Jump to content
Premed 101 Forums

Family Med 3 years?


Recommended Posts

1 hour ago, bellejolie said:

NPs will never be able to see as many patients as family docs do, and that'll eventually become clear. sure patients might like they get an hour, but that means NPs are seeing 10 patients a day. Our staff see 30-40 in a day. also anything outside their algorithms they have no idea how to handle, so again i'm not worried. NPs are useful for simple one issue things like UTIs and can help alleviate the burden for those kinds of things, similar to pharmacists. however there's no chance they can really take over. ridiculous they're getting paid that much (what i saw above). 

Despite the fact the public & policy makers don't seem to care that much, the NP clearly doesn't have same depth or breadth of training to MD.   

While the NPs were effectively getting paid more per rostered patient in BC, after year 3 they were expected to carry at least 1000+ patients (compared to 1250+ after year 2 for a GP).  They were fully independent - unlike a pharmacist.  Essentially the only difference was the compensation & title in the two contracts offered by BC government to MDs & NPs.    

What does this mean practically?  more referrals when NP is out of depth/scope.. etc.  In theory the NPs shouldn't be able to spend an hour per patient either if they have a comparable patient load - so in the long term, if they were seeing a comparable number of patients, we should expect to see the same complaints re "hurried NPs".  So I wonder how it's possible they can spend an hour per patient..     

Link to comment
Share on other sites

4 hours ago, gogogo said:

This is one of the major concerns I have with entering FM (note: CaRMS is done, all my applications are to FM, and at least for now, I intend on a community clinic practice). How much of this is a regular problem for you vs. having a minority of bad apples you know you'll have to deal with once a week or so?

The cases when a patient will explicitly challenge you is rare (but it does happen - especially with MTO license reporting).

Your day-to-day troubles are more in the form of micro-aggressions (I don't mean to co-opt that term but it does accurately describe the situation). For example: they'll ask you to order or prescribe a very specific test or treatment, and then you spend the entire appointment (trying) to talk them out of it. They'll say things like: "oh but my old doctor ordered antibiotics for my cold", after you educate them about antibiotic stewardship. They'll bring in forms (usually ones related to disability) and try to convince you to sign them for non-disabilities. The common theme in all those examples is that they don't see you as a medical expert, they see you as more of an enabler to get what they want. On the other hand, specialists are more insulated from this behavior (but they have a different set of problems, I'm sure).

3 hours ago, bellejolie said:

NPs will never be able to see as many patients as family docs do, and that'll eventually become clear.

The issue is not about volume, it's that NPs / midlevels, by virtue of having more time to spend on patients, are providing parallel care in a way that is perceived to be more attentive, comprehensive, and "better" than family physicians. That is the problem. Perception goes very far in medicine (and in life in general).

What I don't want is to practice in an environment where we are deemed "not as knowledgeable" as the specialists, and "not as nice" as the NPs / midlevels. I don't want family medicine to like the metaphorical employee who works super hard, puts in unpaid hours, carries a massive sunk cost from schooling, but never gets recognized or promoted because of an inability for self-branding and a lack of professional identity. NPs / midlevels can advance their case by making the point that they are cheaper for policy-makers and better-liked by the public. Specialists advance their case because their work is basically synonymous with their field (i.e. cutting down on oncology pay means less money to fight cancer). How can family physicians advance our case? Well, I've proposed this by making a specialized family medicine stream just to focus on primary care - again, to make us the indisputable experts in the field. However, given the direction of the CFPC to keep us as the "jack of all trades", I don't think this will ever happen. 

 

 

 

 

 

 

 

 

Link to comment
Share on other sites

3 hours ago, brackenferns said:

Well, I've proposed this by making a specialized family medicine stream just to focus on primary care - again, to make us the indisputable experts in the field. However, given the direction of the CFPC to keep us as the "jack of all trades", I don't think this will ever happen. 

If anything I think the rhetoric is even worse - when every single specialty has increased sub-specialization, somehow, a third year (with more curricular adjustments) will make FM shine again with all FPs capable of managing anything at all in the ES realms (effectively compressing multiple +1s into a single year).  

I believe that my half-hearted literature review demonstrates this magical broadening of scope will not occur.  It's almost hubris in the face of an increasingly embittered practice landscape to believe this will somehow "fix" the issues.  Instead, as you mention, mid-levels can use the opportunity present to demarcate themselves as primary care focused as opposed the "jack of all trades" FPs.  It's unfortunate that your suggestions are limited to this realm, as I do think they could potentially aid FM.

Link to comment
Share on other sites

11 hours ago, indefatigable said:

It's almost hubris in the face of an increasingly embittered practice landscape to believe this will somehow "fix" the issues.  Instead, as you mention, mid-levels can use the opportunity present to demarcate themselves as primary care focused as opposed the "jack of all trades" FPs.

Agreed. It's also totally plausible to rework the FM curriculum within the two years to produce the kind of primary care physicians that can hit the ground running.

