Having Second Thoughts about FM

[medigeek]

17 hours ago, 1029384756md said:

 

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

You can bring them back for more than 1 visit and a knowledgeable physician should know some complex workups off the top of their head and hence should know what to do efficiently. I'm not sure what you mean by specialist standards? Can you provide an example? A good diagnostic workup should either rule out possibilities in a step wise fashion or arrive at a diagnosis. 

17 hours ago, 1029384756md said:

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

Do you mean that family doctors shouldn't be prescribing super expensive niche biologics? I'd agree with that. Or do you mean I can't do a very thorough transaminitis or secondary hypertension workup or manage many of those conditions? There's also a difference between diagnosing a complex disorder vs managing it. 

17 hours ago, 1029384756md said:

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

Step wise fashion.

17 hours ago, 1029384756md said:

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.

Can you provide an example? And are you specifically talking about treatments for rare disorders? There are certain expensive medications family doctors can easily manage such as PSCK9 inhibitors or hepatitis C treatment. Some do HIV treatment or start methotrexate sometimes. I'd say those things are probably the limit as far as treatment goes. 

If you are referring to diagnostic testing, that's different. You can order any test if you can interpret it and it is useful for the patient. You actually have a good reputation with specialists when the patient arrives fully diagnosed each and every time and initiates treatment. If I diagnose GPA vasculitis or SLE or membranous nephropathy before they arrive to the specialist, that's saving a ton of time for the patient and improving their outcome by expediting treatment. 

17 hours ago, 1029384756md said:

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.

I disagree since I routinely work with complex patients and I know other family doctors who do so as well. But yes, there are many referologists out there too. 

17 hours ago, 1029384756md said:

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.

Just an FYI, NPs and PAs are defacto specialists in the US and take referrals from primary care doctors and work them up. I'm not sure how you're debating that a family doctor can't do it but NPs/PAs do so everyday in the US. Yes different country, but given almost identical styles of practice; it's a worthy point. 

[medigeek]

14 hours ago, gangliocytoma said:

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".

I have no comment if your preceptor is not comfortable managing AUD. Just keep in mind you can practice however you like once you're done. 

9 hours ago, JohnGrisham said:

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.

The thing with workups is that once you do it once or twice, you should sort of know how to do it in the future too. I use transaminitis as an example because it's somewhat common, but any reasonable doctor should know how to do a full in-depth workup for this and only refer when it's obviously time to biopsy or start treatment. Arguably, some things you could manage anyways on your way (ex. hemochromatosis).

With regards to the cardiac meds, any examples? I know PSCK9 inhibitors can be prescribed in most provinces by family doctors for example.

9 hours ago, brackenferns said:

 

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.  

 

 

It's reasonable to refer someone who is non compliant and needs a lot of resources and time. But a compliant diabetic on high dose insulin is still pretty easy territory for a family doctor. You literally don't need that much time for insulin titration visits. 

[medigeek]

5 hours ago, brackenferns said:

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.

 

 

In regards to the bolded, isn't it just easier to do it yourself? Seems like it would save time, at least in my experience. 

[frenchpress]

1 hour ago, medigeek said:

 

If you are referring to diagnostic testing, that's different. You can order any test if you can interpret it and it is useful for the patient. You actually have a good reputation with specialists when the patient arrives fully diagnosed each and every time and initiates treatment. If I diagnose GPA vasculitis or SLE or membranous nephropathy before they arrive to the specialist, that's saving a ton of time for the patient and improving their outcome by expediting treatment. 

I disagree since I routinely work with complex patients and I know other family doctors who do so as well. But yes, there are many referologists out there too. 

 

I agree with this. There’s no reason why you can’t work most stuff up as a family doctor. Sure, you might not necessarily be trained in the details of exactly how to do all of it in two years, but no one is. Specialists look stuff up all the time. I am happy to spend a few minutes some evenings on my couch looking into more complex presentations and figuring out a workup - I guess it’s true I am not being ‘paid’ for the reading I do after hours, but again, neither are the specialists. 

