FM Scope of Practise

[Bede]

What or who defines the procedures a family doc can and can't do? Some Family docs do a PGY-3 of additional surgery and do minor surgeries like appendectomies, c-sections, etc. However I believe a family doc would never do any complicated surgeries.

 

So, if a family doc is in a small community, could they really do anything a ped, or IM, can do without shipping the patient out, as long as they're comfortable with the procedure? Do they get paid the same for a given procedure as a specialist would?

[moo]

A family doc can pretty much do what he or she is comfortable with doing. However, he or she probably would not be able to bill as much as a specialist can. Yes, family docs in rural communities typically do appys, choles, c-sections, etc. They provide anesthesia and other minor procedures. Other times, family docs will "specialize" in certain areas like doing vasectomies or other minor procedures.

 

No one really defines what a family doc can or cannot do. In theory they can do cardiac surgery if they want but no hospital would let them and it is unlikely that any patient would allow a family doc to operate on their heart. Of course, however, they can do surgical assists and many do just that.

 

Many family docs can do what GIM or peds do if they're comfortable doing it. For example, I rarely refer to GIM as I am comfortable with most office based GIM stuff. If anything is too complicated, I usually refer to IM subspecialties.

[physiology]

Yes, I believe in the past family doctors had a much more expanded scope of practice.

 

As a family physician, you can obtain a special license to do C-sections, but I'm not sure if these are widely available anymore in rural areas.

 

Furthermore, if general surgery is available in the area, they would do the sections, not the family doctor.

 

The role of the family doctor in the OR is mainly as a surgical assist nowadays. If the attending surgeon was comfortable with the FP doing the C-section, appy or whatever, then so be it, but you wouldn't be the one in charge.

 

For smaller communities Penticton, BC, family doctors aren't even allowed to use forceps or vacuum, as they have round-the-clock access to OB/GYNs.

 

Physio

[Bede]

Thanks for the great responses. Moo, I was curious can FP do a lot more in BC? I think that's where you are. In Ont FP recently got their cosmetic surgery privileges removed so I was curious who says who can do what procedure. In a major center, I don't think any FP would be doing c-sections or appy's, but I have heard of FP doing minor surgical stuff in small rural settings, as long as he/she feel comfortable.

 

I was talking with my doc that does my annual professional. He graduated med school in 1953 with an MD and Master in Surgery (he is old). He said at the time there was no specialization and he did whatever he wanted: surgery, FM, paed's, etc.

 

Are there any procedures that a paed or GIM would do that a FP would not be allowed to do? Who says you couldn't do these procedures? CCFP? OMA?

[Monaco]

Family medicine is, aside from the worried well, mostly chronic disease management, prenatal care, uncomplicated psych, and well-baby checks. Lots of what they deal with are cardiorespiratory disorders that have been studied so much that the care is basically cookbook. The scope of practice is getting tighter everyday.

 

I know family medicine can be quite flexible depending on your situation. However, you are right - I have a friend who initially wanted to do family, but ultimately decided against it because she did not like paeds, ob (gyn okay) or psych....which made up the bulk of our family experience. But some other people did have some more specialized experiences - like adolescent/young adult medicine, HIV, etc.

[A-Stark]

Note that something like HIV will only be relevant in larger centres - it's a good example of something that will be covered mostly by ID specialists. Around here patients come from all over the province; I really don't know the extent of family docs' involvement in treatment decisions.

[ploughboy]

He graduated med school in 1953 with an MD and Master in Surgery (he is old).

 

...and he is probably a McGill grad if he did his meds in Canada (or Queens... I think Queens granted the degree of MDCM back in the day). AFAIK having an MDCM in this day and age doesn't grant the holder any special-ness relative to a plain old MD, except for the nerdy/coolness factor.

 

As for who determines what is or isn't within a doc's scope of practice, ultimately that would be the decision of the College of Physicians and Surgeons of whatever province the doc is practicing in.

[moo]

Thanks for the great responses. Moo, I was curious can FP do a lot more in BC? I think that's where you are. In Ont FP recently got their cosmetic surgery privileges removed so I was curious who says who can do what procedure. In a major center, I don't think any FP would be doing c-sections or appy's, but I have heard of FP doing minor surgical stuff in small rural settings, as long as he/she feel comfortable.

 

I was talking with my doc that does my annual professional. He graduated med school in 1953 with an MD and Master in Surgery (he is old). He said at the time there was no specialization and he did whatever he wanted: surgery, FM, paed's, etc.

 

Are there any procedures that a paed or GIM would do that a FP would not be allowed to do? Who says you couldn't do these procedures? CCFP? OMA?

