The case against family medicine

[Dongzhuo]

[quote=KitKat;8732 post written by a passionnate GP!

 

http://www.huffingtonpost.com/penny-wilson/myths-about-general-practitioners_b_3937618.html

 

This is exactly the essay I was referring to in my original post. This essay, in my opinion, is quite embarrassing. Why is there a need to defend the realm of family medicine. This just screams insecurity. Being "specialists in the person", "specialist general practitioner", "subspecialized expert gp"....

[Dongzhuo]

The biggest case against family medicine is encroachment of NPs and physician assistants as well as the lost respect from the general population. Long gone are the days where a patient will go in with a chief complaint completely blind and respectfully listen what their family physician says. Today, they've already spent hours on the internet and go into the encounter partially convinced that they know more than their GP and all they really need is to see a specialist. It's very sad.

 

True. Family doctors are specialists in referrals

[Dongzhuo]

Interesting how we bounced to income on this thread as the original concern was not income at all but rather respect - which the OP really valued. I am guessing that form him/her that money beyond a point was not as important has that respect as a result. Point is overly focusing on only one aspect of things probably doesn't make much sense when doing analysis.

 

Let's say GPs earned more but were obviously respected less (respect by the way is not well correlated with income in medicine in Canada. You could argue academic docs are respected the highest - do the most complex procedures, research new cures, run departments, and teach the next generation - but they earn less than a lot of community docs that are just focusing on doing billable things). Neither income nor respect are particularly altruistic but they are things some people of course value.

 

and yeah you can really tell that people have initially problems digesting how doctors earn money and how averages are not all that useful (median is often quoted actually internally because as we all learned in stats for a distribution with a lot of outliers averages are not really a good descriptor). With a few exceptions fully practicing doctors don't have salaries, fixed hours, fixed incomes, or fixed practice structures. It is like asking what the average restaurant makes makes - well they are small ones, and huge ones, franchises on major highways, well run ones, poorly run ones, and of course their success can change over time .......

 

Thank you. Money was never the concern. The money is very good in family medicine, if you make it your priority. If you do full time walkin in Alberta, you may make 600-700k.

[Jochi1543]

Sorry that you're unhappy with residency. It sounds like your main issue is just about reputation and prestige. So basically if you're very concerned about what other people think about you, then don't be a family doctor. That said, I don't have the same feelings as you about what people think about family doctors.

 

I agree with your assessment wholeheartedly. As I read through every point made by the OP, I thought how it was totally incorrect in my personal experience. I'm also doing my residency in BC, where GPs run all hospitals except for the biggest urban centers. My preceptor and I have patients in the ICU - we'll consult a cardiologist or general internist for some suggestions, but we do 90% of the management. As a first-year resident, myself and my peers are expected to be able to admit people to the ICU if necessary, manage a hot stroke or STEMI, and with the exception of the ER doc, we are the only doctor in house overnight. I'm in my 3rd month of residency and I've called a physician for an opinion at night maybe 5 times so far.

[bloh]

It's true. Rural medicine is the last bastion of good family medicine. You get to do a lot, patients tend to be more respectful and loyal. That's not the case in the urban world of walk-in McMedicine.

[rmorelan]

I agree with your assessment wholeheartedly. As I read through every point made by the OP, I thought how it was totally incorrect in my personal experience. I'm also doing my residency in BC, where GPs run all hospitals except for the biggest urban centers. My preceptor and I have patients in the ICU - we'll consult a cardiologist or general internist for some suggestions, but we do 90% of the management. As a first-year resident, myself and my peers are expected to be able to admit people to the ICU if necessary, manage a hot stroke or STEMI, and with the exception of the ER doc, we are the only doctor in house overnight. I'm in my 3rd month of residency and I've called a physician for an opinion at night maybe 5 times so far.

 

That sounds pretty awesome actually

[Dongzhuo]

I agree with your assessment wholeheartedly. As I read through every point made by the OP, I thought how it was totally incorrect in my personal experience. I'm also doing my residency in BC, where GPs run all hospitals except for the biggest urban centers. My preceptor and I have patients in the ICU - we'll consult a cardiologist or general internist for some suggestions, but we do 90% of the management. As a first-year resident, myself and my peers are expected to be able to admit people to the ICU if necessary, manage a hot stroke or STEMI, and with the exception of the ER doc, we are the only doctor in house overnight. I'm in my 3rd month of residency and I've called a physician for an opinion at night maybe 5 times so far.