[medigeek]

3 minutes ago, frenchpress said:

I agree with this. There’s no reason why you can’t work most stuff up as a family doctor. Sure, you might not necessarily be trained in the details of exactly how to do all of it in two years, but no one is. Specialists look stuff up all the time. I am happy to spend a few minutes some evenings on my couch looking into more complex presentations and figuring out a workup - I guess it’s true I am not being ‘paid’ for the reading I do after hours, but again, neither are the specialists. 

Exactly. And over time, you learn how to pick up on the nuances of these trickier patients as well. So in the future, you should be able to do it in an expedited fashion. Hence I don't find that these patients take up any more time than other patients. 

I also find it odd and ironic that the medical education system makes us work so hard to get into medicine but then once actually practicing (including residency), the learning takes a back seat. I mean endless organic chem nonsense but now we don't want to learn how to work up nephrotic range proteinuria? 

[frenchpress]

10 minutes ago, medigeek said:

 

I also find it odd and ironic that the medical education system makes us work so hard to get into medicine but then once actually practicing (including residency), the learning takes a back seat. I mean endless organic chem nonsense but now we don't want to learn how to work up nephrotic range proteinuria? 

Exactly! Our medical education system really beats the desire to learn out of people. One of the things I really appreciate about family medicine residency is that the reasonable hours actually give me some space to learn. When I’ve been on call for 24 hours on an off-service doing endless consults where no one teaches me anything, I barely have the will to eat the next day let alone crack a book. At least when I am on family med blocks or back in clinic and get off at 3pm, or have a lunch break, I often actually feel like spending some of that time learning something. 

[medigeek]

28 minutes ago, frenchpress said:

Exactly! Our medical education system really beats the desire to learn out of people. One of the things I really appreciate about family medicine residency is that the reasonable hours actually give me some space to learn. When I’ve been on call for 24 hours on an off-service doing endless consults where no one teaches me anything, I barely have the will to eat the next day let alone crack a book. At least when I am on family med blocks or back in clinic and get off at 3pm, or have a lunch break, I often actually feel like spending some of that time learning something. 

Very true. 

I'm also not super convinced that the medical system can even support a role that primarily refers in the long term. I mean the whole point of being a doctor is to do the complex thinking. They can simply insert an NP and get the same results, if anything somewhat hard is being shipped elsewhere. Again, it's the whole point of so many years of schooling and training. 

[LoquaciousLoquat]

The difference between resident and staff practice is volume. 

Once you start as a staff, you will eventually (for most people anyway) carry a roster of over 1000 patients. The average seems to be around 1200-1500. You will also be expected to cover the practices of your colleagues when they are away / sick / etc.., and they will have similar volumes. 

At that point, how good you are as a family physician has less to do with the depth of your skills and knowledge, and more to do with providing timely access to care (i.e. being a competent medical coordinator / secretary / manager).

Yes, you can bring a complex patient back for multiple visits, but you'd be taking appointment slots away from your other patients. An otherwise healthy patient with a viral URI deserves the same timely access to care as a patient with multiple complex comorbidities. But while you can refer out your complex patients (and free up appointment slots for yourself), you can not do so for simpler medical problems, or secretarial tasks, or the first presentation of an undifferentiated complaint - all of which will eventually comprise the core part of your family medicine practice. Hence, that's why we talk about the system "incentivizing" you to practice a certain way.

To further illustrate this point, I can take 50 of the most complex patients in my practice, and literally fill up an entire week's worth of appointments for them by practicing at / near a specialist's level for all of their issues. So it's not that I'm unwilling or unable to practice in depth medicine. The issue, as you can imagine, is that were I to do so, the rest of my patients won't have any appointments for an entire week. In that case, they will either leave my practice, go to walk-in-clinics (increasing inefficiency), go to mid-levels (further justifying scope creep), suffer a complication (because you need to see undifferentiated symptoms in a timely manner), lose their social support (because I didn't fill out a form), complain about me and my clinic online or to the college (breaking down the therapeutic relationship), or they may decide to go to the emergency department for their issue (which is probably just as costly to the system as a "soft" referral to a specialist).

