What kind of options are available after a FP residency?

[Guest moo]

Is there a list somewhere that will list the types of options you can do after a FP residency in Canada (other than going straight into practice)? My friend here in the US was pretty surprised at the number of options available after FP training in Canada. I told him it's because in Canada the FP is akin to the internist in the US except that the FP can do a lot more, even though the training is shorter.

[Guest UWOMED2005]

The one year extra training programs I know of include:

 

CCFP - Emergency Medicine

CCFP - Anaesthesia

CCFP - Sports Medicine

CCFP - Geriatric care

CCFP - Palliative Care

CCFP - OB/Gyn (rumoured)

CCFP - Peds (rumoured)

 

In addition to the above programs, I know CCFP trained docs (without a 3rd year) who a) work rural emerg departments run the inpatient floor at the LRCC c) do dermatology clinics at the LRCC d) assist on operations in cardiac surgery at South Street in here in London and help run the inpatients e) supplement the psychiatry staff at Regional Mental Health London f) run methadone clinics for heroin addicts.

 

You are NOT limited to a family practice by doing a CCFP training program.

 

I'm currently taking a long serious look at one of these options. Simply put, I can't see myself focussing on one minute area of medicine for the next 35 years. There seems to be a lot more flexibility in doing a CCFP program plus one of the extra years.

 

I know the CCFP-emerg and CCFP-anaesthesia programs involve a significant amount of time in the ICU and CCU as well as anaesthesia and/or emerg.

 

Of interest I talked to an Anaesthesia 3rd year resident who made the excellent point that as you can still work emerg (many rural emerg docs and a limited number of urban emerg are CCFP only) AND you get the extra Anaesthesia qualifications, plus get to assist on some procedures. At least, I've been looking at the Emerg program and I find that perspective interesting. . .

[Guest Ian Wong]

Great post! These aren't really formalized fellowships post-residency (which is what I think you were mainly looking for), but some more options include:

 

- Locums, Medical Clinic management

- International Health/Outreach work

- Surgical first assistant

- Biotech/pharmaceutical/medical insurance consultant

- Hospitalist

- Addiction Medicine/Methadone/Rehabilitation

- Disability/Physcial Rehabilitation/Worker's Comp

 

Some FP's are even starting to add Botox into their practice for patients with facial wrinkles, to try to cash in on some of those lucrative out-of-pocket procedures.

 

Ian

[Guest UWOMED2005]

Yeah, I have heard of FPs doing botox and other cosmetic procedures to cash in on North America's image conciousness.

 

I also wanted to add I recently learned New Zealand and Australia have both greatly decreased their visa/licensing requirements for Canadian docs - meaning you can do locums in Australia with little red tape. That's something I've been thinking about doing. . .

 

With all these non-family medicine options with a CCFP, it really makes the fact so few med students are choosing family medicine much scarier, doesn't it? I mean, everybody was concerned to find out only 24% of med students from the graduating class of 2003 matched to family medicine in the first round. . . but nobody brought up the fact only a fraction of that 24% will practice actual family medicine!

[Guest moo]

This is interesting. I would like to specialize but I would also like to have some broad exposure to medicine. I can't see myself focusing on doing only one thing without having been exposed to the real nitty gritty parts of medicine (for example, rad onc or derm). In some ways, I guess the FP residency is like a longer internship of sorts.

[Guest driedcaribou]

Can someone in a different field take CCFP's as well?

 

Or can only FP docs do so?

 

I would really like a lot of variety in a job but specializing in something still appeals to me.

[Guest UWOMED2005]

The CCFP IS the family physician training program.

 

As a specialist, I guess you could go back and retrain in a family medicine residency program.

 

The unfortunate thing is that, in the olden days (pre 1993) when everyone did a rotating internship to get their GP accreditation, after which they could then choose to specialize, all specialists were by definition trained and qualified to do general (ie family) practice. This is still true - you can still find ex-general surgeons who burnt out and now work walk in clinics or start family practices. But I believe you won't find this to be true of those MDs graduating after 1993 - once they're in their career, they're locked in.

[Guest dakar]

I hear conflicting reports on this.

 

Some FRCP ER docs (for example) have said "Sure, you can open your own practice after, you just get an independent practice license, and hey, you bill at FRCP rates so it's worth it...", others say the same thing as you.

