Having Second Thoughts about FM

[MedZZZ]

I am a PGY1 in FM and I am having second thoughts about my future job security and satisfaction. I am 6 months into residency and I am having second thoughts whether I should try to switch to IM or stick to FM. This is the following reasons:

1. I don't particularly enjoy all aspect of FM like OB, GYN, PEDS, etc. However, I have done a hospitalist rotation and I can see myself working as a hospitalist in the future so this is an option.

2. So many of my preceptors seem to be unhappy with their work-life balance and they all seem to be somehow regretting choosing FM and it is really discouraging to see unhappy staff in your profession as a new resident.

3. There has been recently many articles glorifying NPs as primary care providers which is frustrating to me. And also many articles written by Family Doctors which highlights the lack of compensation, paperwork/admin stuff. Reading/hearing about these issues really scare me that I would regret my choice in the future.

4. I enjoy the patient interaction and clinical medicine but I feel that FM as an outpatient does not provide much of clinical medicine.

On the other hand, IM has it's own set of challenges:

1.  FIVE years of TOUGH residency (I am already in my early 30s so I will be graduating in my very late 30s) and it can be tough to look for jobs while you have other commitments at that age.  **This is the number 1 reason giving me doubts.**

2. Two difficult royal college exam

3. Possibly difficult to find a job given the competition.

I know it is ultimately a final decision and even transferring is not guaranteed but I just wanted to ask people who are currently residents/staff/or where in the same boat if they have any insight. I would really appreciate it as I am having difficulty making a decision.

 

 

[HoopDreams]

I would recommend that you be patient and just accept that residency is not a reflection of your future life as a staff. You currently have no freedom. You are completing rortations that you have not chosen and that are required for your residency program. That does not translate in any way in you not enjoying the practice that you will tailor to your preferences as a staff. You will have control over what you will do. If you don't enjoy obsgyn and peds, simply don't do it. You can work as much as you want or as little as you want. The main advantage of family medicine is flexibility. You can work as a hospitalist, do palliative care, geriatrics, etc. Is it a perfect world? No. In IM, you will have limited freedom for at least 5 years (+ fellowship years) and have a lot of uncertainty to face regarding where you will work. 

[LoquaciousLoquat]

I would ask yourself if you can at least tolerate peds / ob / gyne, or if you just flat out dislike it. For example, imagine if you had a clinic day that was JUST peds / ob / gyne; for illustration purposes I'll just make up some typical cases:

11 month infant w/ fever, 20 yo F for contraception counselling, 50 yo F for ?menopause, 15 mo well-baby visit, a PAP smear, 6 yo M for ?asthma, 27 F for prenatal counselling, pregnant patient w/ 1st-trimester vaginal bleeding, 14 yo M with "mood changes" per parent, 11 yo F for ?ADHD, 3 yo M with a rash, 6 month infant spitting up breastmilk, an infant w/ a diaper rash, another infant who bumped her head after falling out of the crib, 13 yo F w/ knee pain, another teenager who wants STI testing...

If those cases sound okay (as in you can tolerate doing them) then sure, FM may be the right call. But if you don't want to see any of those issues (and would actively dislike it if you did), then I would consider switching. Sure you can narrow your practice once you're staff, but some points to ponder:

1 - The more lucrative family medicine outpatient practice settings (i.e. FHO / Family Health Organization) requires you to practice comprehensive care. You can't just not see a certain patient population in those settings. (To touch on the point of FHOs, the majority of the family medicine staff I know want to / or are working in a FHO. The salary discrepancy is rather noticeable. For example, the average FP doing fee-for-service in 2017/2018 earned $188,260.79, while the average FHO FP earned $366,740.55. Source below).

2 - If your goal is to practice hospitalist medicine because you don't want to see peds / ob / gyne, then you'll get that in Internal Medicine. Yes, it'll be harder than an FM residency, but remember: Burnout = Difficulty / Enjoyment (that's difficulty divided by enjoyment). If you enjoy what you do, your intrinsic satisfaction will cancel out the extrinsic difficulty, and you can still thrive and prosper. Conversely, if you dislike or hate what you do, then you can be unhappy or burn out even if you have an easier work or residency program.

3 - You can do geriatrics or palliative care from family medicine to avoid seeing peds / ob / gyne, but keep in mind that you can approach those two disciplines from Internal Medicine as well. Moreover, personally I don't think it's the best idea to go into a field and then plan to literally avoid the bread-and-butter of the discipline (peds / ob / gyne are a staple in FP). You can make it work but it'll feel like fighting an uphill battle.

