then it would definitely be a good choice. also once you start making a staff salary, i think itll be a lot easier to enjoy the bread and butter tbh lol.  

[CrazyRay]

Thanks for all your replies so far, it's great to hear that a lot of other people are also in my shoes. I'm wondering if anyone could explain how GPs manage to juggle different positions at once? For example, the GP who works as an emergency doc or anesthesiologist and as a regular GP, how do they manage the overhead associated with their clinic? Do they share their clinic with someone else who comes in for the days/weeks they are in the hospital? Any insight on this would be very appreciated!!

[shikimate]

That's crazy what QC government is doing, hard to believe physicians in QC put up with that. Is it language barriers that are preventing them from moving elsewhere? 

From what I've seen in small town practice groups, a bunch of FMD will get together and share a clinic and its staff. Each will contribute a percentage of income as overhead, and of course the more clinic you do the more overhead you contribute, so it's pretty fair. I think it's same with walk-in clinics and other gigs, basically it's like 70-30, 60-40, or whatever percentage split. Disclaimer I don't do FM so I can only speak from my previous experiences.

[bellejolie]

20 minutes ago, shikimate said:

That's crazy what QC government is doing, hard to believe physicians in QC put up with that. Is it language barriers that are preventing them from moving elsewhere? 

From what I've seen in small town practice groups, a bunch of FMD will get together and share a clinic and its staff. Each will contribute a percentage of income as overhead, and of course the more clinic you do the more overhead you contribute, so it's pretty fair. I think it's same with walk-in clinics and other gigs, basically it's like 70-30, 60-40, or whatever percentage split. Disclaimer I don't do FM so I can only speak from my previous experiences.

well they're compensated pretty well, i haven't really heard of a family physician making less than 350K per year with 5days/week work ~50 hours/week. most make more and i've asked a large majority of my preceptors. the remuneration schemes are forgiving and allow you to take more time with patients without sacrificing compensation, and you make a lot more working in LTC homes, with vulnerable populations etc. francophone doctors prefer to stay here for sure, but it's mostly that people from quebec tend to stay here, their families are here etc. quality of life is v good here people really know how to live! very much the euro mentality. 

for me - i just don't think the pay in a 5 year+ specialty program at all compensates for the time and stress and years of training. surgeons in the public system make what, 400-500K working about 60 hours a week. if you work 60 hours a week as a family physician, you're probably making the same (at least in quebec). with only 2 years of training (which is the case for most family physicians here, most do not do fellowship training), it's a pretty sweet deal to me. if you like family medicine, it's silly not to do it. but the caveats are you need a PREM (license to practice), have to have 2000 patients registered, and follow the rules depending on which government is in power. lots of rules, crazy amounts of construction, and plenty of politics but i can't imagine living anywhere else lol. 

[Lilirose]

3 hours ago, bellejolie said:

well they're compensated pretty well, i haven't really heard of a family physician making less than 350K per year with 5days/week work ~50 hours/week. most make more and i've asked a large majority of my preceptors. the remuneration schemes are forgiving and allow you to take more time with patients without sacrificing compensation, and you make a lot more working in LTC homes, with vulnerable populations etc. francophone doctors prefer to stay here for sure, but it's mostly that people from quebec tend to stay here, their families are here etc. quality of life is v good here people really know how to live! very much the euro mentality. 

for me - i just don't think the pay in a 5 year+ specialty program at all compensates for the time and stress and years of training. surgeons in the public system make what, 400-500K working about 60 hours a week. if you work 60 hours a week as a family physician, you're probably making the same (at least in quebec). with only 2 years of training (which is the case for most family physicians here, most do not do fellowship training), it's a pretty sweet deal to me. if you like family medicine, it's silly not to do it. but the caveats are you need a PREM (license to practice), have to have 2000 patients registered, and follow the rules depending on which government is in power. lots of rules, crazy amounts of construction, and plenty of politics but i can't imagine living anywhere else lol. 

@bellejolie, I am considering FM also, as I am older and FM is my primary interest anyway. I reallly don't want to be a surgeon... I was looking at the PREM and its so obscure to me... Lets say an md wants to practice part time... is it doable? Even in the first years? Any idea about this? I think there are also additionnal activities that you are obligated to do, such as working 1 day a week in a CHSLD, for example... Is this true? I was also looking at the possibilities of working as a hospitalist, but I am not sure this is even a thing in Qc? I looked at the FMOQ and FMRQ webpages and still have so many questions! 

You seem very familiar with the FM practice in Qc!! Any info would be great if you ahve the time! You already clarified so many points by responding to the OP! 

@CrazyRay, thanks for posting this question. I have the same questions... FM practice is very intruiging and there is not much info out there!!

[MDinCanada]

8 hours ago, bellejolie said:

I think the issue with not liking the core aspect isn't that it isn't possible to not do it (i.e if you don't like clinic it's possible to get away with that), but that you're in a profession where yes you are an independent contractor, and have freedoms and liberty and some sense of power, but we're are controlled by government mandates. In quebec for instance, a family physician told me in 5 years, they are going to have the greatest number of family doctors retire (she's on the family medicine cfpc equivalent in quebec) and it's going to be a huge crisis which will likely involve the government mandating clinic hours and having to see rosters of patients. I know Quebec is different than other provinces, but you can see even in Alberta, the government is changing the rules and family physicians tend to bear the brunt of these changes. It's already mandated in Quebec to have 2000 registered patients or something like that otherwise you lose 30% of your salary, and with the boomers retiring in the next 5-10 years, clinic may be something you will be mandated to do. it's just food for thought. 