Now that I'm in practice, this is the curriculum I would've found to be the most useful (for solely ambulatory / outpatient primary care practice):

(Assuming family medicine clinics are half-days and intermixed with the rotations)

- 3 months of general pediatrics (mostly newborn clinic + ambulatory care; some inpatient / NICU but keep it minimal)

- 1 month of subspecialty pediatric clinics (1 week in each of: asthma / resp, developmental delay, feeding / constipation, and what selective of choice); on-call will be pediatric consults in the ED for the entire 4 months

- 2 months of general office-based gynecology / obstetrics (learn how to insert IUDs; rotation with MFM), on-call will be a mix of being overnight in L&D + doing ED consults

- 1 month of addictions / STI / HIV clinic; no call but use this block to one of those QI / social determinants of health / research things that resident directors love

- 5 months of internal medicine (I actually don't think GIM ambulatory clinics are that useful, because patients are often in the middle of their medical workup and you don't have the full context; I'd rather do disease specific clinics like HTN, DM, CHF, COPD, CKD, did I mention DM?, fatty liver / cirrhosis, IBS, hepatitis, ID / wound care...; can do some CTU but just enough so you get the in-patient context), on-call for internal medicine consults in ED

Now we are at 12 months.

- 0.5 month (2 weeks) of general surgery (add some OR time if you want surgical assist, otherwise just do ambulatory clinic so you recognize all the common pathologies; get good at lumps + bumps), on-call for gen surg so you recognize acute abdomens

- 1.5 month (6 weeks) of surgical subspecialty ambulatory clinics (1 week each in ENT, urology, ophthalmology, plastics, orthopedics, whatever selective of your choice; the takeaway is to learn 1 - the emergencies in each field, and 2 - indications / workup for common referrals), on-call for each of those specialties so you get a flavour of the emergencies in each field

- 3 months of psychiatry (get some experience with CBT; mostly outpatient clinics; do rotations in memory clinic so you know how to diagnose and manage cognitive disorders / dementias), on-call for psych

- 2 months of dermatology (yes, that long in dermatology, get really good at biopsies + rashes because they are so common), not too much derm emergencies so you do ED shifts as your call

- 1 month of emergency medicine (I would recommend have a teaching day before your first shift just to ensure you know all the ACLS / trauma protocol / procedures / etc.. before you start)

- 2 months of MSK clinics (sports med + rheumatology), on call for orthopedics during this time, learn how to cast + do joint injections

- 2 months of neurology clinics so you really know how to do a neuro exam (I'd say 2 weeks of headache clinic, 2 weeks doing something in peripheral neuro, 1 week in TIA clinic so you know the workup + general management, 1 week doing seizure so you know the meds + approach, 1 week in movement so you can recognize Parkinsonism, and 1 week doing MS so you at least know what to say when patients ask you if so-and-so symptom is MS), on call for neurology during this time, see if you can work with neurosurg too so you  see some acute intracranial stuff (again just to recognize the clinical findings so you can disposition to ED)

On-call should be a combination of consults + also being called up seeing specific clinical presentations + findings on the wards (i.e. you don't have to manage ward issues on call but at least know what clinical finding Y looks like so you won't miss it in the outpatient world). The staff you're with should facilitate this.

Also, family medicine programs be more hands-on with its trainees. I would've gotten more out of the experience if I was explicitly told, at the beginning of each rotation, that this is how you're supposed to do a consult, these are the learning objectives, and these are the cases you have to see. Being hands-off and doing the self-directed learning thing works for other specialties that are 1 - longer, and 2 - have more immersion (i.e. you live at the hospital). Two years finish fast and you need to have a program that pulls you from rotation to rotation and tells you what to learn.

And... that's it! Main thing that's missing here is palliative care but it can probably be included in the family medicine half days as home visits, or maybe on internal medicine. Same with LTC / geriatrics. Or just do the +1.

 

 

Link to comment
Share on other sites

13 hours ago, brackenferns said:

Agreed. It's also totally plausible to rework the FM curriculum within the two years to produce the kind of primary care physicians that can hit the ground running.

Now that I'm in practice, this is the curriculum I would've found to be the most useful (for solely ambulatory / outpatient primary care practice):

(Assuming family medicine clinics are half-days and intermixed with the rotations)

- 3 months of general pediatrics (mostly newborn clinic + ambulatory care; some inpatient / NICU but keep it minimal)

- 1 month of subspecialty pediatric clinics (1 week in each of: asthma / resp, developmental delay, feeding / constipation, and what selective of choice); on-call will be pediatric consults in the ED for the entire 4 months

- 2 months of general office-based gynecology / obstetrics (learn how to insert IUDs; rotation with MFM), on-call will be a mix of being overnight in L&D + doing ED consults

- 1 month of addictions / STI / HIV clinic; no call but use this block to one of those QI / social determinants of health / research things that resident directors love

- 5 months of internal medicine (I actually don't think GIM ambulatory clinics are that useful, because patients are often in the middle of their medical workup and you don't have the full context; I'd rather do disease specific clinics like HTN, DM, CHF, COPD, CKD, did I mention DM?, fatty liver / cirrhosis, IBS, hepatitis, ID / wound care...; can do some CTU but just enough so you get the in-patient context), on-call for internal medicine consults in ED

Now we are at 12 months.