Good luck!

https://www.ices.on.ca/~/media/Files/AHRQ/AHRQ-Reports/Physician-Compensation-Update-2005_06-to-2017_18.ashx (this will download a PDF)

[lovemedicinesomuch]

3 hours ago, MedZZZ said:

I am a PGY1 in FM and I am having second thoughts about my future job security and satisfaction. I am 6 months into residency and I am having second thoughts whether I should try to switch to IM or stick to FM. This is the following reasons:

1. I don't particularly enjoy all aspect of FM like OB, GYN, PEDS, etc. However, I have done a hospitalist rotation and I can see myself working as a hospitalist in the future so this is an option.

2. So many of my preceptors seem to be unhappy with their work-life balance and they all seem to be somehow regretting choosing FM and it is really discouraging to see unhappy staff in your profession as a new resident.

3. There has been recently many articles glorifying NPs as primary care providers which is frustrating to me. And also many articles written by Family Doctors which highlights the lack of compensation, paperwork/admin stuff. Reading/hearing about these issues really scare me that I would regret my choice in the future.

4. I enjoy the patient interaction and clinical medicine but I feel that FM as an outpatient does not provide much of clinical medicine.

On the other hand, IM has it's own set of challenges:

1.  FIVE years of TOUGH residency (I am already in my early 30s so I will be graduating in my very late 30s) and it can be tough to look for jobs while you have other commitments at that age.  **This is the number 1 reason giving me doubts.**

2. Two difficult royal college exam

3. Possibly difficult to find a job given the competition.

I know it is ultimately a final decision and even transferring is not guaranteed but I just wanted to ask people who are currently residents/staff/or where in the same boat if they have any insight. I would really appreciate it as I am having difficulty making a decision.

 

 

 

I am also in similar situation, although a bit younger than you. My perspective is that you will age anyways, might as well age whilst doing the things you like and following your dreams. If you are having regrets about FM that early in your career ( as a PGY-1), these feelings are not going to go away ( you should try to switch).

I tried to like FM, as I  would like to be done next year and start to make money, but I can't get rid of the feeling that I don't truly enjoy what I am doing in FM.  Just like you, I appreciate the complexity/problem solving/intensity/ level of knowledge/expertise of internists/ how in depth you can go with learning medicine.  I also like being challenged, so the prospective of writing two exams does not scare me though!!

[Synth1]

19 hours ago, MedZZZ said:

I am a PGY1 in FM and I am having second thoughts about my future job security and satisfaction. I am 6 months into residency and I am having second thoughts whether I should try to switch to IM or stick to FM. This is the following reasons:

1. I don't particularly enjoy all aspect of FM like OB, GYN, PEDS, etc. However, I have done a hospitalist rotation and I can see myself working as a hospitalist in the future so this is an option.

2. So many of my preceptors seem to be unhappy with their work-life balance and they all seem to be somehow regretting choosing FM and it is really discouraging to see unhappy staff in your profession as a new resident.

3. There has been recently many articles glorifying NPs as primary care providers which is frustrating to me. And also many articles written by Family Doctors which highlights the lack of compensation, paperwork/admin stuff. Reading/hearing about these issues really scare me that I would regret my choice in the future.

4. I enjoy the patient interaction and clinical medicine but I feel that FM as an outpatient does not provide much of clinical medicine.

On the other hand, IM has it's own set of challenges:

1.  FIVE years of TOUGH residency (I am already in my early 30s so I will be graduating in my very late 30s) and it can be tough to look for jobs while you have other commitments at that age.  **This is the number 1 reason giving me doubts.**

2. Two difficult royal college exam

3. Possibly difficult to find a job given the competition.

I know it is ultimately a final decision and even transferring is not guaranteed but I just wanted to ask people who are currently residents/staff/or where in the same boat if they have any insight. I would really appreciate it as I am having difficulty making a decision.

 

 

 

1. There are tons of options to create a niche practice if you decide to continue w/ FM and want to work as an outpatient. Yes, you need to do some gyne and peds if you provide full spectrum care but there are lots of other options, including hospitalist as you mentioned. 

