****The Family Practice FAQ****
This post is LONG overdue as there is a LOT of misinformation out there. Hopefully through this extensive FAQ, we will be able to clarify the truth about Family Practice as well as have an honest discussion about the good, bad, and ugly of FP. This has been previously posted on another forum. Just wanted to share it with y'all on this forum, as it will answer most of your questions if you were considering FP as a specialty choice.
What is the definition of Family Practice?
Here is the official definition from the American Board of Family Practice (ABFP):
Family Practice is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth, which integrates the biological, clinical, and behavioral sciences. The scope of family practice is not limited by age, sex, organ system, or disease entity.
What are the history/origins of the specialty?
[Excerpts derived from the American Board of Family Practice (ABFP) website]
Prior to Family Practice being officially recognized as a specialty by the American Board of Medical Specialties in February of 1969, there was the General Practitioner, or GP. This was an individual who did 1 year of an internship after medical school, and went into private practice. Various studies in the 1950s and 1960s concluded that "General Practice" was moribund. An analysis was made of specialty distribution of all graduates of every medical school by five-year periods since 1900 and from this data it was learned that the number of general practitioners was rapidly and steadily dwindling. In 1964, the percentage of graduates going into General Practice fell to 19%, down from 47% in 1900 and continuously diminishing. It was also noted that the ratio of physicians in private practice was dropping rather rapidly, and the deficit was obviously in what was termed the "Family Physician Potential."
The general response to this precipitous decline was "this is an age of specialization." The founders of the Board could only affirm this fact, believing that this response to the dearth of General Practitioners strengthened their argument for a new generalist-type of specialty called "Family Practice." Many students expressed the concern that the broad body of knowledge required for general practice was too great. This concern was also based in truth, in light of the tremendous expansion of medical knowledge and skills in the past few decades. Four years of medical school and a year of internship were indeed not adequate. The inadequacy of this training could be remedied only by having residency programs in a new specialty, Family Practice, argued the proponents of the specialty.
Additional factors explaining the decline were the lack of "prestige" assigned to the general practitioner in comparison to his/her more "specialized" colleagues as well as the difficulty experienced by the general practitioner in obtaining hospital privileges which were being given increasingly only to those physicians who were board certified.
In view of the data gathered by the Board proponents, it was proposed that:
-Family Practice IS a specialty, and
-as a specialty, Family Practice deserves well-defined but flexible graduate training programs, and
-That a Board of Family Practice is essential for the certification of competency of Family Physicians and for the participation in the guidance and approval of training programs.
The specialty of Family Practice, based on the heritage of General Practice, would have graduate programs (residencies) for physicians whose training would encompass 1) first-contact care; 2) continuous care; 3) comprehensive care; 4) personal care (caritas); 5) family care; and, 6) competency in scientific general medicine.
What procedures can Family Practitioners do?
Let me preface this by saying something that will ring true THROUGHOUT this FAQ, and that is MEDICINE IS REGIONAL Let me repeat that again so that it sinks in MEDICINE IS REGIONAL What goes down in rural Kansas, does NOT necessarily go down in South Florida. What is acceptable in New York City might NOT be acceptable in Dallas. What is ok in one county, may not be acceptable in the neighboring county. Other factors that contribute to what an FP can do are:
-Availability of other practitioners to do a procedure in a particular region
-POLITICS, POLITICS, POLITICS - Local hospital/regional politics play a MAJOR
ROLE in what can be done by whom.
-How aggressive the particular FP has been in getting the necessary training in that procedure in order to be competent in that procedure.
-What the local insurance companies are willing to pay for. Obviously one is not going to do a procedure if there is no chance for reimbursement.
-How much EXTRA one is willing to pay for in malpractice insurance premiums for the privilege of getting covered for that procedure.
-What the local hospital credentialing committee will allow in terms of staff privileges.
That being said, here is a list of procedures that FP’s can do depending on the ABOVE factors:
-Joint injections (knee, shoulder, etc)
-Suturing of lacerations
-Biopsies (punch, excisional, shave, etc.)
