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FM block call


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Can someone explain to me the concept of being on-call in a FM residency during your FM block? Does this simply imply that clinic hours are late till 8 pm, or are you required to deal with emergencies that arise after hours? But shouldn't patients with emergencies just go straight to the ER? Sorry I am a bit confused.

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Generally,

When the clinic is closed, the clinics should have after-hours coverage on evenings, weekends, and holidays. You would answer calls from patients, labs, pharmacies, specialist, hospitals, just to name a few. It would be up to the individual clinic to determine how best to provide that care.

Some residency programs would ask the resident to answer the pager and call the patient back (Telehealth consult). Others would ask the resident to open the clinic or to do a house call, and so on.

The various provincial Colleges have made it clear that it is not sufficient to simply have a voicemail asking the patient to go to ER.

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In my experience it’s mostly triage: you get calls from clinic patients and either think it’s an emergency and send them to emerg, or arrange for them to be seen in the clinic as per urgency, I.e. next morning, same week, next week, etc. Hospitalist or obstetrics call can be common in family block too, depending on the scope of practice at your clinic. I’ve done both. 

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2 hours ago, klamar said:

Even for a typical community family medicine office?

In many cases - the province is looking for ways to reduce ER usage. The ERs are overloaded to say the least, and people stuck in the ER for endless hours end up complaining and from a cost point of view they are very expensive. The ER is certainly not the right place for everyone to go but access to urgent care (rather than purely emergent) is very important. 

 

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At my program on call means that you attend after hours clinic in addition to your normal clinic and then cover long term care pages over night or respond to the family health team pages which tend to be prescription refills, affiliated group home visits, etc. The long term care resident tends to be much busier than the other one.

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6 hours ago, Arztin said:

Very variable. Program and site dependant.

Some programs will have you do ER shifts. Some places, hospital medicine admissions in the evenings. Sometimes, walk in clinics. Sometimes, nursing home calls. Some places don't have calls during their FM blocks.

Ugh need to find those programs and have other programs take note 

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On 12/13/2021 at 10:37 AM, Arztin said:

100% wholeheartedly disagree. FM is already short enough with 2 years. They will miss a significant chunk of exposure during their residency. The residents themselves know their training is lacking vs other FM residents.

100% disagree. Call does not equal good learning and many (not all) programs with heavy call schedules are more service oriented. 

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On 12/14/2021 at 2:40 PM, chateau22 said:

100% disagree. Call does not equal good learning and many (not all) programs with heavy call schedules are more service oriented. 

The CCFP has so many competencies that they expect residents to demonstrate in the 2 years that dropping call would make it difficult to do that. Heck, FM is moving towards being a 3 yr program soon because there isn't enough time to learn everything that is expected. Roughly 1/3 of these competencies are acute care oriented, which you'd be more likely to see in a call based setting/after hours. I think the benefit of call is that it puts a bit more pressure on residents to make decisions and think things through when staff aren't immediately available (i.e. dealing with an acutely decompensating full-code patient overnight at LTC while your staff who is at home sleeping doesn't routinely do LTC, know the patients, or deal with acute situations other than the 2 nights per year). I personally find the situations where I'm pushed out of my comfort zone to be best for learning and most memorable going forward.

This might not apply to someone who strictly plans to do 9-4 pm clinic based family med, but as long as the CCFP considers family medicine grads to be "true generalists" I think call is a valuable learning experience

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On 12/13/2021 at 10:37 AM, Arztin said:

100% wholeheartedly disagree. FM is already short enough with 2 years. They will miss a significant chunk of exposure during their residency. The residents themselves know their training is lacking vs other FM residents.

agree with this - i chose a site i knew was heavy because the exposure is just too short. encourage you to work hard in those 2 years its all you're going to get before you're a staff. 

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On 12/14/2021 at 2:40 PM, chateau22 said:

100% disagree. Call does not equal good learning and many (not all) programs with heavy call schedules are more service oriented. 

but being service heavy still means you're seeing more presentations and getting comfortable. in a 2 year program those experiences really count and add up. 

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50 minutes ago, bellejolie said:

but being service heavy still means you're seeing more presentations and getting comfortable. in a 2 year program those experiences really count and add up. 

Depends. Being up all night managing a DKA patient(i.e. watching labs, titrating insulin and directing nursing staff) or a hyponatremia patient on IM or doing consult after consult of appy's, chole's etc on a surgical rotation had zero value to my learning.  Once you've seen those once or twice, after that it is just service based scut work for many learners in FM.  