2. FM gives you the most flexibility to create the life-work balance *you* want. Your preceptors could pretty easily change their situation if they are unhappy. Not so easy if you are working in a hospital and need to meet requirements for call etc. 

3. The NP thing isn't much of an issue yet, and there will always be work for FM doctors, even if things change a little over the years. 

4. This is where IM might be a better fit for you, but it needs to worth that extra training and opportunity cost. That is a question only you can answer, but it is THE question IMO. 

[LoquaciousLoquat]

I'm just going to add on a few points here. As a staff I can tell you that it's not that easy to create a niche practice. You have to have a unique skillset where 1 - There is a large enough patient load to support your practice, and 2 - Patients will want to see you and/or MDs will want to refer to you. If your preferred niche is only seeing adult patients for non-gyne / obstetrical issues, then you will be easily outcompeted by GIM... because GIM's entire residency is built around that particular patient population. This applies even if you want to do hospitalist medicine (i.e. GIMs will have far more job opportunities and are basically a "better" version of the FP hospitalist).

Also, the point about FM giving flexility to create a work-life balance you want... that's not always the case. If you want to work in a FHO, you need to work after-hours to provide urgent care / same-day access. Moreover, you will find it hard (if not impossible) to take long vacations (i.e. >1 week) because patients will start clamouring for appointments and forms / prescriptions will remain unfilled. This is not even mentioning all the time spent doing paperwork / forms / billing / finishing your notes / making referrals / chasing referrals / checking semi-important labs on your own time (because your administrative staff may "forget" to upload it in the chart), which is often unpaid. It's often said (and I would agree) that the family physician is basically a part-time medical secretary. Finally, you may never really have the economic freedom in FM to work part-time, because you won't generate enough billings to pay back your line of credit / mortgage / everything else in life. Most FPs I know would love to scale down their hours... but they simply can't afford to.

[carmsregrets]

7 minutes ago, brackenferns said:

 

Also, the point about FM giving flexility to create a work-life balance you want... that's not always the case. If you want to work in a FHO, you need to work after-hours to provide urgent care / same-day access. Moreover, you will find it hard (if not impossible) to take long vacations (i.e. >1 week) because patients will start clamouring for appointments and forms / prescriptions will remain unfilled. This is not even mentioning all the time spent doing paperwork / forms / billing / finishing your notes / making referrals / chasing referrals / checking semi-important labs on your own time (because your administrative staff may "forget" to upload it in the chart), which is often unpaid. It's often said (and I would agree) that the family physician is basically a part-time medical secretary. Finally, you may never really have the economic freedom in FM to work part-time, because you won't generate enough billings to pay back your line of credit / mortgage / everything else in life. Most FPs I know would love to scale down their hours... but they simply can't afford to.

 

FM often feels like you are a counsellor or a secretary than a medical doctor... Wish I knew that earlier.

[LoquaciousLoquat]

27 minutes ago, carmsregrets said:

 

FM often feels like you are a counsellor or a secretary than a medical doctor... Wish I knew that earlier.

Our healthcare system needs a steady stream of "providers" to do the unglamorous, secretarial, and increasingly difficult job of "primary care", which in practice is just filling in for the numerous gaps and inefficiencies of the system.

Specialists are more protected against these inefficiencies since their scope of work is more well-defined. (Oh how I wish I could say "that issue is for your family doctor")

I don't regret family medicine, in the sense that I'm still content to do what I do. But I probably would look into a different specialty if I had to do it over again.

[carmsregrets]

23 minutes ago, brackenferns said:

Our healthcare system needs a steady stream of "providers" to do the unglamorous, secretarial, and increasingly difficult job of "primary care", which in practice is just filling in for the numerous gaps and inefficiencies of the system.

Specialists are more protected against these inefficiencies since their scope of work is more well-defined. (Oh how I wish I could say "that issue is for your family doctor")

I don't regret family medicine, in the sense that I'm still content to do what I do. But I probably would look into a different specialty if I had to do it over again.

I have had regrets about backing up with FM since first month of residency - I don't wish to live my entire life with regrets though, and I am currently exploring doing another residency. I went into medicine to do medicine, not to work as a secretary.

Having said so, the biggest advantage of FM is that you can practice anywhere in the country, there are always jobs for you. That can't be said for other specialties.

 

[LoquaciousLoquat]

30 minutes ago, carmsregrets said:

 

Having said so, the biggest advantage of FM is that you can practice anywhere in the country, there are always jobs for you. That can't be said for other specialties.