-Central line and peripheral line placement
-Closed reduction of simple fractures
-Drain simple abscesses
-Simple vaginal deliveries
-Chest tube placement
What can I do after completing my family practice residency?
The beauty of FP is that it is VERY flexible. One can mold what they do in private practice based on their individual needs and interests. There is NOT one model of private practice. Some possible variations:
-Inpatient-only practice (i.e. hospitalist)
-Mixed inpatient and outpatient
Can an FP work as a hospitalist?
The answer is YES, it CAN happen, but one must consider the above factors (region, politics, etc). It may be perfectly OK in one region, but not in another region. For example in my area (Southeastern US), FP’s CAN work for hosptialist groups, and make a good living doing hospital admissions for the different HMOs. I do not know the percentage of hospitalists who are FP’s, but it is MUCH smaller in proportion to the internists who are hospitalists. In other regions of the country, hospitalist work is pretty much exclusive to IM docs, and they are expected to take on more tasks than their counterparts in other regions (i.e. manage the vent themselves and place their own lines)
What about fellowships?
There are a limited number of fellowships available to FP’s. The main options are:
For a comprehensive list of fellowships available nationally, go to this website:
How competitive is it to get into a family practice residency program?
Currently, it is not very competitive. The most competitive FP has been was back in 1997-1998 when interest was at its peak and US med schools were actively encouraging people to go into FP. Since then interest has decreased, as the culture of US med graduates is now tending to gravitate towards highly paying specialties (anesthesiology, interventional radiology, IM subspecialties, etc). Obviously big city university programs, will have a larger applicant pool, and thus be more competitive. Every match season is different, and the applicant pool differs as well, so the competitiveness differs year after year.
What does a family practice residency consist of?
An FP residency is 3 years long and consists of a variety of rotations which include:
-Rural Medicine (depending on location)
-IM subspecialties (cardio, pulmonary, GI, etc)
-Continuity clinics (frequency per week depending on PGY level) in
which you steadily grow your panel of patients and follow them
throughout residency. With the exception of certain rotations,
continuity clinics happen no matter what rotation you are on.
What combined Family Practice programs are there?
There are programs that combine FP with IM, FP with Psych. These programs lead to dual board certification. This would be primarily for people who want a broad based training with the option of doing IM fellowships.
What do they mean by an “unopposed” program??
An unopposed program means that the FP program is based in a hospital with no other residencies in it. You will find these in smaller community based hospitals. You are unlikely to see that in a university hospital which has multiple residencies. In the opinion of this writer, unopposed programs are better, because it allows to more exposure and experience especially with procedures without having to compete with other specialties for that same case/procedure.
What kind of MONEY can I make being an FP??
This is the "million-dollar question". For me to just throw out a number would be MISLEADING. Although the PUBLISHED average is approx 120,000 per year, this in NO WAY indicated how much YOU as an individual will make. There are ZILLIONS of factors that determine how much you can potentially make. Here is a list of them.
-Years in practice - remember that you will not be rolling in dough the first year. First of all, you do not have a Medicare or a Medicaid number yet. That can take up to 6 months OR MORE to get. When you first start out, you are not on ANY plans yet either (Blue Cross, Humana, Avmed, TriCare, etc). Some of these plans are VERY slow to act, and it can sometimes take OVER A YEAR to get on. This is dependent on region, panel size, and whether a panel is open or closed. For example, it took me a WHOLE YEAR to get on Blue Cross and Humana. A panel may be closed on a particular month, and the next month, it is open, so panels can be very whimsical.
-Business Acumen - PLEASE remember this equation??
MD =/= MBA (MD DOES NOT EQUAL MBA)
That being said, just because you had the intellectual acumen to finish medical school and residency, THAT DOES NOT MEAN, that you have the business acumen to run a successful business and manage money. The two are NOT one in the same. If you are not good at being frugal and sensible and making good business decisions, you will fall into situations that will not be financially beneficial to you, and you will lose money.