 

You must be doing your residency in a very remote area I presume? In any urban or any site even remotely close to an urban center, GPs do not run the entire hospital. GPs by and large do not treat patients in the ICU- have never even heard of this (perhaps in some place like Iqaluit they do, I'm not sure). But in any reasonably sized centre (not just large cities), GPs are certainly not expected to deal with STEMI's and ICU admissions and hot strokes. Generally if they didn't have neurologists and intensivists the role would fall upon general internists.

[A-Stark]

I agree with your assessment wholeheartedly. As I read through every point made by the OP, I thought how it was totally incorrect in my personal experience. I'm also doing my residency in BC, where GPs run all hospitals except for the biggest urban centers. My preceptor and I have patients in the ICU - we'll consult a cardiologist or general internist for some suggestions, but we do 90% of the management. As a first-year resident, myself and my peers are expected to be able to admit people to the ICU if necessary, manage a hot stroke or STEMI, and with the exception of the ER doc, we are the only doctor in house overnight. I'm in my 3rd month of residency and I've called a physician for an opinion at night maybe 5 times so far.

 

You don't call to review admissions or consults? Even if you might need to tPA or lyse someone in the middle of the night?

[Hockeynut]

You must be doing your residency in a very remote area I presume? In any urban or any site even remotely close to an urban center, GPs do not run the entire hospital. GPs by and large do not treat patients in the ICU- have never even heard of this (perhaps in some place like Iqaluit they do, I'm not sure). But in any reasonably sized centre (not just large cities), GPs are certainly not expected to deal with STEMI's and ICU admissions and hot strokes. Generally if they didn't have neurologists and intensivists the role would fall upon general internists.

 

I don't think you realize how few internists there are in communities of say 30000 people which aren't adjacent to Montreal/Toronto/Vancouver etc.

[bloh]

I don't think you realize how few internists there are in communities of say 30000 people which aren't adjacent to Montreal/Toronto/Vancouver etc.

 

There's more than half a dozen internists in a city of 50k like Grande Prairie.

 

There must be some level of untruth in what Jochi is saying; no way in hell are you thrombolysing someone as a resident without consulting someone.

[rmorelan]

You don't call to review admissions or consults? Even if you might need to tPA or lyse someone in the middle of the night?

 

It would shock me they didn't have to review cases etc - but even in large centres over night non internists residents are in charge often.

[Dongzhuo]

Not the point man...GP`s still don`t get respect.

[medigeek]

Not the point man...GP`s still don`t get respect.

 

You shouldn't pick your specialty based on respect/prestige.

It should be:

 

1) Job market status/job viability

 

2) Your interest for the field

 

3) Prestige/income

 

 

Without 1) , 2 and 3 won't be relevant. Of course unless you're willing to relocate and have a hardcore passion for your field...

[future_doc]

You shouldn't pick your specialty based on respect/prestige.

It should be:

 

1) Job market status/job viability

 

2) Your interest for the field

 

3) Prestige/income

 

 

Without 1) , 2 and 3 won't be relevant. Of course unless you're willing to relocate and have a hardcore passion for your field...

 

No. 2 rules for me, together with market conditions (1). Income will take care of itself and prestige is not a factor. How I feel is of importance, not the perception of others.

[TheBoss]

You shouldn't pick your specialty based on respect/prestige.

It should be:

 

1) Job market status/job viability

 

2) Your interest for the field

 

3) Prestige/income

 

 

Without 1) , 2 and 3 won't be relevant. Of course unless you're willing to relocate and have a hardcore passion for your field...

Says some premed barely out of high school to a resident physician?

[A-Stark]

I don't think you realize how few internists there are in communities of say 30000 people which aren't adjacent to Montreal/Toronto/Vancouver etc.

 

I don't think you realize how ridiculous that statement is. Certainly most smaller community/regional hospitals are GP-run when it comes to most admissions, but there are internists in Yarmouth, Miramichi, and Corner Brook.

 

It would shock me they didn't have to review cases etc - but even in large centres over night non internists residents are in charge often.

 

Sure. Sometimes there will be an R2 in plastics off-service on ICU as the "senior" on in-house call.

 

A hospital can't be that busy overnight if one resident can cover all the ICU, cardio, and neuro admissions. I certainly don't review much with the senior float if on floor call, and the only time I call staff is to let them know if a patient dies or there's some other big change in status (always after the fact). Otherwise it would be inappropriate not to review emerg consults, both for supervision and medico-legal reasons.