So how do I keep the ship afloat? By referring. As soon as I've narrowed down my patient's medical problem to a specific expertise of a specialist, and I've stabilized them well enough so that they can wait for an appointment, I will (often) delegate further management to a specialist. If I tried to play the specialist's role for all my patients, I would not be able to have timely access for anything else.

[fam_res]

3 hours ago, brackenferns said:

The difference between resident and staff practice is volume. 

Once you start as a staff, you will eventually (for most people anyway) carry a roster of over 1000 patients. The average seems to be around 1200-1500. You will also be expected to cover the practices of your colleagues when they are away / sick / etc.., and they will have similar volumes. 

At that point, how good you are as a family physician has less to do with the depth of your skills and knowledge, and more to do with providing timely access to care (i.e. being a competent medical coordinator / secretary / manager).

Yes, you can bring a complex patient back for multiple visits, but you'd be taking appointment slots away from your other patients. An otherwise healthy patient with a viral URI deserves the same timely access to care as a patient with multiple complex comorbidities. But while you can refer out your complex patients (and free up appointment slots for yourself), you can not do so for simpler medical problems, or secretarial tasks, or the first presentation of an undifferentiated complaint - all of which will eventually comprise the core part of your family medicine practice. Hence, that's why we talk about the system "incentivizing" you to practice a certain way.

To further illustrate this point, I can take 50 of the most complex patients in my practice, and literally fill up an entire week's worth of appointments for them by practicing at / near a specialist's level for all of their issues. So it's not that I'm unwilling or unable to practice in depth medicine. The issue, as you can imagine, is that were I to do so, the rest of my patients won't have any appointments for an entire week. In that case, they will either leave my practice, go to walk-in-clinics (increasing inefficiency), go to mid-levels (further justifying scope creep), suffer a complication (because you need to see undifferentiated symptoms in a timely manner), lose their social support (because I didn't fill out a form), complain about me and my clinic online or to the college (breaking down the therapeutic relationship), or they may decide to go to the emergency department for their issue (which is probably just as costly to the system as a "soft" referral to a specialist).

So how do I keep the ship afloat? By referring. As soon as I've narrowed down my patient's medical problem to a specific expertise of a specialist, and I've stabilized them well enough so that they can wait for an appointment, I will (often) delegate further management to a specialist. If I tried to play the specialist's role for all my patients, I would not be able to have timely access for anything else.

This. Specialist spots are usually 45min at least, plus the time you’re adding reviewing labs, reviewing imaging….in that time you can see 4 shorter less complex problems. You can either spend an hour doing disability applications, which specialists will never do for their patients, or use that time doing a work up that a specialist can do if you refer. Yes, it’s boring and you’re not learning as much but also it is what a family doctor does because there just is not another option. No one else is going to be doing forms, organizing home care for your geriatrics patients, calling moms to book immunizations, organizing mammograms, you can’t offload that work so you need to offload what you can - referrals. 
 

or you can prioritize what you find fun and interesting and give sub par care to the vast majority of patients in your care who are not needing work up of something undifferentiated and just need you to be their family doc.

[medigeek]

6 hours ago, brackenferns said:

The difference between resident and staff practice is volume. 

Once you start as a staff, you will eventually (for most people anyway) carry a roster of over 1000 patients. The average seems to be around 1200-1500. You will also be expected to cover the practices of your colleagues when they are away / sick / etc.., and they will have similar volumes. 

At that point, how good you are as a family physician has less to do with the depth of your skills and knowledge, and more to do with providing timely access to care (i.e. being a competent medical coordinator / secretary / manager).

Yes, you can bring a complex patient back for multiple visits, but you'd be taking appointment slots away from your other patients. An otherwise healthy patient with a viral URI deserves the same timely access to care as a patient with multiple complex comorbidities. But while you can refer out your complex patients (and free up appointment slots for yourself), you can not do so for simpler medical problems, or secretarial tasks, or the first presentation of an undifferentiated complaint - all of which will eventually comprise the core part of your family medicine practice. Hence, that's why we talk about the system "incentivizing" you to practice a certain way.