-Who is working your front desk?? - This is often overlooked, your front desk person can make you GAIN money, and some can make you LOSE money. This is done by their attitude over the phone, how they treat patients when they come, how they handle the cash money, etc (remember, physicians are all at risk of getting embezzled).
-Who is doing your billing?? - This is another MAJOR factor. Are they making sure that $$ is collected, do they properly handle rejected claims and correct them so that you can get paid?? Do they give you a heads up to incorrectly coded claims??
How many plans are you on?? - Insurance managed care plans bring a certain VOLUME to your clinic. We always complain about the reimbursement, but most of the managed care plans do bring a significant volume to your clinic.
-Type of practice - Do you have an inpatient-only practice?? Outpatient-only practice?? Mixed inpatient/outpatient practice?? If you do inpatient work, do you take on call for unassigned admissions?? If so, what type of hospital?? county or private. Obviously, if it is county, you will get a higher percentage of uninsured admits that may or may not pay you. A private facility will have a higher percentage of insured patients.
-Do you do procedures?? - Procedures reimburse quite well. Don?t lose those skills.
-Group or solo?? - That plays a role too. In a group, expenses are shared, thus lower overhead, but in a solo situation, all the expenses are borne on you.
-Are you coding right?? - If you code all of your visits a certain level and miss out on opportunities to code a higher level based on YOUR documentation, you will lose money that way.
-Employed vs. Partner - Are you an employee of the practice or are you a full partner?? Keep in mind, one is not necessarily better than the other, cause in a partnership, everybody ELSE has to get paid before you do (secretary, nurse, bills, etc). If there isn?t anything left after everybody else gets paid, then, then you don?t get any money that month. As an employee, you have to get paid no matter what, cause you are on a fixed salary.
As you can see, I just scratched the surface on the factors that make a difference in how much $$ you make.
What is the lifestyle of an FP like??
Given the above-discussed variables, it is downright IMPOSSIBLE to say what one’s lifestyle will be like. No 2 FP’s are alike, thus no 2 lifestyles are alike.
How is FP viewed by the other specialties??
This is another variable situation depending on where you are. Local and regional politics play a BIG role in this. For example, in an academic university hospital setting that also has a department of internal medicine, it is often the case that FP plays a “second-fiddle” role. FP often gets treated as the red-headed stepchild. As, I have said in a previous post, if the University hospital were the Jackson family, FP often gets treated like TITO...LOL...The more complex cases (i.e. vented trainwreck with multiple problems) go to the IM folks, the leftovers go to FP. The situation is often OPPOSITE in a private practice private hospital. I will use my hospitals as examples. Where I am (Southeastern US), IM and FP are treated equally and interchangeably. There is just ONE on call list for medicine for unassigned admissions that both FP and IM take part in. One day it might be me on call for medicine, another day, it might be one of the IM docs on call for medicine. As far as the specialists are concerned, keep in mind, that they NEED FP and IM as a source of referrals. When I admit, I decide who I want to consult. So if they want me to call them for referrals, they better be nice to me 8)
As an interesting side note, check out your local FPs office around Christmas time, you will see it FULL of various gift bags and food, all sent from the local specialists .
If you are good at what you do and interact well with others, you will be viewed positively by the other docs. If, on the other hand, you are lazy, shiftless, don’t get along with others, don’t evenly distribute consults, etc, then you will not be looked on favorably by other specialists.
What is the role of FPs in the ER??
This is another case that depends on region and local politics. Throughout the country, FPs work in the ER in various capacities. In a large city ER, this may be restricted to only board certified ER docs who did ER residency. Long time ago, when ER was beginning as a specialty, they allowed certain # of FPs to grandfather into board certification if they did certain # of hours in the ER and documented it. That no longer exists. In certain big ERs, FP can still work there, but they make them work in the fast-track section of the ER. That is the area where people with minor stuff are seen (lacerations, cold/flu, etc). Each hospital will have their own policy with regards to FPs working in the ER. Some FPs use the ER work for extra income, whereas some make their full time gig. That is the beauty of FP, one can tailor it to fit your taste and preferences.