 

Anyway, as to the original issue here, I certainly have heard the "are you just going to be a GP or specialize" bit repeatedly, but I wouldn't read too much into that. I've also heard patients praise their family doc's attention to their issues and thoroughness, and in almost any rural area in the country they are extremely valued. I suppose that correlates with respect.

 

Of course, I have almost no exposure to urban family practice, so perhaps my view is coloured by rural experiences. Even so, I don't really enjoy the routine prescription refills or BP checks or the like. But every area in medicine has the routine stuff which you may or may not dread. I find stable ACS pretty irritating/boring, but that's just me and why I'm not overly interested in (clinical) cardiology.

[medigeek]

Says some premed barely out of high school to a resident physician?

 

Not really.. 3rd year.

 

And what was it you disagreed with me on exactly?

[Jochi1543]

You must be doing your residency in a very remote area I presume? In any urban or any site even remotely close to an urban center, GPs do not run the entire hospital.

 

Population 100,000 here.

[Jochi1543]

You don't call to review admissions or consults? Even if you might need to tPA or lyse someone in the middle of the night?

 

Emerg docs admit after consulting the family physician on call.

 

And yes, these are the types of things I've called for.

 

I haven't worked on a consult service yet, my first one would be psych coming up in about a month, then internal.

[Jochi1543]

A hospital can't be that busy overnight if one resident can cover all the ICU, cardio, and neuro admissions.

 

See, I think your problem is that you are seeing this from a perspective of a giant teaching hospital with 50 wards. Most hospitals around the country actually aren't your typical university hospital with 20 levels of hierarchy.

[A-Stark]

No, that's not my problem, as I work mainly in a smaller service-oriented teaching centre with 8 floor nursing units. There's one senior on for each medicine and cardio and a PGY1 ("intern") on for medicine floors. Occasionally there's a senior float on as well, but that's rare. There's always a resident in the unit too, covering both Med/Surg and CV and anything that comes up on the floor or emerg.

 

There are no GP-hospitalist units, so everyone who needs to be admitted gets seen by a consult service first. Emerg docs don't do any admissions (which is for the moment as I'm pretending to be one this block).

 

I was surprised when you said you've only called in 5 times or so for advice. I suppose if you meant apart from admissions that might make sense, but it is expected around here that you review all consults directly with staff. There's certainly not much of any hierarchy, at least among housestaff.

[NLengr]

No, that's not my problem, as I work mainly in a smaller service-oriented teaching centre with 8 floor nursing units. There's one senior on for each medicine and cardio and a PGY1 ("intern") on for medicine floors. Occasionally there's a senior float on as well, but that's rare. There's always a resident in the unit too, covering both Med/Surg and CV and anything that comes up on the floor or emerg.

 

There are no GP-hospitalist units, so everyone who needs to be admitted gets seen by a consult service first. Emerg docs don't do any admissions (which is for the moment as I'm pretending to be one this block).

 

I was surprised when you said you've only called in 5 times or so for advice. I suppose if you meant apart from admissions that might make sense, but it is expected around here that you review all consults directly with staff. There's certainly not much of any hierarchy, at least among housestaff.

 

I call staff for anyone I send home from the ER. Most of the time it's just a medico-legal thing as opposed to a "I don't know what to do thing".

 

If I'm admitting, it will depend on the time and the problem:

-If the person is unstable or I think needs an OR that night, I'll call no matter what the hour.

-If it's after 12 and it's a routine admission + stable patient, I'll defer on calling the staff till the AM.

 

If I was doing consults where I was giving tPA or stroke interventions (i.e. serious, life threatening stuff), I would be reluctant not to call the staff to review. If something goes wrong, and you go to court without a staff being involved, you are essentially screwed.

[Real Beef]

To the OP: What were your reasons for choosing family medicine in the first place? and what specialties would you have choosen instead knowing what you know now?

[aKGDH]

Sounds like family medicine wasn't the right specialty for you. Are you sure it's not just a "grass is greener" thing? Trauma surgeons, neurosurgeons, interventional cardiolgists etc. are sexy specialities that command respect, but they sacrifice any sort of measurable lifestyle. There are pros and cons of every specialty.

 

Have you thought of transferring?

[medigeek]

Sounds like family medicine wasn't the right specialty for you. Are you sure it's not just a "grass is greener" thing? Trauma surgeons, neurosurgeons, interventional cardiolgists etc. are sexy specialities that command respect, but they sacrifice any sort of measurable lifestyle. There are pros and cons of every specialty.

 

Have you thought of transferring?

 

Is there even a single job in any of the more "prestigious specialties?" In Canada that is.