 

I know a couple of internists in Toronto that run general/family practice offices and do very little classical "internal medicine".

 

I don't know the answer to this, but I wonder how "locked-in" you really are after sub-specializing. Perhaps ER and Internal are bad examples because they're so general to begin with, but those are the only ones I know about.

 

Anyone know? UBC seems to specify that you can apply for a general practice license after two years of an FRCP residency as well.

[Guest cheech10]

You can't bill at FRCP rates unless doing a consult (or following one up) which needs a referral letter from an FP, but I don't know if you'd be able to have your own family med practice anyways.

[Guest Ian Wong]

The thing is, if you did a rotating internship (ie. your PGY-1 was done before 1993), you had the ability to apply for a GP license, and then after getting your FRCPC/FRCSC in your specialty, you'd also be boarded in that as well. So, you could do whichever one you wanted.

 

BC has a little quirk in that several residencies here have essentially a rotating internship year built into them (ie. Ophtho, Derm, Radiology, etc), where they rotate through Psych, Ob/GYN, Medicine, Surgery, Peds, and upon finishing their PGY-2 year, they've actually completed the requirements for the CFPC, or something to that extent. They can sit the CFPC exam, and if successful, are licensed to do Family Medicine in BC only, and can therefore moonlight, locum, run walk-in clinics, or anything else even while they are enrolled in their residency program.

 

Ironically enough, people from hardcore residency programs like General Surgery aren't able to challenge this exam, because their PGY-1 isn't a rotating year (they don't get Psych, or Obs, or other stuff), and therefore, the General Surgery residents can't get this license, yet the Dermies, Ophtho guys, and Radiologists can. Weird stuff.

 

As a result, your statement about "UBC seems to specify that you can apply for a general practice license after two years of an FRCP residency as well." is only true for selected specialties that still do a very general, rotating internship-like PGY-1 year.

 

I do not think that someone trained after 1993 as say a Neurosurgeon (where no rotor year is done), can just drop down and open up a full-service walk-in clinic. I don't have anything to back up this statement, but that's what I suspect. Otherwise, why even bother having a Family Medicine residency, and a Family Medicine board exam, if any ol' ex-specialist doctor could practice Family Med without doing either the residency or passing the exam.

 

Ian

[Guest UWOMED2005]

You can't bill at FRCP rates

 

True for most specialties. Thing is most emerg departments are moving to an Alternate Payment Plan salary structure, and under this most CCFP emerg docs make the same as FRCPC emerg docs.

 

The only trick is getting yourself hired.

[Guest Tomclock]

Hey all,

 

I'm doing some personal research into family medicine (especially rural) and I noticed this thread.

 

We get such little exposure to family med and family docs that it's really hard to make a life long decision to do it. I know we get some time in clerkship, but I've had landscaping jobs that have lasted longer than six weeks. We can do electives, but now that we have such competition for specialties and no rotating internship after medicine, we pretty much have to guess what we are going to like and book our electives near the beginning of third year to edge out competition. I want to spend four months or so doing something hard core before I decide to devote my life to it. That doesn't seem like an unreasonable thing to request to me.

 

It's very frustrating. But the question is do you rank family come CaRMS time or are you better to go unmatched and reapply the next year both to Canada and the States (which is full of problems from high USMLE scores to not being able to come back to Canada) for whatever you think you want? Things are going to be really competitive in Ontario due to increases in class size and I like family so I'm thinking about ranking it, preferably in a rural area.

 

My question is this: let's say a year goes by of your family residency and you decide you don't want to do family forever. I know that you can do third year training and specialize (probably having to stay in rural areas) and I also know that the various administrations are making it impossible to reapply into the first iteration of the match (where everything but family will soon be gone). But could we take the two years of experience in family medicine and use as a basis to apply into the first iteration of the American match?

 

That way there are still options if you decide you don't like family and you could always come back to Canada to practice family if you ever wanted to. The two years of training would not be waisted learning everything (or maybe 60% of everything) that a primary care specialist needs to know.

 

That's my question. I hope someone can help. Thanks. And good luck to all the brain surgery residents... losing our licensing in the states for residents from places with the brain surgery history of Toronto, McGill and Western is an international embarrassment.