 

I think it's the same in all provinces. I don't think anyone really defines the scope of practice for FPs. Like I said, I'm pretty sure you can do whatever you want BUT the logistics of getting hospital privileges for some expanded scope is impossible. For instance, to get hospital privileges, you have to sign a contract stating what you're limited in providing, i.e., as a FP you are not allowed to do any taps, LPs, etc. that internists and emerg docs can, UNLESS you can prove to the hospital that you have the proper training. (Theoreticallly if you have the equipment, you could legally do these things in your office but I don't know any FP who would due to lack of training and time.) Similarly for ob-type stuff UNLESS you can prove you've had extra OB training (may not be a RC specialty, but could be a one year fellowship).

 

For cosmetic medicine, again, you can pretty much do whatever you want, until the College starts clamping down. You definitely cannot advertise yourself as a Plastic Surgeon but you can advertise yourself as a "Cosmetic specialist", a "Cosmetic medicine doctor" or whatever other name you fancy. One of my colleagues does cosmetic medicine and she makes a ton of money doing it.

 

For me, I am leaving family medicine not because of renumeration (you will get paid if you are willing to put in the hours) but because of boredom. Clinic is boring. Walk-in consists of the same things, coughs, colds, flus, skin infections, allergies, etc. You have annoying patients. The nice patients unfortunately don't come to the doctor often and the annoying ones come in every week complaining of the same old stuff, "I'm tired", "I'm hurting everywhere", etc. And the annoying thing is you can never fix all their problems. Even the stuff that I once liked, chronic disease management, has become a bore and a chore. It's the same old thing, control BP, control sugars, blah blah blah. Academic family medicine may be better because you teach students but I find academic family medicine to have a lot of BS as well (e.g., "SOOS"). Also FM research, which is what I eventually want to do (well not FM research but public health, and more specifically cancer epidemiology), is not really rigorous. If you look at some of the stuff in the CFP journal, you'll see what I mean.

 

And just a plug for Community Medicine: if you like research and/or intellectual challenges and like to make changes on a grand scale then CM is for you. No annoying patients, don't have to deal with other allied health professionals who think they know more than you, and no headaches. Pay may not be that great, (180k-250k) but it's a salary, which means tons of benefits, a pension, etc. (And if you don't think benefits matter, wait until you're a bit older and then tell me that again).

 

Sorry if I sound really pessimistic and have dampened anyone's enthusiasm in family medicine. Family docs are a crucial part of our health care system and do a lot of good. Once in a while you'll really help a patient. But I just can't imagine doing this for the rest of my life.

[blinknoodle]

At least in Ontario, they are limiting how you can advertise yourself. The recent Dialogue had an article about this.

 

See page 15:

http://www.cpso.on.ca/uploadedFiles/policies/publications/dialoguearchives/dialogueissues/Sept09.pdf

[da_birdie]

I agree with moo that traditional urban family practice can get 'boring' after a while

 

I can't find myself doing 8 hours a day, 5-6 days a week of fee-for-service work, at least not at this (early) stage in my life.

 

I currently balance FFS by doing 2 days a week of sessional service in hospital (inpatient care for transfers from VGH), and occasional shifts at community clinics / refugee clinics, where I get to see more weird and wonderful diseases : )

 

Government pensions/benefits are definitely a huge plus with working for the government. Even with the looming pension/budget crisis and major changes to the public pension system (caused by the poor economy, aging baby boomers), I think government pensions/benefits package will still be quite attractive (compared to..having no pension/benefits at all!).

Just need to hope that by the time its our turn to retire, the economy has already turned the corner

[physiology]

With my family practice experience in residency, after a while, I found the clinic day in and day out very boring.

 

My family practice preceptor was on a different billing system, where she would receive a yearly fee for the patient. The more complicated the patient, the higher the fee. Thus, there weren't any time constraints. You could afford to spend more time on the chronic patients. Also, if your patients went to any other clinic (ER excepted), you'd have to pay the government back for their visit.

 

In medicine, we're taught to treat the patient like gold, but after you've hacked away at it for some time, sometimes, the best thing is not seeing patients.

[Monaco]

My family practice preceptor was on a different billing system, where she would receive a yearly fee for the patient. The more complicated the patient, the higher the fee. Thus, there weren't any time constraints. You could afford to spend more time on the chronic patients. Also, if your patients went to any other clinic (ER excepted), you'd have to pay the government back for their visit.

 

Can someone explain this billing system? I remember signing some form at my GP's office years ago saying I wouldn't go to other clinics (I think), but I'm no longer in the same city so I can't always go to her for urgent situations (vs. immunizations). I don't want her to be penalized for this.