Can FPs be consultants?
YES. Although your role is that of a primary care doc 90+% of the time, there are times when you are called in for a medicine consult both in the office as well as hospital setting, and thus can BILL accordingly. For example:
-OB-GYN?s sometimes want a medicine consult.
-Surgeons sometimes want medical consult and/or clearance prior
to a procedure.
What about kids?? What is the difference between the care provided by a pediatrician vs. an FP??
This is another issue that depends on region. But before I do so, I need to point out TWO important concepts?
1) The world of residency and the world of private practice can possibly be 2 COMPLETE DIFFERENT WORLDS
2) MEDICINE IS REGIONAL (I cannot say that ENOUGH TIMES)
That being said, let me start off with the differences in training during residency:
PEDS - This residency consists of 3 years of JUST KIDS ONLY less than 18 y/o. During the 3 years, one rotates in the various pediatric subspecialties (cardio, pulm, neuro, hem-onc, general inpatient ward, NICU, PICU, etc) as well as continuity clinics where they follow a panel of patients throughout the 3 years. After training, there are 2 common pathways: One is Fellowship in one of the pediatric subspecialties, and the other is general pediatric practice which may be outpatient only, outpatient/inpatient mixed, or inpatient only (i.e. hospitalist)
FP - This residency consists of 3 years of various adult and pediatric rotations. Most of the pediatric rotations will center around general peds with some subspecialty exposure. Of the 36 months of FP residency, approx 6 of those are devoted to pediatrics and ped-related subspecialties (general outpatient peds, general inpatient pediatric ward, NICU). In addition to that, when one is on the FP Inpatient service, this will be a mixed service made up of both adult and kids of all ages, so your rounds may consist of a trip to the NICU, Labor & Delivery, as well as the adult ICU. In addition to that, one has electives in which one may choose to do an extra month of peds or ped-related subspecialty (I did one in Pediatric Dermatology when I was a senior resident). Even further experience is gained through your continuity clinics which you do from day 1. In your continuity clinics, you follow ALL ages, from newborn babies to the elderly. Through the 3 years, you get a well rounded balanced pediatric experience that mirrors the issues you will encounter in private practice - which leads me to the next question??
“Wait a minute, Peds residents get much more months of exposure during their training, aren’t they better equipped in the private practice setting to handle kids vs. an FP???”
Before answering that question, let me repeat/remind you of the 2 concepts I stated before:
-MEDICINE IS REGIONAL
-THE WORLD OF RESIDENCY AND THE WORLD OF PRIVATE PRACTICE CAN Be VERY DIFFERENT.
In a residency setting, peds residents see on average more “sicker” patients and do more inpatient work than is done by FP residents, however this is not the reality of private practice. In the world of private practice, peds clinic is the main source of income (unless you are a hospitalist, which in that case you are salaried). For an FP in residency, you will get plenty of exposure to the bread & butter stuff that you will likely see in private practice. Yes, you will have some sick/critical cases, but NOT the same volume as your PEDS counterparts. The scenario changes in private practice:
For a pediatrician in private practice, 95% of the cases seen in that clinic are what we call “bread & butter” cases (well child checks/vaccinations, upper respiratory infections, otitis media, gastroenteritis, rash, ADHD, asthma, school/sports physicals etc.). If you admit to the hospital too, most admissions will be bread & butter as well (asthma exacerbation, dehydration, meningitis, pneumonia, etc). Anything exotic or beyond the bread and butter gets a referral/consult to a specialist or possible transfer-PERIOD. The reasoning is twofold. One is LIABILITY. In this lawsuit culture that we live in, you WILL be faulted for not consulting a specialist if the child had a serious condition that could have been prevented from getting worse. Second is REIMBURSEMENT. In private practice, the LARGE proportion of kids will fall under the state Medicaid program. In most places, these programs are CAPITATED HMOs. That means you get a fixed dollar amount per month per patient WHETHER YOU SEE THEM OR NOT. After you see someone for 1 or 2 visits for a particular problem, it works AGAINST you to keep on seeing them for the same problem. It is the prudent thing to refer out after 2 visits for the same problem, especially if you are on a capitated Medicaid plan. Even if the child has a fee-for-service PPO (which is not capitated), the prudent thing to do is still refer out if the problem hasn’t been solved in 2 or 3 visits.