To further illustrate this point, I can take 50 of the most complex patients in my practice, and literally fill up an entire week's worth of appointments for them by practicing at / near a specialist's level for all of their issues. So it's not that I'm unwilling or unable to practice in depth medicine. The issue, as you can imagine, is that were I to do so, the rest of my patients won't have any appointments for an entire week. In that case, they will either leave my practice, go to walk-in-clinics (increasing inefficiency), go to mid-levels (further justifying scope creep), suffer a complication (because you need to see undifferentiated symptoms in a timely manner), lose their social support (because I didn't fill out a form), complain about me and my clinic online or to the college (breaking down the therapeutic relationship), or they may decide to go to the emergency department for their issue (which is probably just as costly to the system as a "soft" referral to a specialist).

So how do I keep the ship afloat? By referring. As soon as I've narrowed down my patient's medical problem to a specific expertise of a specialist, and I've stabilized them well enough so that they can wait for an appointment, I will (often) delegate further management to a specialist. If I tried to play the specialist's role for all my patients, I would not be able to have timely access for anything else.

And over time, government realizes you don't genuinely need years of extreme training to manage simple issues then diverts to midlevels like in USA. 

I can't imagine as a family doctor, not doing things like insulin titration or doing procedures in clinic or rheum workups and things like that. Do you seriously think you need a decade of school to take care of simple issues? And you have a point about "complex patients" depending on how you define complex. Do you mean patients with multiple advanced comorbidities? I mean those will likely have specialists following anyway. Or do you mean someone with 1-2 undifferentiated complaints who falls into one organ system eventually (but is tough to figure out) and needs workup/proper treatment initiation. The latter does not need referral if you are on the right track. Most workups, even when more advanced, have some degree of repetition and should be on "instant recall" anyway hence not be a big time sink. 

I have patients who are on very high amounts of insulin who I can titrate myself, if they are compliant. If they need a lot of resources, I may refer. But it doesn't take long for me to workup their nephrotic range proteinuria , rule out other causes and manage it. Again, once you start doing it then it goes into repetition mode. 

 

[medigeek]

2 hours ago, fam_res said:

This. Specialist spots are usually 45min at least, plus the time you’re adding reviewing labs, reviewing imaging….in that time you can see 4 shorter less complex problems. You can either spend an hour doing disability applications, which specialists will never do for their patients, or use that time doing a work up that a specialist can do if you refer. Yes, it’s boring and you’re not learning as much but also it is what a family doctor does because there just is not another option. No one else is going to be doing forms, organizing home care for your geriatrics patients, calling moms to book immunizations, organizing mammograms, you can’t offload that work so you need to offload what you can - referrals. 
 

or you can prioritize what you find fun and interesting and give sub par care to the vast majority of patients in your care who are not needing work up of something undifferentiated and just need you to be their family doc.

I don't see how the job you're describing requires that much education or training. A nurse can do those tasks easily, you don't even need an NP or PA. And a midlevel can handle virtually all common easy issues. They also refer a lot, lol.

The entire argument that is made in favor of doctors having exclusive access to medical practice is that it allows patients to get more knowledgeable care. Literally the argument made in legislatures is that a doctor can recognize less common or atypical presentations. And, another argument is that a doctor can manage multiple issues at once and hence save the system money. If you're just going to do what any fresh graduate NP can easily do, there's really no point in having a lot of training. 

 

[a1b1]

On 2/12/2022 at 4:05 PM, 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. Thats fine you dont have to do everything either. I dont do obs, never liked ER, never really liked hospital work, i mainly do clinic. This is the beauty of FM, you can pick to do exactly that which you want to do and wont be stuck to change if ever you decide to switch things up in the future.

2. Haha, maybe you just dont have the right perceptors :P. I guess this depends where you are doing your residency. Where i did mine everyone was loving their job/life.

3. I guess this might depend on your province. In quebec, family doctors seem to be the punching bag whenever they want to blame it on someone. People dont have enough access to doctors? family doctors are the one to blame!..... it is frustrating, but at the end of the day i just brush it off my shoulder and dont let it affect me. In terms of compensation... look you are not going to be making as much as a specialists, there is no hiding this, but most family doctors can make 300K minimum pretty easily (i feel) and live a very comfortable lifestyle without being overly busy. If you really want to make more you can also, you are free to choose how many days/week and how much vacation time you want. There are family doctors who make a lot more than the average too and can be competitive with a specialists salary if that is what you want. Basically the more you work, the more you earn. There is a lot of paperwork and admin, but its part of your everyday, eventually you will be able to incorporate this in your day to day well enough so it doesent stack up too much, it takes maybe 1-2 years of practice before you get there.

