Family Practice or Internal Medicine???

[anu]

I had applied in IM and FM. I have been offered residency in both. Can't make-up my mind. Which is better in the long run. Please advise.

Anu

[teratos]

are you interested in doing OB/gyn and peds. If so do FP. If that doesn't appeal to you, or if you may condsider a fellowship after residency, then you really should do IM. G

[jim]

if you would prefer taking care of people who are not too sick,a nd then calling in the "cavalry" when things go bad, do FP. if you would prefer to be teh cavalry, do IM.

[anu]

Thanks for the reply.
Thats an excellent way of putting it.
It makes it clearer to me.
Any more suggestions?

Anu

[dksamp]

if you would prefer taking care of people who are not too sick,a nd then calling in the "cavalry" when things go bad, do FP. if you would prefer to be teh cavalry, do IM.

{I apologize for my LATE response...been busy...Couldn't resist}

LAWD HAMMERCY!!!!!!! this has got to be the most IGNORANT thing I have ever heard heard. What are U?? Medical student?? Resident?? You obvioulsly don't know a GAT DAYYUM about the world of private practice. Please don't confuse the world of residency with the world of private practice, cause that can skew your view of the real world.

Now, I WILL admit that, in MANY UNIVERSITY-BASED RESIDENCY settings, when it comes to the ER unassigned stuff, the train-wreck vented ICU patient goes to the IM service and the leftovers go to FP. That is NOT the case in the community-based programs where FP runs the show. In the world of private practice, where in my region, IM and FP share the SAME unassigned on-call rotation in the hospital, so BOTH have equall access to the good, bad, and UGLY cases.

One correlation I HAVE noticed is that the "sickness" of the patients you take care of is NOT necessarily correlated by the whether comeone is FP or IM, I see more of a correlation with the INSURANCE that the patient is carrying, for example, patients with the CAPITATED medicare HMO's in my experience seem to all be sick-as-all-hailll.

Also remember, that is private practive, the "cavalry" is your CONSULTANTS, NOT the IM doc with no specialty. BOTH IM and FP rely on the consultants to be our Calvary when presented with a challenging case. In this malignant medico-legal-litigious society of ours, BOTH IM, and FP call in the calvary in equal degrees, cause NOBODY is paying you one extra penny to be the cowboy/hero, and by the way, trying to be the cowboy-hero is the fastest way to get yourself SUED!! COMPRENDE??
I am getting reimbursed the EXACT SAME as my IM counterparts for a medicare case whether it is a simple case or a TRAINWRECK, and the consultants are more then willing to help, cause these are your buddies that you see daily. So let's please drop this 2-tiered mentality regarding FP vs IM, cause in the real world, the differences are not as profound as you think.

Tha MAIN thing in deciding between IM and FP is this............

IM
-adults ONLY, large proportion of geriatric action
-can do subspecialty after residency (Card, GI, Nephro, etc)

FP
-adults, geriatric, kids, babies +/- OB (depending on region)
-VERY LIMITED choices for fellowship after residency (OB, Sports med, Geriatrics, Faculty development)...NOT FOR YOU if you want to subspecialize

In the real world of private practice, BOTH see the bread & butter cases on a daily basis with a referral out to a specialist for anything funky. No heroics here 8)

And with that I close...PEACE!!!

-Derek

[Picard]

As a private practicing internist/hospitalist who also teaches in residency programs on occasion, here's my observation.

FP training is broad based outpatient training. They do not get anywhere near as much inpatient training as internal medicine residents do. The also have very little critical care training in residency. FP's make excellent primary care outpatient docs. But they are not trained in inpatient care. This is why there are virtually no FP-trained docs practicing as hospitalist, as many do not qualify for category 2 privileges.

IM training is very much inpatient based. Many IM residents who go into traditional outpatient practice find themselves having to re-learn outpatient medicine in the first few years of private practice. Since UCSF coined the term/concept of "hospitalist," it's spreading like wildfire across the country. And that makes sense -- traditional internal medicine training IS inpatient based. Most hospitalist have full ICU privileges. We flow our own swan ganz catheter, manages our own patients on ventilators, intubate patients, run codes, do our own thoracentesis/paracentesis/central lines, and chest tubes. A few of us even have privileges to flow temporary intravenous pacemakers. Yes, we do consult subspecialists on difficult cases... but by-and-large, by the time we consult subspecialists, all the work up has been done and we are asking the subspecialist to do procedures we can't do -- cardiac cath, EGD, bronchoscopy... etc, where as FP docs in our community who admit their own patients will often consult subspecialists from day one.