I think overall call is valuable, but having it in such a way of being in more relevant settings to the learner is key - i.e. some programs have most call oriented around Emergency room shifts, or  hospitalists admit shifts, or secondarily maternity care. Emerg is super relevant for FM, to be able to manage subacute conditions in the community and knowing pathways to get them the appropriate level of care they need...rather than saying "sorry i dont have any appointments until 2 weeks from now, just go to the ED".  Hospitalists admit shifts are helpful to get a feel for how chronic care patients navigate their care.

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7 hours ago, JohnGrisham said:

Depends. Being up all night managing a DKA patient(i.e. watching labs, titrating insulin and directing nursing staff) or a hyponatremia patient on IM or doing consult after consult of appy's, chole's etc on a surgical rotation had zero value to my learning.  Once you've seen those once or twice, after that it is just service based scut work for many learners in FM.  

I think overall call is valuable, but having it in such a way of being in more relevant settings to the learner is key - i.e. some programs have most call oriented around Emergency room shifts, or  hospitalists admit shifts, or secondarily maternity care. Emerg is super relevant for FM, to be able to manage subacute conditions in the community and knowing pathways to get them the appropriate level of care they need...rather than saying "sorry i dont have any appointments until 2 weeks from now, just go to the ED".  Hospitalists admit shifts are helpful to get a feel for how chronic care patients navigate their care.

that's part of the theory of competency based education - sure doing ANYTHING medical has some form of value but the real question is whether it actually has the most benefit to the learner (with a background of course residency is more than just training - it is actually also a job, and shocking not everything you do actually is educational, which some services just needing warm bodies for lack of a better term). Ideally things are more in alignment to be useful and practical. More and more we are seeing services dropping rotations that of less utility - which shocking also happen to "suck" for the trainee in some fashion. 

There sure were some 1st year rotations I was on that were shall we politely say of "low yield". 

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20 hours ago, JohnGrisham said:

Depends. Being up all night managing a DKA patient(i.e. watching labs, titrating insulin and directing nursing staff) or a hyponatremia patient on IM or doing consult after consult of appy's, chole's etc on a surgical rotation had zero value to my learning.  Once you've seen those once or twice, after that it is just service based scut work for many learners in FM.  

I think overall call is valuable, but having it in such a way of being in more relevant settings to the learner is key - i.e. some programs have most call oriented around Emergency room shifts, or  hospitalists admit shifts, or secondarily maternity care. Emerg is super relevant for FM, to be able to manage subacute conditions in the community and knowing pathways to get them the appropriate level of care they need...rather than saying "sorry i dont have any appointments until 2 weeks from now, just go to the ED".  Hospitalists admit shifts are helpful to get a feel for how chronic care patients navigate their care.

yes i meant more specifically FM call - for us it's ward or walk in when it comes to on service call, both of which are useful. Ward is short lived and overnight in quebec (you're either doing days or nights) and walk in/urgent care provides a lot of exposure which is needed for a short residency. on other services i can't say i always see the utility but in a 2 year residency im really trying to soak it all up. 

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On 12/14/2021 at 2:40 PM, chateau22 said:

100% disagree. Call does not equal good learning and many (not all) programs with heavy call schedules are more service oriented. 

I agree that if you do completely irrelevant calls, you are certainly not doing things that are useful for your own training. But then again, is there really anything completely irrelevant for a FM trainee, where the goal of the training is to be a true generalist? Are there FM programs where most of your calls are not useful for your learning? 

Let's take an extreme example. Sure, learning how to adjust ventilator settings while doing ICU calls is absolutely not useful for someone who will only practice in the office setting. But even doing ICU and seeing what sick patients look like and progress, and knowing how to deal with electrolyte issues is definitely very useful for a FM resident who will work as a hospitalist. I definitely learned much more actual inpatient medicine during my ICU months (electives) vs my FM hospital medicine months where I was mainly only doing Geri with almost no active medical issue. If I were to do wards, I think the transition wouldn't be so difficult for me right now, but if I was never exposed to these active medical issues, I would feel much less comfortable to the thought of being a hospitalist.

In my program, during my FM blocks (about 2 third of my residency), I had different calls: walk in clinics, ED shifts, OB calls, nursing home calls, hospital medicine calls (typicall FM type of calls) etc... I'm doing full time EM now. I'm not doing OB nor hospital medicine, nor will I ever work in a nursing home, and most likely never in a clinic. Even then, I still learned many useful things for my practice and I don't regret doing these calls. I think for the average FM resident, those calls are all very useful and pertinent.