Keep in mind that the higher job opportunities of FM is largely because of FM's status as a jack-of-all-trades "safety net" for our healthcare system. There are pros and cons to this.

Specialists have a harder time finding jobs (with some exceptions like GIM / neuro / psych), but their work is far more streamlined and well-defined than FMs. 

[gangliocytoma]

1 hour ago, carmsregrets said:

 

FM often feels like you are a counsellor or a secretary than a medical doctor... Wish I knew that earlier.

I'm having the same feelings you are. I'm hardly using my knowledge to solve actual medical problems when in clinic. 

[carmsregrets]

56 minutes ago, gangliocytoma said:

I'm having the same feelings you are. I'm hardly using my knowledge to solve actual medical problems when in clinic. 

50% of residents in my cohort feel that way. The older residents  with families are learning to be content w/ FM ( although they also feel devastated to have matched to it), and the younger ones are still trying to escape. You are not alone!

 

 

[1029384756md]

Best time to switch to IM is in PGY1 - apply and see what you get.

[medigeek]

7 hours ago, carmsregrets said:

 

FM often feels like you are a counsellor or a secretary than a medical doctor... Wish I knew that earlier.

 

5 hours ago, gangliocytoma said:

I'm having the same feelings you are. I'm hardly using my knowledge to solve actual medical problems when in clinic. 

 

What is stopping you from working up your more complex patients and managing them as much as possible? 

[1029384756md]

4 hours ago, medigeek said:

 

What is stopping you from working up your more complex patients and managing them as much as possible? 

 

1. It pays the same whether or not you work them up to specialist standards

2. Better outcomes for patients to be managed by specialists (imo debatable depending on which health outcomes you measure)

3. Spending too much time working up one patient takes your expertise away from multiple others who need it too - ain't fair

4. The more you play with stuff in specialists' realm, the more you risk making a bad decision. Not good for your own career or reputation.

Bottom line: don't do FM for the interesting and technically challenging medicine. FM is challenging in many other ways but not by depth of expertise, that's literally not what FM training is for.

A good FM is a good manager who knows how to allocate limited resources appropriately and involve the right people in the system with the least amount of BS in the way.

FM residents who are frustrated by the managerial nature of FM: wait till you plebs become attendings and start billing for those stupid forms, physicals, refills without visits, etc. The cash really helps to realign your expectations.

Also, stop thinking being satisfied = being technically knowledgeable and nothing else. Don't be one-dimensional. The most successful and influential people I work with developed their technical skills in addition to "soft" skills, finance skills, and maintaining mutually beneficial networks. If you want "success", knowing the 4th line Tx for relapsed myeloma by heart ain't gonna get you there.

[gangliocytoma]

8 hours ago, medigeek said:

 

 

What is stopping you from working up your more complex patients and managing them as much as possible? 

I don't seem to see many of those in my clinic. The ones that become complex tend to do so after a hospital admission for an acute problem and are discharged with a team of specialists following them. Otherwise the main patients I see are socially complex but medically not so much.

Also my staff tend to have a low threshold to refer. I wanted to start naltrexone and gabapentin to treat someone with severe AUD but my preceptor insisted we refer to the local addictions specialist (who btw has an 6 mo waiting list now). I did all my research and had a concrete plan in place with multiple papers supporting the protocol I was proposing. The rationale was "we need to have someone who knows what they're doing follow this patient".

[LoquaciousLoquat]

I agree with what everyone has said. 

Medical schools try to sell family medicine because: 1 - They want to advertise higher match rates, and 2 - They know the healthcare system desperately needs fam MDs (mostly as medical secretaries / managers).

In fact, if I had to go back in time and tell my med student self one thing: it would be to seriously explore all the specialties and gun for the one that you like. Don't just coast through med school with the idea that "I like everything so I will do family medicine". It's a bit of a rude awakening as a staff to realize that your role in the healthcare system is literally just to be a healthcare secretary / manager / jack-of-all-trades safety net (like what other people have said), and you'll never really become the medical expert that you've probably dreamt about as a med hopeful.

