futureGP Posted October 27, 2012 Report Share Posted October 27, 2012 Hi guys, so what are some good electives (not part of a regular FM curriculum) to take in order to be an effectively skilled FM -- for most cases that shouldn't require specialist referral e.g. dermatology, ENT Link to comment Share on other sites More sharing options...
Jochi1543 Posted October 27, 2012 Report Share Posted October 27, 2012 I second derm and ENT. I personally think ophtho is another good one, as long as it's primarily clinical rather than cataract OR. Peds, obs-gyne (non-OR), geriatrics, GIM, cardiology, community ER...almost everything that's not OR or extremely subspecialized, really. Link to comment Share on other sites More sharing options...
japlanet Posted October 28, 2012 Report Share Posted October 28, 2012 It sounds ridiculously sub-specialized, but peds urology is a great one for FM. Especially if you think you will offer circumcision (within your scope, but not covered by OHIP, so $$$). Link to comment Share on other sites More sharing options...
1234 Posted October 28, 2012 Report Share Posted October 28, 2012 Ortho, Ophtho and ENT will make up a huge portion of your practice. Most people have no clue how to assess a joint. And guess what, a huge portion of your population will come in with shoulder, wrist, hip and knee issues. Link to comment Share on other sites More sharing options...
Larrivee Posted October 29, 2012 Report Share Posted October 29, 2012 Ortho, Ophtho and ENT will make up a huge portion of your practice. Most people have no clue how to assess a joint. And guess what, a huge portion of your population will come in with shoulder, wrist, hip and knee issues. Hmm, if that's the case then I could see physiatry being quite useful as well! Maybe even more so than ortho? Link to comment Share on other sites More sharing options...
futureGP Posted October 29, 2012 Author Report Share Posted October 29, 2012 It sounds ridiculously sub-specialized, but peds urology is a great one for FM. Especially if you think you will offer circumcision (within your scope, but not covered by OHIP, so $$$). how hard is it to do circumcision? + vasectomies? -- is this within the normal skill level of a FP? or more on the higher side? :S Link to comment Share on other sites More sharing options...
Satsuma Posted October 29, 2012 Report Share Posted October 29, 2012 Hmm, if that's the case then I could see physiatry being quite useful as well! Maybe even more so than ortho? I would have to agree that physiatry or rheum would be better for learning MSK exams. Not sure if being in the OR doing hip and knee replacements will be all that useful to a family doc. You won't be doing ORIFs, so closed reduction of fractures is a better skill to learn, which you'll get in ER rather than ortho. And I would second geriatrics. So many people think that just because they see alot of old people they know how to treat them. Not really true. A good geriatrics rotation could help you manage their issues better. How good the rotation is might be location dependent. Some places are geri rehab. Some are "acute care of the elderly" units. I really like my rotations on those. Generally healthy old people who are expected to go back home soon. So your healthy 80 year old who had a downhill skiing accident and needed an ORIF, for example. Not your 65 year old diabetic COPDers who takes weeks to leave and then come right back in a week! Also some time spent doing a full geriatric assessment could be good. Here they get assesed by OT, PT, geri psych and geriatrician. Very comprehensive. And great to learn about multifaceted issues. Link to comment Share on other sites More sharing options...
peachy Posted October 30, 2012 Report Share Posted October 30, 2012 I would have to agree that physiatry or rheum would be better for learning MSK exams. Not sure if being in the OR doing hip and knee replacements will be all that useful to a family doc. You won't be doing ORIFs, so closed reduction of fractures is a better skill to learn, which you'll get in ER rather than ortho. Fracture clinic can be quite high yield though, and is usually run by the orthos. Certainly, weeks on end of being in the OR is not helpful to a family doc. But part of electives is to see and do the part that you WON'T do in the rest of your practice, so that you can really know what's happening when you send your patients to the ortho and they get that knee replacement. So when they are scared of surgery you can explain what the process will be like. So you can understand how the orthos decide who is a good surgical candidate and then give the best advice to your patients and refer them at the appropriate time. Overall, for any field, I think there can be a lot of benefit in taking time to do things that you WON'T do in your primary career -- you will eventually learn to be good at doing MSK exams as a family doc, no matter what electives you do. Choose electives that give you something that complements your eventual practice, not duplicates it. Not that I know anything about ortho or MSK, I'm mostly glad that I'll never have to examine a joint ever again in my career! So I'll also suggest some things I actually do know about... I highly recommend that future family docs do an elective in sleep medicine. For the most part, it's not something you'll get good training on otherwise, and will affect a huge proportion of your patients. Some things you'll learn in a good sleep medicine elective: - spend a night seeing what goes on in the sleep clinic - see lots of obstructive sleep apnea patients - learn techniques to improve compliance with CPAP - learn the difference between being tired and being sleepy - get exposure to the many other sleep disorders - learn the basics of CBT for sleep - learn when and how to use pharmacotherapy for sleep PROPERLY - etc, etc, etc! If you have a good grip on sleep medicine you can do brief interventions with folks that can make a HUGE difference in their lives. If you haven't done any inpatient psychiatry during your core medical school training, please, PLEASE try to get some exposure to this during even a brief elective. It is so important to have even a minimal exposure to SEVERE mental illness so that you can see the difference between a mild depression and a severe depression, for example, or what psychosis really looks like. You will do TONS of psychiatry in primary care but if you don't have a good perspective on what severe mental illness looks like then you can get a skewed perspective that will cause you to overdiagnose mild cases and underdiagnose severe cases, imho. Also, do some general child psychiatry if you can! Mood and anxiety disorders are so often missed in this population and if you don't know what it looks like in children you can't find it. These kids are in SUCH distress and early diagnosis and intervention makes a huge difference, and as a primary care provider you are in the ideal position to be identifying these kids early. If you can get a rotation that gives you even basic exposure to attachment theory and disorders, you can make a HUGE difference in the life of moms and kids. You can learn basic ways to identify attachment problems, and there are just as basic skills you can teach parents to bond better with their children. It's easy, obvious stuff once you learn it, but not at all obvious until then. Link to comment Share on other sites More sharing options...