4. Not sure what you mean by clinical medecine? It is medecine, you have people come to you with problem X, you evaluate it with an appropriate history and physical, build a ddx, send for tests, treat however need be and refer PRN (this is medecine).

5. I have grouped up all your other questions into this section. You could switch for somewhere else, but the grass may not be greener on the other side. I was in a similar boat as well, i started my FM residency early 30s. Going into a speciality you are looking at a minimum of 5-7 years, those 5-7 years are not going to be easy by any means. Friend of mine is doing a residency in cardiologie, he's basically on call every other night for the past 5 years.... not sure I would want that lifestyle, regardless of the reward at the end of the tunnel. 

I may have a differing opinion then most peoples here, but i believe all jobs "suck", no job is "fun", you go to work to work. You do your duties and responsabilities, come home, rinse and repeat. The important thing here is that you want a job that when you are working it is somewhat enjoyable and the day flies by fast, and i do feel with FM i am getting that. Hearing people's stories, being a part of their lives, helping them during their good times and bad times is what family medecine is about.

 

hope this helps

[LoquaciousLoquat]

5 hours ago, medigeek said:

I can't imagine as a family doctor, not doing things like insulin titration or doing procedures in clinic or rheum workups and things like that. Do you seriously think you need a decade of school to take care of simple issues? And you have a point about "complex patients" depending on how you define complex. Do you mean patients with multiple advanced comorbidities? I mean those will likely have specialists following anyway. Or do you mean someone with 1-2 undifferentiated complaints who falls into one organ system eventually (but is tough to figure out) and needs workup/proper treatment initiation. The latter does not need referral if you are on the right track. Most workups, even when more advanced, have some degree of repetition and should be on "instant recall" anyway hence not be a big time sink. 

Of course I will titrate insulin or do an autoimmune / rheumatological workup. My point is that as a family physician, your value to the healthcare system is more in your accessibility and ability to handle issues specialists cannot (or would not) do: such as doing secretarial work, managing simple medical cases, seeing undifferentiated cases for the first time, and just generally be available to your patients such that they can see you without an inordinate delay.

If a specialist is too busy, they can simply stop accepting referrals ("sorry, wait times are too long, please refer elsewhere", or "I don't manage this issue, refer elsewhere"). You cannot do that as a family physician. In a sense, the family physician is always accepting "referrals" from all the rostered patients. So imagine over 1000 people who have no medical knowledge, or in some cases, mislead by fake medical knowledge, and each and every one of them have the legal power to hold you accountable and answerable to all of their whims, questions, and concerns. That's the reality of family medicine once you become a full-fledged staff. In such a reality, medical knowledge alone won't take you very far - it's more about accessibility, managing expectations, and knowing how to offload your work (i.e. with referrals).

In contrast, specialists can grow their careers and professional reputation via medical knowledge, because their referrals don't come from a largely uninformed public, it comes from other physicians. They will never be held directly accountable to the whims of the public in the same way that family physicians are.

Finally, I will reiterate this point again, most family physicians don't refer out of a lack of knowledge. We refer because we literally do not have the bandwidth to bring a patient back for multiple visits. Many times when I referred, I already knew exactly what the specialist was going to do. I'm enlisting specialists so they can help offload my work by providing longitudinal followup for a particular disease for which they were trained.

[medigeek]

1 minute ago, brackenferns said:

 

Of course I will titrate insulin or do an autoimmune / rheumatological workup. My point is that as a family physician, your value to the healthcare system is more in your accessibility and ability to handle issues specialists cannot (or would not) do: such as doing secretarial work, managing simple medical cases, seeing undifferentiated cases for the first time, and just generally be available to your patients such that they can see you without an inordinate delay.