- 0.5 month (2 weeks) of general surgery (add some OR time if you want surgical assist, otherwise just do ambulatory clinic so you recognize all the common pathologies; get good at lumps + bumps), on-call for gen surg so you recognize acute abdomens

- 1.5 month (6 weeks) of surgical subspecialty ambulatory clinics (1 week each in ENT, urology, ophthalmology, plastics, orthopedics, whatever selective of your choice; the takeaway is to learn 1 - the emergencies in each field, and 2 - indications / workup for common referrals), on-call for each of those specialties so you get a flavour of the emergencies in each field

- 3 months of psychiatry (get some experience with CBT; mostly outpatient clinics; do rotations in memory clinic so you know how to diagnose and manage cognitive disorders / dementias), on-call for psych

- 2 months of dermatology (yes, that long in dermatology, get really good at biopsies + rashes because they are so common), not too much derm emergencies so you do ED shifts as your call

- 1 month of emergency medicine (I would recommend have a teaching day before your first shift just to ensure you know all the ACLS / trauma protocol / procedures / etc.. before you start)

- 2 months of MSK clinics (sports med + rheumatology), on call for orthopedics during this time, learn how to cast + do joint injections

- 2 months of neurology clinics so you really know how to do a neuro exam (I'd say 2 weeks of headache clinic, 2 weeks doing something in peripheral neuro, 1 week in TIA clinic so you know the workup + general management, 1 week doing seizure so you know the meds + approach, 1 week in movement so you can recognize Parkinsonism, and 1 week doing MS so you at least know what to say when patients ask you if so-and-so symptom is MS), on call for neurology during this time, see if you can work with neurosurg too so you  see some acute intracranial stuff (again just to recognize the clinical findings so you can disposition to ED)

On-call should be a combination of consults + also being called up seeing specific clinical presentations + findings on the wards (i.e. you don't have to manage ward issues on call but at least know what clinical finding Y looks like so you won't miss it in the outpatient world). The staff you're with should facilitate this.

Also, family medicine programs be more hands-on with its trainees. I would've gotten more out of the experience if I was explicitly told, at the beginning of each rotation, that this is how you're supposed to do a consult, these are the learning objectives, and these are the cases you have to see. Being hands-off and doing the self-directed learning thing works for other specialties that are 1 - longer, and 2 - have more immersion (i.e. you live at the hospital). Two years finish fast and you need to have a program that pulls you from rotation to rotation and tells you what to learn.

And... that's it! Main thing that's missing here is palliative care but it can probably be included in the family medicine half days as home visits, or maybe on internal medicine. Same with LTC / geriatrics. Or just do the +1.

 

 

I LOVE THIS. This is everything. This would change our lives. Instead of 8 months of family medicine months lol. 
 

the realllll problem is… you guessed it… COVERAGE! The reality is none of these academic FM sites can function without the residents. And the useless rotations like peds wards and even all the oB need our hands and labour. It’s not about our learning. 
 

i totally totally agree. And wish they would listen but CFPC (now that I’ve attended the meeting) has no desire to really streamline or make residency really reformed. They seem to think just adding 12 months more of rotations will be the solution. Sigh. 

Link to comment
Share on other sites

20 hours ago, brackenferns said:

Agreed. It's also totally plausible to rework the FM curriculum within the two years to produce the kind of primary care physicians that can hit the ground running.

Now that I'm in practice, this is the curriculum I would've found to be the most useful (for solely ambulatory / outpatient primary care practice):

(Assuming family medicine clinics are half-days and intermixed with the rotations)

- 3 months of general pediatrics (mostly newborn clinic + ambulatory care; some inpatient / NICU but keep it minimal)

- 1 month of subspecialty pediatric clinics (1 week in each of: asthma / resp, developmental delay, feeding / constipation, and what selective of choice); on-call will be pediatric consults in the ED for the entire 4 months

- 2 months of general office-based gynecology / obstetrics (learn how to insert IUDs; rotation with MFM), on-call will be a mix of being overnight in L&D + doing ED consults

- 1 month of addictions / STI / HIV clinic; no call but use this block to one of those QI / social determinants of health / research things that resident directors love

- 5 months of internal medicine (I actually don't think GIM ambulatory clinics are that useful, because patients are often in the middle of their medical workup and you don't have the full context; I'd rather do disease specific clinics like HTN, DM, CHF, COPD, CKD, did I mention DM?, fatty liver / cirrhosis, IBS, hepatitis, ID / wound care...; can do some CTU but just enough so you get the in-patient context), on-call for internal medicine consults in ED

Now we are at 12 months.

- 0.5 month (2 weeks) of general surgery (add some OR time if you want surgical assist, otherwise just do ambulatory clinic so you recognize all the common pathologies; get good at lumps + bumps), on-call for gen surg so you recognize acute abdomens

- 1.5 month (6 weeks) of surgical subspecialty ambulatory clinics (1 week each in ENT, urology, ophthalmology, plastics, orthopedics, whatever selective of your choice; the takeaway is to learn 1 - the emergencies in each field, and 2 - indications / workup for common referrals), on-call for each of those specialties so you get a flavour of the emergencies in each field

- 3 months of psychiatry (get some experience with CBT; mostly outpatient clinics; do rotations in memory clinic so you know how to diagnose and manage cognitive disorders / dementias), on-call for psych

- 2 months of dermatology (yes, that long in dermatology, get really good at biopsies + rashes because they are so common), not too much derm emergencies so you do ED shifts as your call

- 1 month of emergency medicine (I would recommend have a teaching day before your first shift just to ensure you know all the ACLS / trauma protocol / procedures / etc.. before you start)

- 2 months of MSK clinics (sports med + rheumatology), on call for orthopedics during this time, learn how to cast + do joint injections

- 2 months of neurology clinics so you really know how to do a neuro exam (I'd say 2 weeks of headache clinic, 2 weeks doing something in peripheral neuro, 1 week in TIA clinic so you know the workup + general management, 1 week doing seizure so you know the meds + approach, 1 week in movement so you can recognize Parkinsonism, and 1 week doing MS so you at least know what to say when patients ask you if so-and-so symptom is MS), on call for neurology during this time, see if you can work with neurosurg too so you  see some acute intracranial stuff (again just to recognize the clinical findings so you can disposition to ED)

On-call should be a combination of consults + also being called up seeing specific clinical presentations + findings on the wards (i.e. you don't have to manage ward issues on call but at least know what clinical finding Y looks like so you won't miss it in the outpatient world). The staff you're with should facilitate this.