 

[Guest Ian Wong]

If you do Family as a backup, as you correctly mentioned, once you start your residency training, you are forever barred from the first round of the CaRMS match. You can try to switch into a different specialty, although this can be problematic due to funding issues (your funding may stay with the Family Medicine residency, so they can use it to attract a replacement resident, or even if the funding goes with you, as is the case in Alberta or Ontario, there aren't any other residencies you could enter that only require two years of funding).

 

Because of this, you'd need to find alternate funding, which might come in the form of a return-of-service committment, where a rural town puts up the money to train you in return for you committing to practice in that town for a contractually-determined number of years, or perhaps via the military or some other external organization.

 

You could match into Family, and immediately try applying to the US, while doing your Family Med residency. The difficulty is that you will have to schedule your interviews around your residency schedule, and this can be extremely draining, if not logistically impossible. You could also complete your Family Medicine training and then apply to the US, but that means that you will be a perpetual resident (ie. 2 years Canadian Family Med + 5 years US specialty +/- 1 or 2 years fellowship = one heck of a long time to be an indentured servant...).

 

You really need to see if you'd enjoy doing Family Medicine as a career. If you are vehemently dislike it, or can't see yourself doing anything other than your #1 choice in specialty, then I think it's a better idea to go unmatched. Going unmatched allows you to reapply the next year in the first round of CaRMS, and gives you that year to improve your application via research, grad degree, etc. or to apply to CaRMS and the US with ample free time to do all your interviews.

 

It's really not that different than not getting into med school on the first attempt, and in the span of a 25 year medical career, it might be better to spend 1 year research + 24 years in your chosen specialty rather than doing all 25 years in a backup career you don't enjoy as much.

 

If you were unlucky enough to go unmatched for a second consecutive year after the first round, there will most assuredly be a number of Family Medicine spots in the second round from which to choose.

 

As far as neurosurg graduates in Canada not being allowed to sit for the US neurosurg board exam, this is similarly true for ENT, and I believe the direct Cardiac surgery residency as well. A lot of this is political, and has nothing to do with the quality of Canadian residency graduates, which is very often significantly higher than a corresponding US residency graduate. Rather, it's a political attempt to limit the supply of those particular specialties in the US, as a means of keeping average reimbursements per practitioner higher.

 

We do something similar by not allowing certain US specialties to sit for Canadian Royal College exams because the residency training periods are different between the two countries.

 

Ian

[Guest Tomclock]

Thanks Ian,

 

I think once you match to family that's pretty much the medical training you have. Governments don't want anyone to leave simply because of the shortage. Combine this with the fact that interest in family is declining and the students:specialty spot ratio is getting worse, I'd say we're all in for a lot of fun during the next couple of matches. All the more reason to nail that USMLE now, provided of course that you can get a VISA if you match (Can't see Dalton McGuinty <sp?> being a big fan of that). The complexities of this came up in another thread and you gave a very helpful reply. Thanks.

 

I just wish governments would prioritize family medicine and not try to heap a generation of mismanagement on med students.

 

As for being a resident for such a long time, I totally agree. But this is our life. It's no worse than doing another year of undergrad, a tough masters, or what-have-you. Some of the best docs I know didn't get their first job till they were 40 (they did PhDs and so forth).

 

I don't mean to sound to wacky, but could you do your family, then do a year or two long masters (like epidemiology), then match to the States? If you did internal then allergy or something, you'd still only be like 33-34 when you were done (assuming you graduate at about 25-26 or so). That's young in doctorland. Plus you'd be paid.

 

I know that the surgical specialist red tape is not due to lack of quality in our students: I just feel so terrible about such hard working people getting screwed. People get into neurosurgery knowing they are going to work insane hours for less income than many other specialists to look after really sick people. Then they get screwed over for it. Terrible. You shouldn't spend 120 hours a week cutting epilepsy out of infant's heads or tumours out of spines, what you really want to do is zap cataracts or do barium scans. That's what's worth the big money in our system... bizarre...

 

I was not aware however that the problem extended into CVS surgery and ENT.

 

One thing that's concerned me for a while is that I expect people to do exactly what you suggest and not rank family as a backup. Then nationally we're going to start to see a 20% unmatched rate and they'll apply into the next year's round. We won't stay one to one for long. But then again if we don't have family docs, the whole system is in deep trouble.