An FP in PRIVATE PRACTICE functions pretty much the same way as a ped in private practice. The only difference is that you see adults as well, and you can wind up seeing the WHOLE family from grandma to little baby john (the true meaning of FAMILY practice). Because of this, the volume of kids you may see in the clinic may not be as much as your PED counterparts. The kids seen in an FPs office are the same bread & butter stuff that the peds see as well (well child/vaccinations, asthma, URI?s, UTI?s, coughs/colds, otitis media, gastroenteritis, adhd, school/sports physicals, etc). If the FP admits kids to the hospital as well, those admissions are of the same bread & butter type as I mentioned before (asthma exacerbation, dehydration, meningitis, pneumonia, etc.). Anything exotic or beyond the "bread & butter" stuff gets a specialty referral/consult. In some small towns in the US, there are no pediatricians. I have personally been in those towns. ALL the peds work is done by FP. In the larger cities, there is a large volume of peds, thus the # of kids that are seen by FP is much less. There isn?t one specific pattern, it all depends on REGION. Irrespective of FP vs. PED, no matter where you are, a REALLY bad/sick/crashing kid WILL get shipped off to the nearest tertiary facility, as most smaller private do not do not have ped sub specialists, nor the capabilities of handling a very sick kid.
I hope this puts to rest the FP vs. Peds issue
What is the difference between family practice and internal medicine??
The main difference is that Internal Medicine is the specialty that deals with ADULT disease and treatment ONLY. Nobody under 18, and no OB. Family practice deals with adult medicine as well, but also includes treatment for all other age groups (from Newborn till Elderly) and may or may not include an OB component (depending on region and personal preference of the practitioner). First, let me compare the residency training.
For IM residents, ALL rotations are in adult internal medicine and subspecialties. There is NO OB or peds. The only interaction with pregnant patients will be as a consultant for women in labor & delivery who develop a medical problem on top of their pregnancy (ex. out of control diabetes, cardiac problems, etc). As an IM resident, you will get more ICU exposure then the FP residents, and you will get to do more of certain procedures then the FP residents (central lines, Swan-Ganz Catheters, etc)
FP residents not only do adult medicine rotations, but pediatric rotations as well. They also have to do certain months of Labor & Delivery, where they not only play an active role in delivery and management of pregnant females, but also the management of medical conditions on top of the pregnancy that may occur (with the appropriate consultations of course).
Another difference is what occurs after residency. IM residents can do a fellowship in the various subspecialties, whereas FP has a limited # of fellowships that can be done. These have been described earlier in this document.
Here is the interesting twist....
In the world of PRIVATE PRACTICE, these differences are not as sharp as in residency. The reason being is that as a private practitioner, your malpractice insurance as well as your hospital privileges WILL NOT cover the broad range of things you once did as a resident, especially when there are enough specialists around to do that. YES, an IM resident has put in more central lines than an FP resident, and placed more swan-ganz, etc, but in private practice, especially in MY neck of the woods, you will be HARD PRESSED to find ANY private practice general internist who does those things for the reasons described above.
In a nutshell, when it comes to the private practice world of an IM vs. an FP, basically BOTH FPs and IMs on a daily basis handle the SAME bread & butter type of adult cases (hypertension, diabetes, thyroid disorders, upper respiratory infections, gastroenteritis, heart disease, rashes, etc - which will make up 90+% of your office day), and are reimbursed the SAME from Medicare and managed care insurance companies. A level 3 outpatient visit (there are 5 possible levels)-(a.k.a. 99213) is reimbursed the SAME whether you are an internist or an FP. Anything beyond bread & butter management is referred out for the SAME reasons as I described in my Peds vs. FP comparison.