Also, family medicine programs be more hands-on with its trainees. I would've gotten more out of the experience if I was explicitly told, at the beginning of each rotation, that this is how you're supposed to do a consult, these are the learning objectives, and these are the cases you have to see. Being hands-off and doing the self-directed learning thing works for other specialties that are 1 - longer, and 2 - have more immersion (i.e. you live at the hospital). Two years finish fast and you need to have a program that pulls you from rotation to rotation and tells you what to learn.

And... that's it! Main thing that's missing here is palliative care but it can probably be included in the family medicine half days as home visits, or maybe on internal medicine. Same with LTC / geriatrics. Or just do the +1.

 

 

I like it, except its missing proper time on longitudinal FM block, and rural FM?    Truthfully, i dont think half-days alone are enough without block time on FM clinic.  But the rest of it, is spot on and would be great learning to bring into clinic. But you need clinic base of block time to learn how to manage time, run a clinic setting etc

Link to comment
Share on other sites

Maybe it’s because I am coming from a suburban/rural ish site that’s only half block based… but I don’t fully understand how this is different what the programs already do now, aside from that there’s far less family medicine, which I’d argue is actually the most useful thing. 3 months of internal medicine? Maybe if I’m in a community hospital without a CTU or other residents, working directly with general internists and doing a mix of ICU coverage and ward consults for the family hospitalists. But I found CTU pretty useless in terms of teaching because I’m mostly a lackey - if I had to do another two months I might quit. I have found the learning in my many, many months of family medicine and family hospitalist to be far more useful - I learn far more from other family docs, and the volume of seeing 15-20 patients a day in clinic, and from the referrals I make or questions I ask of community specialists when I am not sure what to do, than I do from specialist rotations. 

As soon as things get split into blocks, my learning suffers. What good is another two months of gyne if I then don’t get to use it for another year and a half until I am in practice? Medical school was like this, and I forgot most of the things I learned then until I had to relearn them in residency. And a lot of that I am forgetting again… a half day a week or whatever in longitudinal family isn’t enough to see variety. And if I am not using it, I’ll lose it. 

I think if residents aren’t learning enough in family medicine clinics to hit the ground running, then the problem is the clinics they’re learning in, not the fact that they’re allocated time in family medicine. 

Link to comment
Share on other sites

I think for me, the issue was that the learning in FM clinics was never deep enough that it stuck. It felt more like learning general heuristics and rules-of-thumb, which to me, is a lot less intuitive and memorable than breaking a disease or presentation down to its basic science, or from seeing how it's actually practiced by specialists. 

Personally, the most valuable part of rotating in specialty clinics (and why even now as a staff, I wish I did more of it), is seeing how specialists think about the field and approach common clinical problems. In fact, the most improvement I've had in residency is simply from imitating how a specialist structured their consults / management or performed their history-taking / clinical exam. For example, starting out in residency I saw a paediatrician act weirdly happy-go-lucky with a young child. At the time, I thought it was just a personality quirk. But it wasn't until I got more experienced that I realized what happened was actually a really subtle but extremely well executed clinical exam to see if the child was able to respond to certain social cues. I didn't have nearly as many "aha!" moments like that in my FM clinic rotations.

Link to comment
Share on other sites

On 2/1/2022 at 11:26 PM, innocentius said:

i am a med student considering FM, primarily because of the residency length. if they made it 3 years, i would rather do a specialty instead, or something like GIM, and get paid more for the rest of my life.But I would be happy to do a +1 in something like Emerg.

I would've done a specialty as well if family medicine was three years. Community GIM for example would just be an extra year (i.e. 4 years)

I think the core issue is that family medicine residents are moving away from comprehensive practice, mostly (in my opinion) for these reasons: 1 - To attain a stronger professional identity (i.e. they see being "jack of all trades" as being a second-rate physician), 2 - For financial benefits (i.e. ED / hospitalist can pay more than outpatient medicine), 3 - From a perception that an office-based practice is boring / low-quality medicine, 4 - Due to a contentious practice environment where midlevels are increasingly encroaching on primary care, 5 - From the lack of prestige / respect afforded to generalists from their specialist peers, 6 - From having to deal with patients who are sicker, more demanding, and increasingly seeing their primary care physician as more of an enabler rather than as a medical expert, and 7 - (The most important point) Because practicing the kind of comprehensive outpatient / emergency medicine / hospitalist / addictions / low-risk obstetrics care in this day and age, is very, very hard; moreover, this comprehensiveness is simply unnecessary in more urban settings with accessible specialist consultation.

All of those points are valid. However, I don't really see the CFPC addressing most of them in their document. The "Preparing Our Future Family Physicians" report was mostly fluff about the "Patient's Medical Home" vision, or the same talking-points about how family medicine is more than primary care.