 

Bottom line... let's all do family and solve this shortage! :)

[Guest Ian Wong]

The thing is that action doesn't get taken until crisis levels are present. Family med applicant numbers have been consistently decreasing each year for this last decade, yet little is being done by the government and health care administrators to make Family Medicine a more popular choice for graduating medical students.

 

Also, if the competition for specialty spots gets that backed up by people from previous med classes, people will be less likely to risk going unmatched (by applying with no backup), because their chances of matching the following year will be slim.

 

So, the system should self-correct itself, to an extent. The trouble is then that you've got a bunch of Family Medicine physicians who actually wanted to be Ophthalmologists, Plastic Surgeons, Urologists, etc and this may have negative implications for their future job satisfaction and practive longevity.

 

Ian

[Guest Tomclock]

Thanks Ian,

 

This thread has really helped me at least get good data on the process.

 

From what I gather there are options. I bet you could even do family in the States and then transfer out if you didn't like it and go into internal or something.

 

I almost wish I had taken my very good resume and MCAT and just applied to a good American school right from the get go. I bet lots of good students will be heading south before casting their lot in the Canadian system.

 

You could apply for both the Canadian and American matches after going unmatched a year. It would give you time to really nail the USMLE and do all your interviews. But if the American match happens later, you couldn't rank family in Canada because you would match to it and get knocked out of the American system anyways. You'd have to make family medicine in the States your final back-up. Wouldn't that be kind of ironic.

 

They may change the match dates though. That is being discussed.

 

Thanks again,

 

If I lean anything more of interest I'll post...

 

Tom

[Guest Ian Wong]

Are you a Canadian med student, and if so, what year? Chances are very good that for the forseable future, the CaRMS match will come ahead of the US NRMP match. This has always been the case, and this year has been the only year in the history of CaRMS where the US NRMP match came ahead of the CaRMS match. The CaRMS 2004 match was delayed due to last year's SARS epidemic, which screwed up scheduled electives for many senior Canadian medical students. As a result, it was decided to give them extra elective time by delaying the CaRMS match day, which effectively extends the deadline for obtaining reference letters, doing away electives, etc.

 

As you mentioned correctly, therefore, if you were applying to a competitive specialty in both Canada and the US (such as Dermatology), it becomes a poor option to rank Canadian Family Medicine programs as a backup, because if you match in Canada (in either Derm or Family Medicine), you are automatically withdrawn from the US match, and forfeit any chances of matching into a US Dermatology residency. Therefore, yes, US Family Med would be your ultimate backup.

 

I do think that Canadian medical students and residents get more hands-on training then their counterparts at the equivalent training level in the US. I have heard this repetitively at multiple Canadian institutions from staff physicians who have done residencies/fellowships in both Canada and the US. So, I wouldn't necessarily discount the fact that you're in the Canadian medical education system. If nothing else, you can still apply for a US residency after coming out of a Canadian medical school (as we are LCME accredited as well).

 

Canadian third year med students are often admitting their own patients, writing up orders for those patients, rounding on those patients, following up on consultants, and doing the discharge summaries once the patient leaves the hospital. Much of this is done with minimal resident/staff supervision. I don't think this level of student autonomy exists in most US programs (with the possible exception of the county and VA hospitals) due simply to the pervasive and rather hostile medicolegal environment down there.

 

Ian

[Guest Tomclock]

Thanks Ian,

 

I'm in first year in an Ontario medical program.

 

Honestly I think our education is probably far stronger than what is available in the US in general. Our schools are considered among the best American programs. And in clerkship, we do get tons of practical experience and certainly more than what would be available in major US cities (where patients don't want to talk to anyone but the chief resident, but then again they are paying for him/her).

 

And our healthcare system works fine 95% of the time. You can find examples of unfortunate things happening, but the routine is quality care for everyone regardless of socioeconomic factors. That's something I'd be willing to help us hang on to, even if it means not necessarily winding up doing my first choice specialty.

 

The US has a lot going for it too though. Getting into peds or internal just isn't a big deal down there and it is very hard (or soon will be) for us to do so here. MD/PhD programs are far stronger in the States and research is generally better as well. There are really good programs down there and there isn't the attitude of forcing people into careers they don't want and minimizing flexibility to retrain.