If a specialist is too busy, they can simply stop accepting referrals ("sorry, wait times are too long, please refer elsewhere", or "I don't manage this issue, refer elsewhere"). You cannot do that as a family physician. In a sense, the family physician is always accepting "referrals" from all the rostered patients. So imagine over 1000 people who have no medical knowledge, or in some cases, mislead by fake medical knowledge, and each and every one of them have the legal power to hold you accountable and answerable to all of their whims, questions, and concerns. That's the reality of family medicine once you become a full-fledged staff. In such a reality, medical knowledge won't take you very far - it's all about accessibility, managing expectations, and knowing how to offload your work (i.e. with referrals).

In contrast, specialists can grow their careers and professional reputation via medical knowledge, because their referrals don't come from a largely uninformed public, it comes from other physicians. They will never be directly accountable to the whims of the public in the same way that family physicians are.

Finally, I will reiterate this point again, most family physicians don't refer out of a lack of knowledge. We refer because we literally do not have the bandwidth to bring a patient back for multiple visits. Many times when I referred, I already knew exactly what the specialist was going to do. I'm enlisting specialists so they can help offload my work by providing longitudinal followup for a particular disease for which they were trained.

I see what you're saying. Although to your initial point, I know plenty of family doctors who don't touch insulin and never order any form of antibody testing lol. Do you have examples of things you refer out? 

I guess my experience has been that complex patients or tricky patients are always going to be a smaller minority. And simple cases are by definition going to be very quick and easy. So unless one is doing a lot of small talk with patients, there shouldn't be a huge time sink in seeing the common quick stuff anyway. 

[JohnGrisham]

1 hour ago, brackenferns said:

d each and every one of them have the legal power to hold you accountable and answerable to all of their whims, questions, and concerns. That's the reality of family medicine once you become a full-fledged staff.

 

I'll disagree with this   I think many of our colleagues, simply need more cmpa talks and a bit more in the way of boundary setting CMEs.   Unfortunately a lot of family physicians fear the College(for good reason!) but that gets pushed too far where they overly entertain many patients riff-raff. Setting bounderies doesn't mean you need to be rudely dismissive either, it means setting clear expectations, maintaining professional boundaries, and having clear consequences to inappropriate behaviour or overly needy patients(i.e. sorry, you do not get online booking priveleges anymore, but i will book you more frequently so we have more check-ins but if you spend your time rambling about how xyz is going on, well you unfortunately used up your time for this visit).



 

[JohnGrisham]

59 minutes ago, brackenferns said:

If a specialist is too busy, they can simply stop accepting referrals

A part of why they are so busy is many these days is too many referrals from FM docs who should be able to manage more. Theres endos(i.e a good friend of mine) in my centre who are mostly full with bread and butter diabetes with insulin titrations, and have RNs doing most of the work and they sign off.  Yet will keep asking for q6month re-referrals for re-consult fees. Its a waste of money to the system, and 70% of their patient panel is more than appropriate for FM. Split the difference in cost, pay the FM double their base, and they are happy, system is happy saved money. But now specialist is not, because they lost their dead easy niche billing machine.  
 

[medigeek]

3 minutes ago, JohnGrisham said:

I'll disagree with this   I think many of our colleagues, simply need more cmpa talks and a bit more in the way of boundary setting CMEs.   Unfortunately a lot of family physicians fear the College(for good reason!) but that gets pushed too far where they overly entertain many patients riff-raff. Setting bounderies doesn't mean you need to be rudely dismissive either, it means setting clear expectations, maintaining professional boundaries, and having clear consequences to inappropriate behaviour or overly needy patients(i.e. sorry, you do not get online booking priveleges anymore, but i will book you more frequently so we have more check-ins but if you spend your time rambling about how xyz is going on, well you unfortunately used up your time for this visit).



 

quoted the wrong person lol

[JohnGrisham]

1 hour ago, brackenferns said:

Finally, I will reiterate this point again, most family physicians don't refer out of a lack of knowledge. We refer because we literally do not have the bandwidth to bring a patient back for multiple visits.

But this is mostly brought on by different payment models.