futureGP Posted October 30, 2012 Author Report Share Posted October 30, 2012 thanks everyone for the replies ENT derm physiatry Ortho child inpatient psychiatry geriatrics cardio urology (+peds uro) Optho rheum 2 weeks of each? hahaha Link to comment Share on other sites More sharing options...
tooty Posted November 3, 2012 Report Share Posted November 3, 2012 just like jochi said any specialty in the clinic will help. i'd put neurosurgery spine service up there. you will see amazing pathology and strengthen your neuro exams. Link to comment Share on other sites More sharing options...
A-Stark Posted November 3, 2012 Report Share Posted November 3, 2012 A neurology elective would be a lot more relevant, particularly for examinations. The major purpose of a spine service elective would be to see all the poor referrals... Link to comment Share on other sites More sharing options...
Jochi1543 Posted November 4, 2012 Report Share Posted November 4, 2012 The major purpose of a spine service elective would be to see all the poor referrals... LOL, any non-FM elective is a good opportunity for that. On Gen Surg: "Please assess patient for dehydration" - pt turns out to have a burst appendix and a 2-L abscess. Link to comment Share on other sites More sharing options...
tooty Posted November 4, 2012 Report Share Posted November 4, 2012 just like jochi said any specialty in the clinic will help. i'd put neurosurgery spine service up there. you will see amazing pathology and strengthen your neuro exams. our personal experiences are different. if you enjoyed neurology, it's probably just as helpful as neurosurg for an FM resident. i personally had way more fun and saw more pathology in neurosurg than neurology, both on wards and clinic but i'm biased towards imaging. Link to comment Share on other sites More sharing options...
Robin Hood Posted November 11, 2012 Report Share Posted November 11, 2012 Ortho, Ophtho and ENT will make up a huge portion of your practice. Most people have no clue how to assess a joint. And guess what, a huge portion of your population will come in with shoulder, wrist, hip and knee issues. What can a GP do with eyes? If I was a GP and someone comes with a eye injury, I probably wouldn't be able to stand it... I fear eyes. Link to comment Share on other sites More sharing options...
A-Stark Posted November 12, 2012 Report Share Posted November 12, 2012 Lots of stuff. UpToDate even has an article including a table showing "red eye" presentations that can be managed without an ophtho referral and those that warrant one. Link to comment Share on other sites More sharing options...
tooty Posted November 12, 2012 Report Share Posted November 12, 2012 you can become a referologist with eye complaints if you want, but you won't be respected in the medical community. Link to comment Share on other sites More sharing options...
Robin Hood Posted November 12, 2012 Report Share Posted November 12, 2012 I heard that all physicians can prescribe glasses, but that it won't be profitable. But it requires a lot of precision. I like eyecare, but I fear eyes... Link to comment Share on other sites More sharing options...
Med0123 Posted November 12, 2012 Report Share Posted November 12, 2012 I heard that all physicians can prescribe glasses, but that it won't be profitable.But it requires a lot of precision. I like eyecare, but I fear eyes... ???? I think you missed their point, they don't ask you to perform LASIK on your patients, just don't be that guy who will ask an ophto for consultation for viral conjunctivitis with an evident history and reassuring clinical assessment Link to comment Share on other sites More sharing options...