 

Would you be affected by this if you do private?

[bellejolie]

14 hours ago, Lilirose said:

@bellejolie, I am considering FM also, as I am older and FM is my primary interest anyway. I reallly don't want to be a surgeon... I was looking at the PREM and its so obscure to me... Lets say an md wants to practice part time... is it doable? Even in the first years? Any idea about this? I think there are also additionnal activities that you are obligated to do, such as working 1 day a week in a CHSLD, for example... Is this true? I was also looking at the possibilities of working as a hospitalist, but I am not sure this is even a thing in Qc? I looked at the FMOQ and FMRQ webpages and still have so many questions! 

You seem very familiar with the FM practice in Qc!! Any info would be great if you ahve the time! You already clarified so many points by responding to the OP! 

@CrazyRay, thanks for posting this question. I have the same questions... FM practice is very intruiging and there is not much info out there!!

Honestly I'm not an expert, i think I will learn more in residency if i match to a quebec school, but from what i understand the only mandatory thing is to register a minimum number of patients. however you see them is up to you but you have to have that many registered to see them. I've never heard of mandatory 1 day CHSLD before. everything outside of your personal clinic is extra. you have to do 55% of your practice in your prem region, and 45% can be in anything else (this is how people do the hospitalist, ER, deliveries etc) http://www.fmrq.qc.ca/en/pem-prem-en-mf/vos-obligations-apres-obtention-PREM

More info can be found here but it's only in french: https://www.msss.gouv.qc.ca/professionnels/medecine-au-quebec/prem/

If you don't meet the obligations you lose 30% of your salary, and if you practice without a prem i believe it's the same. it's complicated but don't worry about that now. 

11 hours ago, MDinCanada said:

Would you be affected by this if you do private?

i dont know of anyone who just does private family medicine, but i imagine if you're not billing through RAMQ and only through patients then yes you'd be exempt. but i really don't think this is common here, private practice is obviously discouraged. 

[blah1234]

I've never practiced in Quebec so this is all second hand but isn't it hard to get a PREM in desirable areas (e.g. Montreal)? I thought that was a complaint I've heard from colleagues. Also are those figures gross billings before overhead? Figures seem a bit higher than Ontario if it's after overhead.

[MDee2B]

22 hours ago, bellejolie said:

well they're compensated pretty well, i haven't really heard of a family physician making less than 350K per year with 5days/week work ~50 hours/week. most make more and i've asked a large majority of my preceptors. the remuneration schemes are forgiving and allow you to take more time with patients without sacrificing compensation, and you make a lot more working in LTC homes, with vulnerable populations etc. francophone doctors prefer to stay here for sure, but it's mostly that people from quebec tend to stay here, their families are here etc. quality of life is v good here people really know how to live! very much the euro mentality. 

for me - i just don't think the pay in a 5 year+ specialty program at all compensates for the time and stress and years of training. surgeons in the public system make what, 400-500K working about 60 hours a week. if you work 60 hours a week as a family physician, you're probably making the same (at least in quebec). with only 2 years of training (which is the case for most family physicians here, most do not do fellowship training), it's a pretty sweet deal to me. if you like family medicine, it's silly not to do it. but the caveats are you need a PREM (license to practice), have to have 2000 patients registered, and follow the rules depending on which government is in power. lots of rules, crazy amounts of construction, and plenty of politics but i can't imagine living anywhere else lol. 

Is that really the case, in Quebec? That must be before overhead but still, I thought for FM, the average was lower, more like 250k before overhead -> around 180k after overhead. Obviously depends on different factors. But have really never heard of anyone in FM in QC earning less than 350k working 5 days, with most making more? 

[MDinCanada]

6 hours ago, bellejolie said:

 

If you don't meet the obligations you lose 30% of your salary, and if you practice without a prem i believe it's the same. it's complicated but don't worry about that now. 

i dont know of anyone who just does private family medicine, but i imagine if you're not billing through RAMQ and only through patients then yes you'd be exempt. but i really don't think this is common here, private practice is obviously discouraged. 

I'm from Quebec too and I'd like to eventually practice in Montreal for factors that you mentioned above (quality of life, culture, cost of living, etc.)

A big factor motivating me to do family medicine is the shorter training, career flexibility (you can sort of change careers as you age depending on your interests), lifestyle flexibility (being able to reduce hours when I'll have a family), etc. Does it scare you that the government may want to impose a large amount of patients on each family doctor? Possibly turning it into something that is very not lifestyle? Instead of threatening family doctors, they could make going into family medicine more attractive to students...

The political and administrative bs in medicine bothers me the most... If all goes to shit, I would have no problem changing provinces/going private or doing non-clinical work.

[offmychestplease]

49 minutes ago, MDinCanada said:

I'm from Quebec too and I'd like to eventually practice in Montreal for factors that you mentioned above (quality of life, culture, cost of living, etc.)

A big factor motivating me to do family medicine is the shorter training, career flexibility (you can sort of change careers as you age depending on your interests), lifestyle flexibility (being able to reduce hours when I'll have a family), etc. Does it scare you that the government may want to impose a large amount of patients on each family doctor? Possibly turning it into something that is very not lifestyle? Instead of threatening family doctors, they could make going into family medicine more attractive to students...

The political and administrative bs in medicine bothers me the most... If all goes to shit, I would have no problem changing provinces/going private or doing non-clinical work.

there is not need to make FM more attractive to students as it is already very popular...already 50-60% of graduates from the medical schools in QC go into FM for the reasons you mentioned above and more.