It's not about being "heros" or "calvary"... it's simply that we have very different trainings. We live and breath inpatient medicine where as FP's live and breath outpatient medicine. In the next 10 years, we will see more and more clear split between inpatient and outpatient practices as hospitalists movements gain more and more popularity. I have a great deal of respect for outpatient FP docs who see enormous amount of patients in busy outpatient settings -- I simply don't have the training to do that. I know that when I discharge patients from hospitals, they are going back to capable hands. The reverse is true... our outpatient FP docs have the confidence that when their patients hit the hospital door, they are going to be cared for by "hospital medicine specialist" who live and breath in-patient medicine. Incidentally, "hosptial medicine" is currently a separate department in our private practice.

P

[jim]

I must agree with Picard. and I expect that in the next few years, the gap will widen. But where I am at, the FP docs run the outlieing hospitals, and send us the sick patients, while keeping the easy stuff. and yes, we do swans, vents, and all that, and only call the specialists for thinsg like scopes and caths(and obviosuly surgerys, though we do all chest tubes, lines, etc). oh, and we call OB/gyn for any of that "women stuff".

[dksamp]

Hey Folks,

As a private practicing FP/hospitalist who sees patients in the clinic as well in the hospital, and whose also is on faculty at the local medical school, here's my observation…

First, I wanna say I am glad to be back in the swing of discussions on this forum. If memory serves me correctly, I think Picard and I have had a similar exchange in the past (1 yr ago?? Not sure), however, this exchange highlights one VERY important concepts that I have said over and over again in another forum and that is:

MEDICINE IS REGIONAL….lemme repeat that so that it sinks in…

MEDICINE IS REGIONAL

What goes down in NY doesn’t go down in California, and what goes down in the Midwest does not necessarily go down in South Florida. Even more specific, what may happen in one county would never fly in the neighboring county. That was the first thing I noticed when I moved to the east coast to begin private practice.

Picard, please refresh my memory….are you trained in ONLY IM?? or did you do a Critical Care fellowship as well? My next question is: are you a salaried employee of the hospital?? Or are you an independent contractor?? Because if you did ONLY IM and are doing all those procedures that you listed (swan-ganz, chest tubes, etc), that is very interesting, because where I am located (LARGE east coast city), there is not a single internist at ANY of the hospitals I go (and I am on staff at 4 hospitals) to that do ANY of those things you describe. If they need it done, they pick up the phone and call their specialist buddy to get it done. The specialists are more than willing to help you out. That’s what they are there for. Now I understand that’s how things run in YOUR REGION…However, lemme break it down on how things go in my neck of the woods (large Southeast coastal city)….

I am a board certified FP who trained in an UNOPPOSED training program in the midwest. I am a HUGE proponent of training in an unopposed program as opposed to the big university programs where FP is treated like the red-headed stepchild. If the hospital were the Jackson family, FP often gets treated like TITO !! LOL..but I digress…
I do both inpatient and outpatient medicine and have full admitting privileges (including ICU) in all my facilities. All of the GENERAL internists at my facilities (i.e. those who did NO fellowship training) function in the same way as I do. In fact, I cannot think of one single thing that they do that I am not allowed to do in the hospital. Yes, all of the internists during their TRAINING did swan-ganz, IABP, chest tubes, vent mgmt, etc IN TRAINING. However, when you leave residency, the almighty dollar as well as YOUR MALPRACTICE INSURANCE PLAN plays a HUGE influence in what you do and what you chose NOT to do. I do not care how many vents one has managed in residency, if you come to my hospitals and visit the ICU and see the vented patients. It doesn’t matter if the attending is an IM or FP. On ALL vented patients in my facilities, there is a pulmonary/critical care consultant on the case. Medico-legally, it is the right thing to do (especially in my region), and from a financial POV, neither myself nor any of the IM guys are getting paid one penny more to micromanage a vent patient. I still get the daily 45.00 from Medicare per patient (100.00 for the H & P). so if they are gonna wake someone up in the middle of the night with ABG’s or vent settings, let them wake up my Pulmonary/Critical Care buddy who is more than willing to help out and he gets paid too. I get to sleep and still paid for my daily note.