Satsuma Posted November 12, 2012 Report Share Posted November 12, 2012 you can become a referologist with eye complaints if you want, but you won't be respected in the medical community. I think alot of people are cautious with eyes because loss of vision is a pretty bad outcome. I would rather have a patient with nothing, referred and told that there's nothing to worry about, then see a patient with something serious that wasn't referred until it was too late. Not all family docs are going to have the proper tools to assess eyes. I had a pt come to the emerg with a 3 day hx of painful red eye. The doc at the walk in clinic gave this pt voltaren. I have the benefit of a slit lamp in the emerg and was able to tell the pt that the voltaren was not going to help the piece of metal in his eye, and took it out. Seems pretty silly to me to prescribe voltaren for an eye FB, but that's cause I had a slit lamp to find it. I'm sure there are lots of things I have referred to optho from the emerg that they think is SO obvious. Well yeah, to optho! But I am not an eye specialist. This is the same for any specialty really. Same for imaging. If I don't have enough negative scans, then I'm not scanning enough people and it means I am missing too many things. There is a balance of course. Can't order a CT head for everyone who falls from standing! But at the end of the day, we are all (or should be) on the same side, which is the patient's side. So if a generalist asks the help of a consultant, just remember you're doing it for the patient, not the referring doc. (I tell this to myself for the plethora of non-emergent things family docs send to the emerg. It just makes me a little less frustrated when it happens!). Link to comment Share on other sites More sharing options...
Lactic Folly Posted November 12, 2012 Report Share Posted November 12, 2012 If I don't have enough negative scans, then I'm not scanning enough people and it means I am missing too many things. Do ER docs have a rule of thumb or "sense" of what proportion of scans should be negative? Link to comment Share on other sites More sharing options...
futureGP Posted November 22, 2012 Author Report Share Posted November 22, 2012 mann so specialist criticizes EM for annoying consults, specialist criticizes FM for annoying consults EM criticizes FM for annoying consults Link to comment Share on other sites More sharing options...
Satsuma Posted November 23, 2012 Report Share Posted November 23, 2012 Do ER docs have a rule of thumb or "sense" of what proportion of scans should be negative? That's a good question. And I suspect there is not a good evidence-based answer. I think though, that a certain threshold would change depending on what you are trying to rule out, and what you deem is the acceptable miss rate for diagnosis in the emerg. For example, an acceptable miss rate for a SAH might be considered 0 - and so you might tend to have a lower threshold for scanning, and accept a higher rate of negative scans because missing it would be very bad. I believe the ER staff here get feedback from radiology about their stats (at least another resident told me this but I have never discussed it with staff), but I doubt there is a "target". But if you have no negative scans, then you could be pretty sure you missed some diagnoses. Link to comment Share on other sites More sharing options...
Satsuma Posted November 23, 2012 Report Share Posted November 23, 2012 mann so specialist criticizes EM for annoying consults, specialist criticizes FM for annoying consults EM criticizes FM for annoying consults Meh, every specialty criticizes every other specialty. It's easy to pick on emerg though because that is where most of the consults come from. Also there is a referral bias (the consultants may complain about the 3 consults they just got, but they didn't see the 10 others you sent home without talking to them). And often consultants forget (or just plain don't know) that the goals we have in emerg are not the same as theirs, and that that is why we are consulting them. eg. I recently had a pt with a cough not getting better on abx prescribed by her family doc, and came to the ER to r/o pneumonia. CXR showed a possible mass - that had been then a couple of years ago (and not commented on) and seemed a bit different on the current CXR. So I ordered a CT chest and it came back saying that yes, there was a mass, and 2 other possible masses not seen on the CXR. Woohoo!! What a good job I did for this patient I think. But then the consult to medicine ends with "Well you really should have done a high resolution CT" for a million good reasons that justify THEM ordering a high resolution CT scan now that they have a regular CT chest! They just can't put themselves in your shoes sometimes. But in the end, I did my job for that patient - identified an issue, referred to the right people who can work up further and treat and refer on as needed....and I move on to the next pt. Whatever specialty you pick, as long as you know yourself, you are doing a good job, you'll be fine. But you do have to have a bit of a thick skin to be in emerg! Link to comment Share on other sites More sharing options...
ploughboy Posted November 23, 2012 Report Share Posted November 23, 2012 eg. I recently had a pt with a cough not getting better on abx prescribed by her family doc, and came to the ER to r/o pneumonia. CXR showed a possible mass - that had been then a couple of years ago (and not commented on) and seemed a bit different on the current CXR. So I ordered a CT chest and it came back saying that yes, there was a mass, and 2 other possible masses not seen on the CXR. Woohoo!! What a good job I did for this patient I think. But then the consult to medicine ends with "Well you really should have done a high resolution CT" for a million good reasons that justify THEM ordering a high resolution CT scan now that they have a regular CT chest! Wild guess here, but when you talked to radiology about getting the CT scan in the first place, were they like "does the patient *really* need a CT chest? It sounds like simple pneumonia to me." You just can't win. Link to comment Share on other sites More sharing options...
Lactic Folly Posted November 23, 2012 Report Share Posted November 23, 2012 If the mass had been there 2 years ago, I would think a CT is reasonable. Of course, it would be ideal if patients with relatively long-standing conditions could be seen by primary care and imaged on an outpatient basis in an expeditious manner, instead of presenting in ER and receiving the most convenient test that will determine disposition. It's a systems issue. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.