What family medicine / CFPC needs is to realign its vision of training "the last true generalists", and accept that specialization is inevitable, and even preferred. To that end, multiple residency streams (rural, outpatient medicine, ER / hospitalist) can attract different candidates and streamline the residency curriculum. Additionally, we can consider ideas like making the third year (if they really want to add it on) a sort of "restricted license" year (i.e. like what happened with Covid deferring licensing exams) where you can work as a staff and earn comparable money, but would still need to review cases with a designated supervisor. Near the end of the restricted year you write your exam and then move onto independent practice.

Anyway, we shall see what the CFPC has in store, but I'm not too optimistic it's going to solve the issues beleaguering family medicine. 

Link to comment
Share on other sites

6 minutes ago, 1029384756md said:

A shift away from old-school generalist FM would be good for the field. Specialization leads to easier work, better pay, better outcomes for patients (at least for whatever issue they're being managed for), and results in more work satisfaction.

You mean specialization for a family doctor? Or that we should have every little thing have its own specialty? 

Link to comment
Share on other sites

3 hours ago, brackenferns said:

I would've done a specialty as well if family medicine was three years. Community GIM for example would just be an extra year (i.e. 4 years)

I think the core issue is that family medicine residents are moving away from comprehensive practice, mostly (in my opinion) for these reasons: 1 - To attain a stronger professional identity (i.e. they see being "jack of all trades" as being a second-rate physician), 2 - For financial benefits (i.e. ED / hospitalist can pay more than outpatient medicine), 3 - From a perception that an office-based practice is boring / low-quality medicine, 4 - Due to a contentious practice environment where midlevels are increasingly encroaching on primary care, 5 - From the lack of prestige / respect afforded to generalists from their specialist peers, 6 - From having to deal with patients who are sicker, more demanding, and increasingly seeing their primary care physician as more of an enabler rather than as a medical expert, and 7 - (The most important point) Because practicing the kind of comprehensive outpatient / emergency medicine / hospitalist / addictions / low-risk obstetrics care in this day and age, is very, very hard; moreover, this comprehensiveness is simply unnecessary in more urban settings with accessible specialist consultation.

All of those points are valid. However, I don't really see the CFPC addressing most of them in their document. The "Preparing Our Future Family Physicians" report was mostly fluff about the "Patient's Medical Home" vision, or the same talking-points about how family medicine is more than primary care.

What family medicine / CFPC needs is to realign its vision of training "the last true generalists", and accept that specialization is inevitable, and even preferred. To that end, multiple residency streams (rural, outpatient medicine, ER / hospitalist) can attract different candidates and streamline the residency curriculum. Additionally, we can consider ideas like making the third year (if they really want to add it on) a sort of "restricted license" year (i.e. like what happened with Covid deferring licensing exams) where you can work as a staff and earn comparable money, but would still need to review cases with a designated supervisor. Near the end of the restricted year you write your exam and then move onto independent practice.

Anyway, we shall see what the CFPC has in store, but I'm not too optimistic it's going to solve the issues beleaguering family medicine. 

True full spectrum FM doesn't work all that well nowadays. I would say that there would often be deficiencies in inpatient care compared to a doctor (could be FM or IM) who does more inpatient work. You could argue the same for someone who doesn't work EM all that much and just does it casually (unless they did it a lot in the past). In other words, being in the clinic for most of the week/month means you lose skills in other aspects of that "spectrum." 

So to your numbered points, I'd agree with 1. For 2, not sure on the financial stuff as much. FHOs can certainly bring in a lot and even very high volume FFS could match or exceed inpatient/ed work. But... I think if we could calculate it out per the amount of work actually put in per hour, hospital based work would pay more. 3 can be true or false depending on your patient population and how much you refer. 4 - I'd say midlevels are climbing into every specialty. Look at USA for what it to come in Canada. They see like half of consults for the first time. 5, I don't agree with prestige mattering. I mean other than your family and at work, does anyone really care? I'd strongly argue no. Agree with 6 and 7. 

Link to comment
Share on other sites

22 minutes ago, medigeek said:

You mean specialization for a family doctor? Or that we should have every little thing have its own specialty? 

Keep FM at 2 years and guarantee a +1 year for all FMs who have not done one. Similar to IM 3+2.

Urban outpatient-only comprehensive practice is dying and no amount of extended training will reverse this trend.

Link to comment
Share on other sites

11 hours ago, medigeek said:

True full spectrum FM doesn't work all that well nowadays. I would say that there would often be deficiencies in inpatient care compared to a doctor (could be FM or IM) who does more inpatient work.

I agree. You lose what you don't practice. Not to mention, providing full-spectrum care (i.e. obstetrics / ED / hospitalist) means you are taking time away from your outpatient practice, which just worsens the issue of not having timely access to your primary care physician.

11 hours ago, medigeek said:

3 can be true or false depending on your patient population and how much you refer. 

I believe referring is a symptom, and not the root cause. The real issue is in the CFPC's insistence at branding family physicians as the jack-of-all-trades, as the rest of the world (not just in medicine) becomes more and more specialized. Calling yourself a "generalist" in 2022 is a soft way of saying that you're not the best at anything. The public, midlevels, and policy-makers pick up on this implicit meaning and treat us accordingly.

Hence, all this leads into my point number 6 (patients seeing family physicians as medical enablers rather than medical experts), leading to less leverage on our part to convince patients and policy-makers of our value, which further diminishes our standing in the medical field and public-at-large. For patients, they want more referrals because they want to feel they are seeing an expert for their condition. For policy-makers, they want to save costs by funding midlevels (and cut our compensation) because they perceive our work to be largely replaceable. For specialists, it means they have to work harder to absorb the wave of inappropriate referrals we are sending their way (either from patient insistence at a referral or from a lack of skill, both of which can be ameliorated by having more specialized training).

