Is family medicine = refer-tologist?

[p0tus]

Depends on the how rural the location. When I did my rural family med rotation (less than 3 years ago) in Whitecourt Alberta, the GPs there were doing lap Choles, appes and C/sections with GP anesthetists.

[Geekom]

There are a lot of +1 to be done after the 2 years of FM residency, including ER, Surgery for minor procedures and anesthesia. Many GP also just prefer to tailor their practice according to their likings and do more OB/GYN, geriatrics or palliative care.

[Guest viscous]

I know a family doctor who manages anterior uveitis, episcleritis/scleritis, HSV keratitis, uncomplicated chronic open angle glaucoma, other eye stuff that does not require surgery for management (he refers penetrating corneal ulcerations or perforations to the bow-tie docs of course). He has his own slit lamp, 90D, 60D and 20D lens, Humphrey VF testing apparatus and he works along with an optometrist for patient referrals. Needless to say, some ophthalmologists in his locality do not like him very much as he is "taking over" their business. He did not match to ophthalmology few years ago and this is how he has decided to keep his passion alive.

 

Being able to do whatever you are comfortable with is a huge bonus of FM. However, you cant charge as a specialist and hence if you solely focus your practice on doing one thing as a family doc, you wont do much better financially (no procedures). At its essence, a FM should be a generalist, be able to manage any general issue including emergencies (CCFP still thinks emergency medicine is FM's domain) and that requires a broad knowledge of all types of medicine which is not my thing.

[ldnk]

It's all about comfort level. If the Family Doctor isn't comfortable with the patient case, they are obligated to refer them to a specialist. In some cases that goes to the extreme but some of the generalizations from Pre-Med students are incredibly off base in this thread.

 

Medicine as a whole is a consult-based profession. What often gets glossed over when discussing referral of patients is just how often services consult when you are in the hospital in an acute setting.

 

There are surgeons who won't manage medical issues and will consult internal medicine the second something that isn't a post-op wound infection. There are psychiatrists who don't know how to manage electrolyte abnormalities. There are internal medicine docs who consult surgery the second they get a patient with c-diff. There are Ortho services where non-fracture care issues get ignored until they try and refer the patient to medicine for recovery after an operation.

 

And there are family Docs who made terrible referrals because they don't know enough about their patient to rule in/out plenty of conditions.

 

But it really happens across the board. As for whether it has to be that way, absolutely not. It is 100% about comfort with your ability to manage the medical issues of your patient population.

[Tacrolimus]

As everyone said, it depends on the comfort level of the physician. A lot of FM docs have an area of interest and they can (or feel competent) do much more in that field.

 

Also, Dermatology is a pretty brutal field for most family docs, unless that is their special interest. Having just done Derm, differential diagnosis is extremely difficult. God bless the dermatologists because everything is erythematous, papulous and pruritic. Yes, diseases have "textbook" symptoms (i.e. silvery scales in psoriasis) but in real life, nothing turns out to be that ideal patch shown in class. Hahaha!

[LeBronto2019]

It's all about comfort level. If the Family Doctor isn't comfortable with the patient case, they are obligated to refer them to a specialist. In some cases that goes to the extreme but some of the generalizations from Pre-Med students are incredibly off base in this thread.

 

So if a family doctor was trained primarily in rural areas in med school, residency and was staff for X number of years and they had developed a broader scope of practice, would they be able to manage more complex cases (generally not seen or dealt with in family medicine) if they moved back to an urban centre or would they be required to still refer to a specialist? Like you said, it is based on comfort but is there any point that they would have to refer simply because of the roles each type of physician plays in healthcare? 

[Edict]

I just have to say though that some family doctors can really be pretty rude. Anyone else experience this? Online reviews tend to back me up, maybe its just the area i'm living in. 

[LittleDaisy]

I sense a future dermatologist here ahahah 

In rural areas, the family doctors play a major role and they often handle all the complex cases. I find it personally more challenging to be a family doctor than a specialist (who has done a 2 year fellowship in one specific area), since you have to know everything relatively well and prescribe more than just 40 medications in some specialties. It depends on your area of comfort, to a certain point, the specialists need patients too

As everyone said, it depends on the comfort level of the physician. A lot of FM docs have an area of interest and they can (or feel competent) do much more in that field.

Also, Dermatology is a pretty brutal field for most family docs, unless that is their special interest. Having just done Derm, differential diagnosis is extremely difficult. God bless the dermatologists because everything is erythematous, papulous and pruritic. Yes, diseases have "textbook" symptoms (i.e. silvery scales in psoriasis) but in real life, nothing turns out to be that ideal patch shown in class. Hahaha!

[katakari]

I know a family doctor who manages anterior uveitis, episcleritis/scleritis, HSV keratitis, uncomplicated chronic open angle glaucoma, other eye stuff that does not require surgery for management (he refers penetrating corneal ulcerations or perforations to the bow-tie docs of course). He has his own slit lamp, 90D, 60D and 20D lens, Humphrey VF testing apparatus and he works along with an optometrist for patient referrals. Needless to say, some ophthalmologists in his locality do not like him very much as he is "taking over" their business. He did not match to ophthalmology few years ago and this is how he has decided to keep his passion alive.