In parallel, when I have an off service R1 doing EM with me, I ask them to see cases outside of their own field. Sure, that gen surg resident needs to know how to identify an acute abdomen but they will be doing that for the rest of their life. I make them realize that they also need to know when a patient is sick or not, need to have a sound DDx for common presentations (chest pain, dyspnea and delirium for example).

I don't know at which point of your training you are currently, but message me again when you have 3 months of residency left, and when you start as a staff. Tell me if your perspective changes then.

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12 hours ago, Arztin said:

In parallel, when I have an off service R1 doing EM with me, I ask them to see cases outside of their own field. Sure, that gen surg resident needs to know how to identify an acute abdomen but they will be doing that for the rest of their life. I make them realize that they also need to know when a patient is sick or not, need to have a sound DDx for common presentations (chest pain, dyspnea and delirium for example).

I think the perspective here is, you dont need to see 100+ appy/chole/?surgical abdomen consults at all hours of the night to get a feel for what is "sick vs not sick" aka "outpatient investigations vs send patient to the hospital for further workup".

I guess some of us are still sour from our residency training, where for example, general surgery rotation was very heavy on hours and overnight 26hr shifts..where most of the learning and what you needed to take away for family medicine practice was done in week 1. The rest of the overnights was non-stop consults after a busy day shift, doing bonafide scut work. I can confidently say, my medical school general surgery rotation was already busy enough to see cases and be able to recognize a surgical abdomen effectively and efficiently...and my mentioned residency rotation in the same field, was more or less me acting as a hospitalist for the surgical ward, while the surgeons spent their day operating and the off-service residents managed all their post-operative patients.  Post-op management was great learning, but overnight call doing essentially paper work and scans for run of the mill surgical consults ad-nauseam was not useful.  150+ hours overnight that likely led to premature aging! 

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12 hours ago, Arztin said:

I don't know at which point of your training you are currently, but message me again when you have 3 months of residency left, and when you start as a staff. Tell me if your perspective changes then.

I'm sure you didn't mean this in a demeaning fashion, but i'd be cautious with framing, as we don't want younger colleagues to feel we are diminishing their perspective. Everyone has different learning experiences and perspectives from baseline that level of training isn't always accurate representation. :)

At this point, I would have preferred more MSK training in residency, and focused procedural skin and cancer management, but never once would I say I wish i did more general surgery or obstetrical deliveries! 

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4 minutes ago, JohnGrisham said:

I'm sure you didn't mean this in a demeaning fashion, but i'd be cautious with framing, as we don't want younger colleagues to feel we are diminishing their perspective. Everyone has different learning experiences and perspectives from baseline that level of training isn't always accurate representation. :)

At this point, I would have preferred more MSK training in residency, and focused procedural skin and cancer management, but never once would I say I wish i did more general surgery or obstetrical deliveries! 

Oh yes you are correct. No offense meant. I just wanted to see if their perspective will change with time though. Many FM graduates face another very steep learning curve when they become staff and realize how much they still need to learn before being ''comfortable''.

8 minutes ago, JohnGrisham said:

I think the perspective here is, you dont need to see 100+ appy/chole/?surgical abdomen consults at all hours of the night to get a feel for what is "sick vs not sick" aka "outpatient investigations vs send patient to the hospital for further workup".

I guess some of us are still sour from our residency training, where for example, general surgery rotation was very heavy on hours and overnight 26hr shifts..where most of the learning and what you needed to take away for family medicine practice was done in week 1. The rest of the overnights was non-stop consults after a busy day shift, doing bonafide scut work. I can confidently say, my medical school general surgery rotation was already busy enough to see cases and be able to recognize a surgical abdomen effectively and efficiently...and my mentioned residency rotation in the same field, was more or less me acting as a hospitalist for the surgical ward, while the surgeons spent their day operating and the off-service residents managed all their post-operative patients.  Post-op management was great learning, but overnight call doing essentially paper work and scans for run of the mill surgical consults ad-nauseam was not useful.  150+ hours overnight that likely led to premature aging! 

Yeah I agree, these rotations are not very useful. I think PDs should try to replace or reduce the length of these rotations OR calls with more high-yield ones for the typical FM graduate. Luckily, most PDs are understanding and don't incorporate that kind of rotations when residents consistently give poor feedback.

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15 hours ago, JohnGrisham said:

At this point, I would have preferred more MSK training in residency, and focused procedural skin and cancer management, but never once would I say I wish i did more general surgery or obstetrical deliveries! 

I agree with you that it's hard to understand why FM has so little MSK training despite MSK complaints being so abundant.

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