If you're fee for service, the simple solution is to have a smaller patient panel, and bring these patients back for multiple visits. I see this all the time. But thats also a waste from the patient side? because they have to come in for so many repeat visits(with telehealth this burden has decreased alot.)

Now if youre FHO/salaried, then you are incentivizes to farm out the busy work to a specialist - because the goal is to decrease our work flow burden per patient. 

The system is a mess, with many competing interests.

[Wachaa]

All are good points raised by all. In reality I think there are too many issues with the referral system.

There are rheumatologists in the urban cities who will not start treatments for common rheumatological conditions (such as osteoarthritis) or internists who do not see thyroid conditions. Or gastroenterologists who do not see abdominal pain ("OH, I see the patient already had a CT and a scope. Please refer to someone else.")

Many dermatologists will refer to other dermatologists for genital lesions or hair loss.

Many ophthalmologists will refer to their glaucoma colleagues to measure intraocular pressure.

So I don't feel so bad when I refer off proteinuria workups because MSP gets on my case for ordering too many lab tests myself.

[medigeek]

1 minute ago, Wachaa said:

All are good points raised by all. In reality I think there are too many issues with the referral system.

There are rheumatologists in the urban cities who will not start treatments for common rheumatological conditions (such as osteoarthritis) or internists who do not see thyroid conditions. Or gastroenterologists who do not see abdominal pain. 

Many dermatologists will refer to other dermatologists for genital lesions or hair loss.

Many ophthalmologists will refer to their glaucoma colleagues to measure intraocular pressure.

So I don't feel so bad when I refer off proteinuria workups because MSP gets on my case for ordering too many lab tests myself.

Can you explain?

[gogogo]

1 hour ago, brackenferns said:

So imagine over 1000 people who have no medical knowledge, or in some cases, mislead by fake medical knowledge, and each and every one of them have the legal power to hold you accountable and answerable to all of their whims, questions, and concerns. That's the reality of family medicine once you become a full-fledged staff. 

In contrast, specialists can grow their careers and professional reputation via medical knowledge, because their referrals don't come from a largely uninformed public, it comes from other physicians. They will never be held directly accountable to the whims of the public in the same way that family physicians are.

Really informative discussion overall. As for this point, doesn't the fact that specialists have higher insurance premiums suggest that they carry more liability? Moreover, in my limited experience during clerkship, I did not see a difference in how patients treated family physicians vs. specialists. I remember an OB saying she still fears being sued during every delivery after decades in practice. I remember one patient on general surgery who gave the staff and residents a headache because she insisted on very outlandish treatments for her gallstones and would ask half-knowledgable questions constantly. Had another on IM who adamantly refused the obvious next line in treatment on a daily basis with no reason offered; he only acquiesced after we begged him for a week (and after we had psych, geriatrics, social work, and palliative see him). Inpatient psych is a load of drama every day with an added bonus of possibly being assaulted at any time (same goes with EM). My inpatient psych preceptor had a patient come to his outpatient clinic to kill him (police intercepted in time). Dermatology probably deals with anxious and demanding patients on a daily basis as well. And the list goes on. 

My impression is that dealing with the public just sucks. I would assume that with time and boundary-setting, like JohnGrisham said, as well as just carrying yourself with the respect and professionalism you deserve as a family physician, should solve most of this. But I'm only just finishing clerkship, so maybe I'm wrong.

53 minutes ago, JohnGrisham said:

A part of why they are so busy is many these days is too many referrals from FM docs who should be able to manage more. Theres endos(i.e a good friend of mine) in my centre who are mostly full with bread and butter diabetes with insulin titrations, and have RNs doing most of the work and they sign off.  Yet will keep asking for q6month re-referrals for re-consult fees. Its a waste of money to the system, and 70% of their patient panel is more than appropriate for FM. Split the difference in cost, pay the FM double their base, and they are happy, system is happy saved money. But now specialist is not, because they lost their dead easy niche billing machine.  
 

How cynical. Is there anyway to prevent or avoid this?

[Wachaa]

19 minutes ago, gogogo said:

How cynical. Is there anyway to prevent or avoid this?

 

Yes, because often they are technically wrong to be billing for a full consultation. They should bill the lesser fee code for follow up visit, at least in BC.