Also, let us keep in mind, that the role of a hospitalist DIFFERS by REGION (there’s that word again). Here in my neck of the woods, BOTH IM and FP can serve as hospitalists. The private hospitals do not hire hospitalists, only the county ones do. The way it works is that there are private hospitalists COMPANIES (Hosptialists of America, ICS, etc) that contract with the various HMO’s to provide an admitting panel whenever an HMO patient (blue cross, Cigna, Humana, etc) shows up in the ER and needs to be admitted. You admit them, take care of them till discharge, and send them back to their PCP. It doesn’t matter if a hospitalists is IM or FP, cause they will function about the same. I have YET to see my IM counterparts in MY REGION doing anything different. In fact, just the other day, I asked one of the other hospitalists who is an IM, when was the last time she placed a central line. Her answer was 8 years ago, on her last day of RESIDENCY, and she has been a full-time hospitalist since her IM residency. If she needs a line placed, she calls one the intensivist or calls the surgeon. One of the reasons you will not see any of the hosptialists here doing a bunch of procedures, is that the ones in my region are getting either a flat salary OR a flat per-admission global fee, same for 24 hours as it is for 24 days. “Why do the extra procedure if you are not getting paid for it”?

One region in which I have seen IM play a different role than FP is in areas of the country especially in the small town midwest where there are NO specialists. Under these circumstances, the FP does most of the bread and butter work, and the IM serves as the quasi-specialist (reads echo, EGD, central line, colonoscopy, Bone Marrow Biopsy, etc). I also have seen these types of roles played out in military hospitals.

So my point is, PLEASE don’t make a broad brush statement and apply it to the rest of the country and the rest of the docs,, cause you’ll be amazed at the differences in the flavors of medical practice in the different regions. And with that I close. PEACE!!

-Derek

[grace]

Thanks for that post, very informative!

[Picard]

Derek,

No flame intended. I have much respect for my FP counterparts who are primary care physicians. You are right, medicine is very regional. Hospitalist, as what UCSF coined/envisioned/started is an evolving specialty, much like what Emergency Medicine was when it first achieved primary board status. And yes, there is a HUGE difference in hospitalist practice across the country. In the next 10 years, we will see a much more clear split between inpatient and outpatient medicine. Your friend who has been out of IM residency for 8 years practice more like a traditional internist than what hospitalist is envisioned to do. We actually see that distinction in our local practice -- hospitalists who have graduated in the last 3 years practice very differently than hospitalists we hire who have been out of residency more than 5 years ago, many of them had worked in traditional practices. General concensus among IM faculty/programs is that in the near future, one of two things will happen -- either categorical IM residency will completely shy away from outpatient training and IM will essentially become hospitalist programs, OR hospitalist will become a subspecialty of IM with "added qualification," either as a one year fellowship or as a separate independent track within IM... And hospitalist practice will evolve and become more like what our practice does. Many IM programs now have a "hospitalist track"... I will be heading up the development of "hospitalist track" in my next faculty appointment. And yes, at this time, it's very regional.
In my current practice (California, but West Coast in general... also in Pheonix, AZ), hospitalists are expected to have full ICU privileges and manage ventilator patients and place our own lines... IR will help with difficult lines, but your run of the mill central lines are ours. And since one of the complications of central lines is pneumothorax, we need to know how to place chest tubes... no, we don't do chest tubes routinely, but we are expected to be able to take care of our own complications. Not all of us have Swan and intubation privileges... but most of us do. We are a step short of requiring intubation skills because we can't always rely on ER or anesthesiologist to back us up in codes. And yes, we get reimbursed for our procedures in addition to our daily 99232 notes. And yes, we can and do bill ICU 99291-99292 and up and get reimbursed accordingly at the same rate as what a pulmonlogist does. Yes, we are a very young group... almost all of us graduated from IM residency within the past 5 years. We are a separate department ("hospital medicine") within a large multispecialty group. Our contract with insurance carriers list hospitalist as a specialty service. Yes, our group is in one extreme of hospitalist work. But in recent years, more and more groups are becoming like us. In Pheonix, you will have a hard time finding a hospitalist job without ICU-type skills.

Yes, it's very regional. And yes, the "west coast style hospitalist" practice is rare on the East coast (wife spent some training time on the East Coast). But what we envision in the next 10 years is that the west coast style hospitalists practice will become more standardized and hospital medicine will become a specialty by itself.

Again, this is just my experience in my neck of the woods. Again, let me say that one is not better than the other... just different training backgrounds, that's all. I have much respect for my FP counterparts because I don't have the skill to see 30 outpatients a day and manage an office...

P