It's all a negative cycle that stems from the CFPC's inability to say: "we are specialists in outpatient primary care, no other specialty can offer the same value proposition , and we will make a residency training stream to reflect this belief."

I agree with your points about midlevels, although I do feel they have made more inroads into primary care than the specialties. Regarding prestige... I agree it's a non-factor in our day-to-day work, but it does matter to the public and policy-makers. In fact, I'd rephrase "prestige" to mean "political capital". Surgeons + medical specialists have said capital because their work is synonymous with their field; jack-of-all-trades physicians, not as much.

Link to comment
Share on other sites

The full spectrum care you keep referencing really only applies to remote rural in Canada at this point, in urban or even semi-rural areas FM doctors do either primary care or hospital-based medicine. So, in reality not many are trying to do everything. Even in remote rural areas pregnant patients are often sent out to a larger centre at 36 weeks, so FM doctors are covering a small ED and taking care of a few in-patients in addition to clinic. I don't disagree that training could be improved, and you have some good ideas, but the jack-of-all-trades thing is not relevant for the majority of FM doctors as is. 

Link to comment
Share on other sites

10 hours ago, brackenferns said:

I agree. You lose what you don't practice. Not to mention, providing full-spectrum care (i.e. obstetrics / ED / hospitalist) means you are taking time away from your outpatient practice, which just worsens the issue of not having timely access to your primary care physician.

I believe referring is a symptom, and not the root cause. The real issue is in the CFPC's insistence at branding family physicians as the jack-of-all-trades, as the rest of the world (not just in medicine) becomes more and more specialized. Calling yourself a "generalist" in 2022 is a soft way of saying that you're not the best at anything. The public, midlevels, and policy-makers pick up on this implicit meaning and treat us accordingly.

Hence, all this leads into my point number 6 (patients seeing family physicians as medical enablers rather than medical experts), leading to less leverage on our part to convince patients and policy-makers of our value, which further diminishes our standing in the medical field and public-at-large. For patients, they want more referrals because they want to feel they are seeing an expert for their condition. For policy-makers, they want to save costs by funding midlevels (and cut our compensation) because they perceive our work to be largely replaceable. For specialists, it means they have to work harder to absorb the wave of inappropriate referrals we are sending their way (either from patient insistence at a referral or from a lack of skill, both of which can be ameliorated by having more specialized training).

It's all a negative cycle that stems from the CFPC's inability to say: "we are specialists in outpatient primary care, no other specialty can offer the same value proposition , and we will make a residency training stream to reflect this belief."

I agree with your points about midlevels, although I do feel they have made more inroads into primary care than the specialties. Regarding prestige... I agree it's a non-factor in our day-to-day work, but it does matter to the public and policy-makers. In fact, I'd rephrase "prestige" to mean "political capital". Surgeons + medical specialists have said capital because their work is synonymous with their field; jack-of-all-trades physicians, not as much.

There is definitely a role in having a strong cohort of family doctors. Increasingly, you see patients who have a whole roster of specialists who don't communicate that well with each other. There are many sort of borderline issues that the family doctor punts off to a specialist who punts it to another one who punts it back to the family doctor and ultimately the patient has seen 3 doctors and spent 6 months and gone nowhere with their issue. It's not great for the patient and it also costs the system money. One of the issues of course is that specialists despite being trained for 10 years are tasked with the responsibility of saying "not my problem" and walking away. A endocrinologist just has to say, "its not diabetes" and can walk away, a neurologist just has to say "its not the nerves" and walk away. That's a very inefficient way to spend human resources.  

At the end of the day though, it makes very little sense to me how the specialist who manages one organ system or sees just several diseases is trained for 5-10 years and the generalist who has to manage everything and cover the gaps is only getting 2 years. One can make an argument that an ER doc only needs to deal with emergencies and the other stuff can be seen by the specialist, but in outpatient medicine there is a role for a true quarterback, one who can also fill in gaps left by specialist. This role should be paid appropriately for their importance. 

Link to comment
Share on other sites

1 hour ago, Edict said:

There is definitely a role in having a strong cohort of family doctors. Increasingly, you see patients who have a whole roster of specialists who don't communicate that well with each other. There are many sort of borderline issues that the family doctor punts off to a specialist who punts it to another one who punts it back to the family doctor and ultimately the patient has seen 3 doctors and spent 6 months and gone nowhere with their issue. It's not great for the patient and it also costs the system money. One of the issues of course is that specialists despite being trained for 10 years are tasked with the responsibility of saying "not my problem" and walking away. A endocrinologist just has to say, "its not diabetes" and can walk away, a neurologist just has to say "its not the nerves" and walk away. That's a very inefficient way to spend human resources.  

As brackenfern has eloquently pointed out some of these referral pattern are driven by patient preferences who are sometimes looking to primary care as enablers to their agenda.  A NP may  not hesitate to refer out at patient's request, whereas in the patient's mind a FP is not a specialist (and therefore may not be very knowledgeable on their issue) and potentially an obstacle to their desire to see a specialist.  This type of referral seeking seems to be much more prevalent in large metro areas.  