 

Being able to do whatever you are comfortable with is a huge bonus of FM. However, you cant charge as a specialist and hence if you solely focus your practice on doing one thing as a family doc, you wont do much better financially (no procedures). At its essence, a FM should be a generalist, be able to manage any general issue including emergencies (CCFP still thinks emergency medicine is FM's domain) and that requires a broad knowledge of all types of medicine which is not my thing.

 

I feel like the requirement for special technology would be the boundary at which a family physician should refer. Slit lamps, scopes, ultrasound etc. If you aren't going to get paid an optho code, why purchase a slit lamp that you may have a challenge recovering the purchase price for.

 

Regarding derm, I was under the impression that most family docs should be very proficient at it. I am told time and time again that a lot of family patients will come in with derm complaints. I plan on doing a few electives in it as, while the language makes it seem foreign and intimidating, when you break it down you can make a quick diagnosis on the more common complaints.

 

Of course, my experience in family is very limited as of now, so...

 

 

 

I just have to say though that some family doctors can really be pretty rude

Avoid walk-in clinics. Use your school's health service if possible. This is off topic.

[3change]

...

[Arztin]

Ok, 1 year later, with quite a lot of fam med exposure this school year.

Fam Med is way more than just a referologist.

You're a full physician dealing with your patients.

You deal with complaints of all sorts: yes you deal with the boring stuff: URTI, small allergies, ingrown nails, cerumen impacted ear canals etc....

However, it's way more than that. You deal with complex problems too: geriatrics (very complex cases, and you need to know your pharmacology very well), some internal medicine problems, etc.....

In rural fam med, you're doing a hell lot. 

I personally find it way more challenging to be an excellent family doc with very short training than a specialist (e.g. a cardiologist that does only clinics of arrhythmia, syncope, defibrillation + consult for 30 years).

During the first years as a FM, I would imagine that a junior FM doc would be slow and refer a lot ''uselessly'', but with time, if one keeps reading and improving, one does not need to refer as much.

 

Anyways, I'm perhaps a bit biased now, but fam med is so very awesome.

[LeBronto2019]

^^ loving the advocacy for family med! 

[xkittens]

Why avoid walk in clinics?

The doctors are usually awful haha. Once in a walk in clinic I had a doctor decide the visit was done (probably lasted total of 40 seconds) and walk out on me as I was asking a question, but to his credit he did shout back an answer from the hallway as he was walking away. 

[ACHQ]

So if a family doctor was trained primarily in rural areas in med school, residency and was staff for X number of years and they had developed a broader scope of practice, would they be able to manage more complex cases (generally not seen or dealt with in family medicine) if they moved back to an urban centre or would they be required to still refer to a specialist? Like you said, it is based on comfort but is there any point that they would have to refer simply because of the roles each type of physician plays in healthcare? 

 

Depends on the setting. Its not just about scope of practice but also the resources they have with them. Usually family docs in the rural setting are not doing everything out of the clinic. They are working the emerg, covering the inpatient hospital wards etc... This means they have the resources (i.e. emerg or ward) to deal with some more acute issues (re: acute not necessarily complex). Usually in the urban setting they run more so out of clinics, but you will see them do emerg, hospitalist work etc...

 

When it come to comfort zone and referring, family docs have to make that call. A family doc (or any specialists for that matter) is only "required" to refer to a specialist when they feel they dont know what is going on, or know what is going on but don't have the ability to completely manage the patient. It boils down to whatever is best for the patient

[LittleDaisy]

That's generalizing. There  are good and bad doctors in every speciality. I shadowed a family doctor in walk-in clinic, they are usually expected to assess the patients in less than 15 minutes. Since there are so many patients waiting (and trust me, they are grudging) , and also they are paid by act (at least in Québec). The doctor expressed the time constraints and limitations of what he/she could do in a walk-in clinic (i.e: no lab tests or imagery). You can't deal with more than 3 problems in a quick consultation, they are pretty good at what they are doing

The doctors are usually awful haha. Once in a walk in clinic I had a doctor decide the visit was done (probably lasted total of 40 seconds) and walk out on me as I was asking a question, but to his credit he did shout back an answer from the hallway as he was walking away. 

[xkittens]

That's generalizing. There  are good and bad doctors in every speciality. I shadowed a family doctor in walk-in clinic, they are usually expected to assess the patients in less than 15 minutes. Since there are so many patients waiting (and trust me, they are grudging) , and also they are paid by act (at least in Québec). The doctor expressed the time constraints and limitations of what he/she could do in a walk-in clinic (i.e: no lab tests or imagery). You can't deal with more than 3 problems in a quick consultation, they are pretty good at what they are doing

Of course I didn't mean to say that all walk in clinic doctors are awful, I was half kidding/half clarifying what the other person meant when they said to avoid walk in clinics in order to avoid rude doctors. But being someone without a family doctor that exclusively goes to walk in clinics, I've had tons of bad experiences with the docs.

[LittleDaisy]

Ahahah it's fine. We all have bad experiences with doctors in all the specialties.

I have great respect for family doctors, and I hope that all my future colleagues will too. It is not easy to treat all the clinical presentations and to be uptodate about all the new treatments and guidelines. 

Of course I didn't mean to say that all walk in clinic doctors are awful, I was half kidding/half clarifying what the other person meant when they said to avoid walk in clinics in order to avoid rude doctors. But being someone without a family doctor that exclusively goes to walk in clinics, I've had tons of bad experiences with the docs.