Anecdote time: so I was a non-traditional applicant and left another career to do medicine. I am also a bit older so the two year family medicine training appealed to me. While on vacation after matching to CaRMS, I met a senior couple, husband was a specialist and wife was non-medical (but pretty distinguished in her own field). When I told them I went to do fam MD, the wife was aghast and literally said: "what happened to you?!". The husband gave an uncomfortable smile but didn't say anything. It was pretty obvious he felt the same way but he didn't want to openly denigrate a colleague. It was as though they pitied me for being suckered into the field of family medicine. I didn't understand their reaction at that time, but I definitely see where they're coming from now after working as a staff.

[lovemedicinesomuch]

On 2/14/2022 at 7:38 AM, brackenferns said:

I agree with what everyone has said. 

Medical schools try to sell family medicine because: 1 - They want to advertise higher match rates, and 2 - They know the healthcare system desperately needs fam MDs (mostly as medical secretaries / managers).

In fact, if I had to go back in time and tell my med student self one thing: it would be to seriously explore all the specialties and gun for the one that you like. Don't just coast through med school with the idea that "I like everything so I will do family medicine". It's a bit of a rude awakening as a staff to realize that your role in the healthcare system is literally just to be a healthcare secretary / manager / jack-of-all-trades safety net (like what other people have said), and you'll never really become the medical expert that you've probably dreamt about as a med hopeful.

Anecdote time: so I was a non-traditional applicant and left another career to do medicine. I am also a bit older so the two year family medicine training appealed to me. While on vacation after matching to CaRMS, I met a senior couple, husband was a specialist and wife was non-medical (but pretty distinguished in her own field). When I told them I went to do fam MD, the wife was aghast and literally said: "what happened to you?!". The husband gave an uncomfortable smile but didn't say anything. It was pretty obvious he felt the same way but he didn't want to openly denigrate a colleague. It was as though they pitied me for being suckered into the field of family medicine. I didn't understand their reaction at that time, but I definitely see where they're coming from now after working as a staff.

 

.

[LoquaciousLoquat]

38 minutes ago, lovemedicinesomuch said:

Yes,  honestly being in FM feels like selling yourself short.  

You go into FM for the two year residency and to get your financial goals sorted out. I was able to do this so I'm content with my choice.

If FM was three years when I applied (which is what the CFPC wants to do - make FM three years), then I would've picked a different specialty (probably IM).

[JohnGrisham]

2 hours ago, brackenferns said:

In fact, if I had to go back in time and tell my med student self one thing: it would be to seriously explore all the specialties and gun for the one that you like. Don't just coast through med school with the idea that "I like everything so I will do family medicine". It's a bit of a rude awakening as a staff to realize that your role in the healthcare system is literally just to be a healthcare secretary / manager / jack-of-all-trades safety net (like what other people have said), and you'll never really become the medical expert that you've probably dreamt about as a med hopeful.

I sense there is an element of practice style and geographical difference that leads to this view.  Some of the smartest students in my graduating medical school class went into FM for various reasons(some the time, some earning potential, and most interest for broad scope), so while i agree some students coast...not everyone who goes into FM are by default slackers. (With how CARMS is, in fact i knew more "slackers" and bottom of the class students who ended up in competitive specialties. They could "turn on" for those few electives and match just fine, but they could barely tell you how other aspects of medicine function.) So If you practice referral-based medicine, then yes, you would feel like a secretary/manager. Its unfortunate that in some provinces, the renumeration pushes people to a style of practice that doesn't allow them the time to get into the depth of family medicine.  I'm amazed when i read posts in provincial FB groups, and people routinely refer out to IM/Psych/X specialist so quickly for basic work-ups and managements that a FM doc should be able to manage.  I dont begrudge them, because i gather they aren't remunerated well enough to spend the extra time managing this on their own...but really, its creating their own demise. Not to mention these are often colleagues(that i personally know and talk with regularly) that bill 300k+ but practice more superficial medicine..because of the fear that if they did more comprehensive medicine their income would drastically drop.  

I agree, unlikely to become a "medical expert" in one specific area, but there is a challenge to be had about being proficient in many different areas and having an often unlimited scope of practice to further expand if you are willing and interested. Lets not forget, there are more than enough specialists who see sub X of field Y, and often if you have to refer to them, its because of some silly health authority logistical reason. I.e. for Certain cardiac medications, I am MORE than comfortable starting the medication and managing after a bit of CME with my cardiology colleagues, but the gov't will only provide the patient coverage if its signed off by a specialist. Despite the specialists actively lobbying that its asinine.  Many cases of this - I have to refer to IM in some locum areas, because only THEY can get the patient set up for IV Iron, despite in other areas, my work-up, counselling and signature on the PPO is more than sufficient to get that sorted. 