When it comes to inpatient medicine in the PRIVATE PRACTICE world, FP and IM function the same way as well. Both admit bread & butter admissions (exacerbation of CHF, chest pain-r/o mi, sepsis, MI, altered mental status, pneumonia, nursing home “trainwrecks”, etc). and BOTH will obtain the appropriate consult when warranted - no difference. Did the internist get more experience managing a vent in residency?? YES, but again, you are going to have a VERY hard time finding an general internist in private practice who manages his own vent without calling pulmonary. Again, varies by region cause recent discussions with my buddy Picard out in California revealed that IM hospitaists out in certain parts in California are expected to take on the FULL ICU role and manage the vent themselves. One must be careful though, cause if there is a bad outcome and you didn’t get a consult when you should have, you WILL get nailed. Lawyers salivate over stuff like that!!!
It is to the point that FP and IM in most regions are both used interchangeably by hospital staffs as well as managed care companies. Obviouly there are places where that is the exception. ONE exception is in places that do not have any IM sub specialists (cardio, pulmonary, gastro, etc), the local internist may be the one that has to do certain subspecialty procedures (reading echocardiograms, central lines, swan-ganz, thallium stress test, bone marrow biopsies, etc), primarily because there is no one around to do it. This phenomenon exists primarily in small towns with NO sub specialists, so the FP does most of the “bread & butter” stuff, and the IM serves as the quasi-specialist. I have seen this myself in certain Midwest towns.
What is the difference between FP residency and Med/Peds residency, and what is the significance in private practice??
Basically, Med/Peds is a combination residency that combines IM and Peds into a 4 year residency (half medicine rotations, half peds rotations). These programs do not include OB rotations or general surgery. At the end, one must obtain and maintain board certification in BOTH specialties (that means 2 separate exams). In FP, there is just ONE board certification to maintain. For Med/Peds, after residency, one may elect to do a fellowship in either an adult, pediatric, or combined adult/ped subspecialty. In FP there are limited fellowships which are already described.
Here is where the differenced end - In the world of private practice, BOTH function the same. The only difference is IF the FP decides to include OB in his/her practice, then the med/peds doc cannot cross-cover. BOTH groups will handle the same type of bread & butter adult and peds cases with the APPROPRIATE referral to a specialist when warranted. There is no difference in insurance reimbursement between the two for a particular case.
What about the OB component of FP?? What is the difference between care provided by an FP vs., an OBGYN??
Here is where the results are VARIED based on REGION. While FP does require certain months in labor & delivery, how intense of an experience it is varies by the program and location. An FP resident will get more OB experience in an UNOPPOSED residency vs. a university based one with OB residents. After residency, many FPs elect NOT to incorporate OB in their practice (including yours truly). This is done primarily because of the numerous liability issues involved (your malpractice premium will SKYROCKET if you include OB). Plus, it may be VERY difficult to get the necessary hospital privileges to do OB (all dependent on region). Furthermore, you BETTER have a sufficient volume of OB work to justify and offset the increase in your malpractice premium or you will LOSE money.
In those areas of the country where FPs do OB. They work together with the OBGYNs and share call coverage for labor & delivery. FPs who do OB commonly handle routine non-complicated pregnancies and deliveries. Complex situations are automatically referred to an OBGYN or transferred out to a tertiary facility. SOME FPs in certain areas have c-sections privileges, and some don’t. All depends on region and local politics as well as the training of the individual practitioner.
And last but not least?
Is FP right for me??
There is NO WAY that anyone can answer this question for you other than yourself. You have to take MULTIPLE factors into consideration like you would with any field. If you go into FP because you are TRULY interested in it, then you will find it rewarding and fulfilling despite the fact that other specialties make more. However, if you went into FP out of default (i.e. couldn’t get anything else), then there is a SIGNIFICANT chance that the stressors will begin to wear on you and your satisfaction will decline. No matter what these political pundits and commissions say, I can tell you categorically, there IS and ALWAYS WILLL BE a need for a GOOD primary care physician who cares for his/her patients and makes people feel better and live longer…PERIOD!!!