 Other referrals may reflect genuine diagnostic uncertainty with  possible need of procedural expertise which FP doesn't have..  Regardless, FP  may have to do a lot of additional administrative work hunting down referrals including follow-ups in fast procedural clinics , to the extent that some FPs have complained they are now "medical secretaries" - very different from a  "quaterback".  In either case, an additional year would probably only have a negligeable effect on practice patterns - some FPs in practice only had a single year of post-graduate training, but decades of experience.    

1 hour ago, Edict said:

At the end of the day though, it makes very little sense to me how the specialist who manages one organ system or sees just several diseases is trained for 5-10 years and the generalist who has to manage everything and cover the gaps is only getting 2 years. One can make an argument that an ER doc only needs to deal with emergencies and the other stuff can be seen by the specialist, but in outpatient medicine there is a role for a true quarterback, one who can also fill in gaps left by specialist. This role should be paid appropriately for their importance. 

 An extra year can't cover the depth of longer focused training in many different areas.  If the resident is safe and can function independently, then they will have their whole career to deepen their general foundations.  FM residents are expected to hit the ground running and be rapidly aiming towards independence from day the beginning of their residency unlike many other residents. 

Besides, the proposed extra year of training seems to be focused on the "jack of all trades" model which doesn't really apply anywhere anymore except rural setting including ob/gyn, etc.. somehow replacing the current ES' which are 6 months to a year long.  THe ES programs seem logical to me as areas like ER, ob/gyn, GP anesthesia have higher acuity and risks, so focused,  supervised, exposure may help in in ensuring practice safety.  A 3+1 would make even less sense to me.

Link to comment
Share on other sites

12 hours ago, brackenferns said:

I agree. You lose what you don't practice. Not to mention, providing full-spectrum care (i.e. obstetrics / ED / hospitalist) means you are taking time away from your outpatient practice, which just worsens the issue of not having timely access to your primary care physician.

I believe referring is a symptom, and not the root cause. The real issue is in the CFPC's insistence at branding family physicians as the jack-of-all-trades, as the rest of the world (not just in medicine) becomes more and more specialized. Calling yourself a "generalist" in 2022 is a soft way of saying that you're not the best at anything. The public, midlevels, and policy-makers pick up on this implicit meaning and treat us accordingly.

Hence, all this leads into my point number 6 (patients seeing family physicians as medical enablers rather than medical experts), leading to less leverage on our part to convince patients and policy-makers of our value, which further diminishes our standing in the medical field and public-at-large. For patients, they want more referrals because they want to feel they are seeing an expert for their condition. For policy-makers, they want to save costs by funding midlevels (and cut our compensation) because they perceive our work to be largely replaceable. For specialists, it means they have to work harder to absorb the wave of inappropriate referrals we are sending their way (either from patient insistence at a referral or from a lack of skill, both of which can be ameliorated by having more specialized training).

It's all a negative cycle that stems from the CFPC's inability to say: "we are specialists in outpatient primary care, no other specialty can offer the same value proposition , and we will make a residency training stream to reflect this belief."

I agree with your points about midlevels, although I do feel they have made more inroads into primary care than the specialties. Regarding prestige... I agree it's a non-factor in our day-to-day work, but it does matter to the public and policy-makers. In fact, I'd rephrase "prestige" to mean "political capital". Surgeons + medical specialists have said capital because their work is synonymous with their field; jack-of-all-trades physicians, not as much.

 

Agree that branding as "jack of all trades" isn't necessarily the best way forward. But I think the win-win-win solution for family doctors/public-politicians/specialists is to minimize unnecessary referrals. This stems down to residency training. Well trained doctors refer less. And a lot of it also has to do with the culture of their training as well. But ultimately if you cut down referrals, it lets specialists see appropriate cases/cuts down wait times + saves money in the big picture too. It also elevates the role of the family doctor because the government sees its return on investment. 

I'm not so much about the public part though. There are a small subset of patients who ask for referrals and continue to demand it. But I find it to be a very small minority. I also find that the public is largely unaware on the training that doctors have and different specialists. A huge chunk of the population doesn't even know that dermatology or sports medicine or ophthalmology are medical specialties who go to medical school. 

Link to comment
Share on other sites

25 minutes ago, indefatigable said:

As brackenfern has eloquently pointed out some of these referral pattern are driven by patient preferences who are sometimes looking to primary care as enablers to their agenda.  A NP may  not hesitate to refer out at patient's request, whereas in the patient's mind a FP is not a specialist (and therefore may not be very knowledgeable on their issue) and potentially an obstacle to their desire to see a specialist.  This type of referral seeking seems to be much more prevalent in large metro areas.  

 Other referrals may reflect genuine diagnostic uncertainty with  possible need of procedural expertise which FP doesn't have..  Regardless, FP  may have to do a lot of additional administrative work hunting down referrals including follow-ups in fast procedural clinics , to the extent that some FPs have complained they are now "medical secretaries" - very different from a  "quaterback".  In either case, an additional year would probably only have a negligeable effect on practice patterns - some FPs in practice only had a single year of post-graduate training, but decades of experience.    

 An extra year can't cover the depth of longer focused training in many different areas.  If the resident is safe and can function independently, then they will have their whole career to deepen their general foundations.  FM residents are expected to hit the ground running and be rapidly aiming towards independence from day the beginning of their residency unlike many other residents. 

Besides, the proposed extra year of training seems to be focused on the "jack of all trades" model which doesn't really apply anywhere anymore except rural setting including ob/gyn, etc.. somehow replacing the current ES' which are 6 months to a year long.  THe ES programs seem logical to me as areas like ER, ob/gyn, GP anesthesia have higher acuity and risks, so focused,  supervised, exposure may help in in ensuring practice safety.  A 3+1 makes even less sense to me.