Just some thoughts. A lot of family medicine is what you make it, if you feel like a secretary, examine what part the system plays in this outcome, and what part of your individual style plays into it etc. I agree, the system overwhelmingly in some jurisdiction is the main issue, but in some areas there is room for individual improvement and practice style change.

[LoquaciousLoquat]

38 minutes ago, JohnGrisham said:

I'm amazed when i read posts in provincial FB groups, and people routinely refer out to IM/Psych/X specialist so quickly for basic work-ups and managements that a FM doc should be able to manage.  I dont begrudge them, because i gather they aren't remunerated well enough to spend the extra time managing this on their own...but really, its creating their own demise. Not to mention these are often colleagues(that i personally know and talk with regularly) that bill 300k+ but practice more superficial medicine..because of the fear that if they did more comprehensive medicine their income would drastically drop.  

 

38 minutes ago, JohnGrisham said:

Just some thoughts. A lot of family medicine is what you make it, if you feel like a secretary, examine what part the system plays in this outcome, and what part of your individual style plays into it etc. I agree, the system overwhelmingly in some jurisdiction is the main issue, but in some areas there is room for individual improvement and practice style change.

I agree with your points. In fact, I'd largely blame the system for creating the primary care practice environment that exists today.

The main issues are that:

1 - Family medicine residents are not trained to operate at the level (or near level) of specialists in outpatient medicine. This is especially the case in more urban training settings where low-threshold referrals are the "standard of care". This obviously will create negative practice patterns once those residents become staff physicians.

2 - As an offshoot of point 1, the system (at least where I practice) does not properly incentivize / compensate family physicians who practice at / near the level of specialists. Sure, I can memorize the DM guidelines and be a master of diabetes.. but in practice, it's just way easier (and more lucrative + better use of your time)  to refer that non-compliant insulin-dependent diabetic to a Diabetes Clinic where they'll see an endocrinologist + diabetes education nurse instead. You can have the knowledge base and do the work of a specialist, but you'll never be compensated the same way (in fact, you'll lose money if you practiced like a specialist).

3 - A large amount of "being a secretary" is unavoidable. It's what happens when you are expected to be the first point of contact in the healthcare system AND to provide longitudinal, accessible care.

4 - Once you refer to a specialist, they will take over all other aspects of management within their domain of expertise. For example, cardiologists will be more than happy to manage their patient's blood pressure and dyslipidemia, even though you obviously can do the same as a family physician. This means even less opportunities for the role of an FP once your patients reach a certain level of complexity.

From my experience, the more "keen" med students / family medicine residents almost always want to go into a specialty, or in the case of family medicine, gun for the emergency medicine +1.  

 

 

[JTFW]

Staff here (hospitalist)

I agree with mostly what people said above. To be fair, everyone has different background/financial status/goals in life so choosing FM does not mean that you are selling yourself short (you might just pick something that's more in line with your career goal, whether lifestyle wise or financially). 

I suggest that if you don't like being a secretary/manager of your own clinic and stuff, hospitalist is not a bad option as most hospitalists are paid sessional and you do not need to worry about overhead/billings. 

[shikimate]

I said this before, and I will say it again, the "intellectual stimulation" made up fairy tail of specialist is wayyyy over rated. It's some utopia pushed on by zealous academics. I've seen too many academics invent something out of thin air just to have something to "research" on or talk at rounds.

Maybe you'll get a person here and there who really enjoy challenges all the time, but honestly it wears you down big time after a while.

I am more than happy to see easy cases day in day out, put in my codes and go home. 

heck even my community GIM friend says he loves it when ER docs to refer to him for high potassium lol.

[LoquaciousLoquat]

41 minutes ago, shikimate said:

said this before, and I will say it again, the "intellectual stimulation" made up fairy tail of specialist is wayyyy over rated. It's some utopia pushed on by zealous academics. I've seen too many academics invent something out of thin air just to have something to "research" on or talk at rounds.

Maybe you'll get a person here and there who really enjoy challenges all the time, but honestly it wears you down big time after a while.

I am more than happy to see easy cases day in day out, put in my codes and go home. 

heck even my community GIM friend says he loves it when ER docs to refer to him for high potassium lol.