 

Read relevant sections: R2, R9, and C11

https://www.doctorsofbc.ca/managing-your-practice/practice-supports/consultations-referrals-and-re-referrals

 

[bearded frog]

44 minutes ago, Wachaa said:

 

Yes, because often they are technically wrong to be billing for a full consultation. They should bill the lesser fee code for follow up visit, at least in BC.

 

Read relevant sections: R2, R9, and C11

https://www.doctorsofbc.ca/managing-your-practice/practice-supports/consultations-referrals-and-re-referrals

 

I agree with you that specialists should not game the system, but you're incorrect about what you're citing. The sections you refer to specify that if a specialist sees a patient more than six months from a previous visit, that may or may not be unreasonable, and based on your clinical opinion, you can either refuse to refer, or re-refer. They further say it may be reasonable for you to re-refer without seeing the patient yourself, and hence there is a code for a "no-charge referral".

R2 says that while a new referral is not required if the specialist is content to treat it as a follow-up, but if its been more than 6 months and the specialist requests a new referral, then you can re-refer without seeing the patient as the PCP. R9 says that there is a delay in patient care as the specialist requests a referral every 6 months, the solution specified is that the PCP can re-refer as per the specialist's request without having to see the patient in clinic, and therefore removing the delay. C11 says that to bill for a new consult, it must be more than 6 months since the patient was last seen, and the specialist must have a new referral. The specialist cannot schedule a future visit in 7 months and then bill a new consult, they must either bill it as a follow up, OR request a new consult from the PCP, which leaves it up to the PCP to decide if this is reasonable.

See C10 which explicitly says q7m referrals are valid. Also C14:

Quote

For most consulting practices, once the patient has been discharged from care and more than 6 months have elapsed since the last service was provided to that patient, any resumption of the consultant/patient relationship will usually require a new referral.

 

[Wachaa]

1 hour ago, bearded frog said:

I agree with you that specialists should not game the system, but you're incorrect about what you're citing. The sections you refer to specify that if a specialist sees a patient more than six months from a previous visit, that may or may not be unreasonable, and based on your clinical opinion, you can either refuse to refer, or re-refer. They further say it may be reasonable for you to re-refer without seeing the patient yourself, and hence there is a code for a "no-charge referral".

R2 says that while a new referral is not required if the specialist is content to treat it as a follow-up, but if its been more than 6 months and the specialist requests a new referral, then you can re-refer without seeing the patient as the PCP. R9 says that there is a delay in patient care as the specialist requests a referral every 6 months, the solution specified is that the PCP can re-refer as per the specialist's request without having to see the patient in clinic, and therefore removing the delay. C11 says that to bill for a new consult, it must be more than 6 months since the patient was last seen, and the specialist must have a new referral. The specialist cannot schedule a future visit in 7 months and then bill a new consult, they must either bill it as a follow up, OR request a new consult from the PCP, which leaves it up to the PCP to decide if this is reasonable.

See C10 which explicitly says q7m referrals are valid. Also C14:

 

I see what you're saying, whereas gogogo/ I were talking about the ones where consultants are asking for re-referrals for follow ups because they are booking past 6 months on purpose.

For example, an endocrinologist starts insulin. The patient leaves the 1st appointment with a note saying to get a re-referral from their GP before the 2nd appointment in 7 months time. Or the patient gets a phone call from the specialist's secretary 7 months later asking to book a follow up and to get a re-referral from their GP before the appointment. Or ophtho, where over the course of the year he/ she is seeing the patient every 3 months for exam, OCT, etc. They usually call the patient to book a follow up, and to get a re-referral letter or 03333 before the appointment to review the results of those tests because time passed since the initial referral. The consultant-patient relationships are not considered as ended in these cases. I think the linked FAQ document helps clarify these practices.

I don't bill anything for re-referrals, whether I see the patient or not. But the consultants we are talking about would cancel the patient's follow up visit if a new referral is not received. Only very few specialists are seeing the patients for follow ups without requesting a re-referral letter.

[Wachaa]

For my own workflow/ billings it has minimal impact. It just makes it even harder for patients without a GP, that’s my main concern.