 

I don't have the answers man. But I do want to know exactly what the full extent of my options are before making these decisions. Asking questions at these forums are probably about the best way to learn those options.

 

And of course I'm booking summer elective time in family medicine.

 

Thanks again,

 

Tom

[Guest everyoneloveschem]

Do you guys think that the type of people they tend to pick as med students is reflected in the decrease in matching to Family Medicine? Sometimes it really seems that way.

[Guest Ian Wong]

The thing is that I think most med students are relatively open-minded and interested about all specialties when they enter medical school. I know that for many people in my class, including myself, we thought Family Medicine would be a great potential career (lots of variety in your patients, run your own office and set your own hours, long-term followup and relationship-building with your patients, lots of potential practice options [ie. locums, surgical first assistant, obstetrics, sports med, walk-in clinics, rural outreach, etc], ability to educate your patients in preventative care, etc).

 

Somehow between those idealistic first days of med school when Family Medicine seems like the perfect specialty, to graduation day, when many med students choose to go completely unmatched for a residency as a superior option over Family Medicine, you know there was a profound personal shift away from Family Medicine.

 

I think medical school has a lot to do with this. Most of your classes are taught by specialists, and in your clinical years, nearly all your clinical experience is in the tertiary care hospital, where poor decisions by family doctors are hashed over and over again. It's obviously easy for a cardiologist to determine that a given family doctor isn't using the latest Canadian guidelines to treat hyperlipidemia and to make fun of that decision. Of course, the cardiologist also doesn't need to know about the newest pediatric immunization guidelines, nor the newest prenatal diagnostic workups for pregnant women, nor the latest news in treating rheumatoid arthritis, etc, so it's easy to feel superior when you can zone in on such a focussed area of the body.

 

Also, the financial reality today is that most specialties are far more lucrative than Family Medicine, and particularly when applicants are often spending 2-3 years re-applying to med school, or doing graduate degrees first, and then getting hit with hugely inflated medical tuitions, such that you will still carrying large amounts of debt as you approach or surpass the age of 30, it becomes easier and easier to justify going after that Ophthalmology residency, where a 10 minute cataract surgery can pay $400, whereas a standard 10-15 minute Family Medicine visit pays just $27.

 

Ditto that for most of the other competitive specialties, which tend to be procedural or highly reimbursed specialties like Ortho, Plastics, Urology, ENT, Derm, Radiology, Anesthesiology, etc. Even in Internal Medicine, which generally isn't as procedure-based as a surgical discipline, the two most competitive fellowships, cardiology and gastroenterology, are very much procedure-based and highly-reimbursed.

 

I think this current low interest level in Family Medicine is certainly multi-factorial (lower pay, tons of paperwork, lack of FM mentors in med school, teaching mainly in tertiary care centers where family doctors are noticeably absent, lots of specialists putting down Family Medicine, perception of daily work being routine and monotonous, etc). I think having the rotating internship year back would potentially spark a lot more interest back into the system, and it would definitely give each medical student a better and more well-rounded education, which just might give them the confidence to tackle the generalist responsibilities of being a family doctor.

 

I'm not sure what the total solution is, but one better be forthcoming soon...

 

Ian

[Guest everyoneloveschem]

It can be quite frustrating hearing how few family doctors there are and how no one is matching to it, but then no one is trying to remedy the situation!

 

I've been fortunate enough to have spent the past year shadowing a family doctor and I work at an office with quite a few FPs, so I think I have a good understanding of a) what they do how important they are (the gateway to all the specialists!) c) how rewarding it can be. I'm trying to get into med school and I think I would seriously consider family medicine, BUT FIRST THEY HAVE TO LET ME IN!!!:eek

 

I'm not idealistic enough to say that if I got in I would 100% become a FP. For goodness sakes, I have only a vague understanding of what specialists do, maybe being a psychiatrist would be way more rewarding, who knows. Its really too bad though. Money isn't everything. It helps and you need it, but it ain't everything (and how many cataract surgeries does one really want to perform in a day anyways? ).

[Guest JSS02]

p084.ezboard.com/fpremed1...D=32.topic

 

It was mentioned by Carolyn in the link above (and I've heard from other people as well) that the Queen's FM program sort of guarantees a 3rd year spot (e.g. in Emerg.). Does anyone know more about this?