I honestly find patients that strongly want a referral to be pretty uncommon. The large bulk of unnecessary referrals are not patient requested. Things like possible secondary hypertension or transaminitis don't require referrals for workup unless everything has been exhausted. 

Link to comment
Share on other sites

18 minutes ago, medigeek said:

I honestly find patients that strongly want a referral to be pretty uncommon. The large bulk of unnecessary referrals are not patient requested. Things like possible secondary hypertension or transaminitis don't require referrals for workup unless everything has been exhausted. 

This seems to be more prevalent in large metro areas where there is greater access to specialists.  Patients in larger metro high-SES areas may be much more sophisticated in their  knowledge of the medical system.  

Earlier I posted a random links to NP vs GP in BC (where it seems to be a hot topic) on **DELETED**.  Notably, more referrals from NPs seem to have been equated with better care (as compared to GPs). (reposted below)

On 1/27/2022 at 9:14 PM, indefatigable said:
Link to comment
Share on other sites

22 minutes ago, indefatigable said:

Earlier I posted a random links to NP vs GP in BC (where it seems to be a hot topic) on **DELETED**.  Notably, more referrals from NPs seem to have been equated with better care (as compared to GPs). (reposted below)

That thread is quite sad in a way. Based on the criteria those posters (and seemingly much of the general public) sets out, most patients would prefer a NP. While our (MD) more extensive training means we can make decisions faster, more accurately, and with fewer unnecessary tests... for the patient faster feels like less care and fewer tests feels like dismissal of symptoms.

Link to comment
Share on other sites

28 minutes ago, indefatigable said:

This seems to be more prevalent in large metro areas where there is greater access to specialists.  Patients in larger metro high-SES areas may be much more sophisticated in their  knowledge of the medical system.  

Earlier I posted a random links to NP vs GP in BC (where it seems to be a hot topic) on **DELETED**.  Notably, more referrals from NPs seem to have been equated with better care (as compared to GPs). (reposted below)

But the absolute percentage is still pretty low. Also a lot of it depends on your exact setting (established practice vs walk in) and how knowledgeable your patients perceive you to be. Are you confidently performing workups and getting the answers for the patients or are you quickly referring? Patients only request referrals due to prior practice patterns anyway. 

6 minutes ago, 1D7 said:

That thread is quite sad in a way. Based on the criteria those posters (and seemingly much of the general public) sets out, most patients would prefer a NP. While our (MD) more extensive training means we can make decisions faster, more accurately, and with fewer unnecessary tests... for the patient faster feels like less care and fewer tests feels like dismissal of symptoms.

Much of that has to do with how little doctors stick up for themselves. But you're right, there is a "customer service" aspect to it and it is impossible to win that. No amount of counselling will convince your patient. And educating the public is literally the most impossible task there is. They will doctor shop then eventually go to the NP who does the tests and referrals they want and then tell everyone that NPs are superior. 

Link to comment
Share on other sites

Even though the NPs seem like they are winning the hearts of patients in that thread, the government may not see it that way. If these NPs are seeing 0-5 patients a day, making 235k and ordering lots of unnecessary labwork and specialist referrals, the government will just see inefficiency. If that is truly the case, I think the government will quickly realize that NPs are not a cost saving measure. 

So if that is truly the case, I am actually less worried for physicians. Of course physicians still need to advocate for themselves. I understand the point others have made about family docs becoming more specialized now. I earlier said I think family medicine plus a sort of junior attending style year was ideal and it seems others agree overall. 

Brackenferns made a good point actually, now that I think about it, it is potentially more reasonable to offer an outpatient medicine stream, a hospitalist stream and an emergency medicine stream, all 2 years but allowing independent practice in just that area, if you want to add a concentration you can do an extra year. I still believe they should be run under family medicine as a whole and I think there should be opportunity to switch streams without much by the way of consequences. The current residency style could be kept as a generalist rural stream leaving it 3 years total with 2 years of residency and 1 year of supervised practice. 

 

 

 

Link to comment
Share on other sites

1 minute ago, Edict said:

Even though the NPs seem like they are winning the hearts of patients in that thread, the government may not see it that way. If these NPs are seeing 0-5 patients a day, making 235k and ordering lots of unnecessary labwork and specialist referrals, the government will just see inefficiency. If that is truly the case, I think the government will quickly realize that NPs are not a cost saving measure. 

So if that is truly the case, I am actually less worried for physicians. Of course physicians still need to advocate for themselves. I understand the point others have made about family docs becoming more specialized now. I earlier said I think family medicine plus a sort of junior attending style year was ideal and it seems others agree overall. 

Brackenferns made a good point actually, now that I think about it, it is potentially more reasonable to offer an outpatient medicine stream, a hospitalist stream and an emergency medicine stream, all 2 years but allowing independent practice in just that area, if you want to add a concentration you can do an extra year. I still believe they should be run under family medicine as a whole and I think there should be opportunity to switch streams without much by the way of consequences. The current residency style could be kept as a generalist rural stream leaving it 3 years total with 2 years of residency and 1 year of supervised practice. 

 

 

 

The US is a model of the future for Canada. Midlevels get independent practice rights in all specialties in all states and also are now going to be immune from lawsuits. No one will see them as an inefficiency. The only path forward for them is increasing privileges. 

Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

Loading...
×
×
  • Create New...