Personally speaking, I feel the advantage of being a specialist is not in the "intellectual stimulation", but it's in having a far more predictable and well-defined scope of work. The system is built to specifically send you cases that you are familiar with and are good at managing (for the most part). Over time this reinforces your sense of competency and you'll become a better physician - since you'll be able to pick up on subtle variations of the same disease / or similar presentations.

Additionally, you are mostly insulated from the secretarial / managerial aspect of medicine, since you are not expected to function as a longitudinal primary care physician. (There are certain exceptions, like GIM dealing with hospital bureaucracy + disposition issues, but I wouldn't say it's worse than what the average FP would have to deal with bureaucratically) Basically, as a specialist, anything outside of your scope can de delegated / dismissed with a "that's for your family doctor to figure out".

Moreover, in practice, specialists will sometimes just flat out refuse a referral. I've referred patients with clear symptomatology mapping onto a body system / specialty, combined with a solid workup + list of potential differentials for the specialist to tease out. The reply? "This presentation is not within my scope. Please refer elsewhere." Or "I only see disease X, Y, Z; do not refer to me for anything else". Back to square one!

Finally, there is a growing trend amongst specialists to dump their scutwork to the family doctor. For example: a neurologist will "ask" the FP to book an EEG (or whatever complicated brain imaging protocol) rather than do it themselves. Or they will "defer" filling out certain forms (which are solidly within their domain of expertise) and bounce it back to the family doctor. 

So for specialists, it's not so much "intellectual stimulation" as it is having the privilege of a protected scope of work where they 1 - Get to be the undisputed experts, and 2 - Can freely delegate out work they deem to be outside their scope. Family physicians can do neither.

 

 

[JohnGrisham]

8 hours ago, brackenferns said:

4 - Once you refer to a specialist, they will take over all other aspects of management within their domain of expertise. For example, cardiologists will be more than happy to manage their patient's blood pressure and dyslipidemia, even though you obviously can do the same as a family physician. This means even less opportunities for the role of an FP once your patients reach a certain level of complexity.

Agreed with most of your other points. I had to chuckle a bit at 4, because in our centre "due to covid" alot of specialists have been lazy and only do telehealth(still) and havent been checking Bps weights etc or doing physicals, and using patient reported data, or assuming FM is probably doing it..
 

 

5 hours ago, brackenferns said:

Moreover, in practice, specialists will sometimes just flat out refuse a referral. I've referred patients with clear symptomatology mapping onto a body system / specialty, combined with a solid workup + list of potential differentials for the specialist to tease out. The reply? "This presentation is not within my scope. Please refer elsewhere." Or "I only see disease X, Y, Z; do not refer to me for anything else". Back to square one!

And another point: alot of specialists decide to just take very poor consults from FM, because they are easy, and they make good money - instead of refusing FM and saying "come on, this is easy and is in your scope...".    I know some of my FM colleagues who refer things, that they really really shouldn't, and it irrationally irks me. Don't get me wrong, I dont think I am special, i've just accepted im not going to be a high biller?  For me to bill an extra 100k or 150k, it would require seeing 50+ patients a day, and doing what i feel is poor medicine. 

 

5 hours ago, brackenferns said:

Finally, there is a growing trend amongst specialists to dump their scutwork to the family doctor. For example: a neurologist will "ask" the FP to book an EEG (or whatever complicated brain imaging protocol) rather than do it themselves. Or they will "defer" filling out certain forms (which are solidly within their domain of expertise) and bounce it back to the family doctor. 

This really bothers me, and I havent noticed it yet in my home base, but when i was briefly in ontario...it was happening quite frequently. Essentially told me the better renumeration in ON, doesn't come without consequences of being a dumping ground. I respectfully punted back to Neuro and Cardio in those specific scenarios, and told the patient to call the specialist daily until they reviewed and followed up.

And you can tell, I also have a big gripe against piss poor specialists who scam the system and dump "please refer back to me to see your patient for the same issue, so i can re-bill a consult". The only ones i do this for are my local ones, who really do take as much of the busy work and admin work off my plate, and always without fail see my patients urgently when i give them a clear reason to. That makes me a hypocrite, but I know they are actually doing work and not saying "sorry, i dont see patients with Red Eye, or general ophthalmology complaints, but please only send X pathology for me, so I can continue to bill 900k doing just that..and leave general work for the peasants". 

Luckily, i am in a mid-sized centre that I dont get stuck with a small selection of referral sources.