Wayfaring MD

I am a family medicine resident who likes to highlight the hilarious in medicine as I write about patients, medical school, residency, medical missions, and whatever else strikes my fancy.



Disclaimer:
HIPAA is for reals, folks. All of my "patient stories" have been changed to protect patient privacy. I will change any or all identifiers, including age, location, race/ethnicity, sex, medical history, and quotes. Also, I am an anonymous internet person. Why should you trust an anonymous internet person to give you medical advice? Don't ask me, ask your doctor!
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Posts tagged "family medicine"
Asker Anonymous Asks:
How much time do family med/primary care doctors spend in the hospital vs at their practice?
wayfaringmd wayfaringmd Said:

That varies highly depending on what type of practice they have (this is all referring to jobs after residency, of course.)

Some family docs are hospitalists who spend 100% of their work time in the hospital.

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Some do outpatient only and don’t spend any time in the hospital.

Family docs who go into “traditional” practice and see their own patients in the hospital may spend 1-2 hours a day in the hospital, not including time spent following laboring OB patients. Then they might work 7-8 hours in clinic, and possibly go back to the hospital after that.

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This type of practice is very draining and is becoming rare with the advent of hospitalists. But if you’re in a small practice or share call with a lot of docs, the mixed practice can still be do-able.

Asker Anonymous Asks:
I heard that family doctors/GP's make $200,000 salary? Is this true? and is this the immediate salary they get after their two or three year residency program? Thanks!
wayfaringmd wayfaringmd Said:

Doctor salaries in the US vary widely based on geographic location, hours worked, years in practice, and practice type (outpatient only, inpatient/outpatient, with/without OB, urgent care, hospitalist, with/without nursing home). But yes, I believe the national average for family doctors is around $185,000 a year. For doctors straight out of residency, it’s a bit lower. The Internet tells me that average starting salary is around $140,000, but in the last few years and my residency program, residents have averaged about $175,000 as a starting salary (and not even working in metropolitan areas). It’s a nice jump from the average $40-$50,000 a year that residents average.

Of course in our current system, salary is based on what you bill for, and procedures generally are reimbursed much higher than office visits. So if you do a lot of procedures, especially if you’ve done something like a sports medicine fellowship and have learned to do ultrasound guided injections or have been trained in endoscopy, your take-home pay will likely be a bit higher.

Asker Anonymous Asks:
Hi! So I've been reading your answers to questions about what family med doctors do. It's cool that you can do so much, but I was wondering if you end up making a good amount of referrals because you can't be highly trained in everything. For example, if a woman came in and she was, say pregnant with twins or triplets, would you refer her to an ob who had training with more complex pregnancies?
wayfaringmd wayfaringmd Said:

I don’t do tons and tons of referrals, but I do them when they are warranted. I’ve seen some family doctors that do nothing but refer all day. They even send all of their diabetics to endocrinologists because they don’t know how to manage diabetes. That’s pretty sad to me.

The point of a referral is to get the opinion or skills of someone who has more training than you do once you have exhausted your capabilities. We also refer out for procedures or treatments that are outside of our comfort zone or scope of practice. Laziness is not a good reason to refer people to specialists.

For example, I might refer a patient to G.I. if I think they need endoscopy or to cardiology for an echo. But I am comfortable managing diverticulitis or heart failure without their help in most cases. I am very comfortable cutting off moles off of arms, legs, and abdomens, but if it’s huge or super deep or on the face I send them to dermatology or plastic surgery. If I think a patient has a complex or uncommon medical problem, I will begin the work up and order the appropriate labs before I refer them out. 

I may also refer out when I have exhausted all the options I am trained in or am comfortable with. I can manage a patients knee osteoarthritis (or back/neck pain) for years with medication, therapy, and injections before I send them to ortho (or neuro) surgery.

I definitely refer out high-risk pregnancies, which would include multiple gestations, severe preeclampsia and gestational diabetes (though I do manage these frequently if they are not severe), moms with multiple complex comorbidities, and certain fetal defects, to name a few.

Sometimes you also need to refer out because a patient requires a drug that is outside your scope of practice to prescribe, like chemo or certain DMARDs for rheumatologic conditions or certain narcotic pain medications. 

Occasionally you get a patient who doesn’t trust you or who has read too much on WebMD and has already diagnosed themselves and they request to be referred to a specialist. Generally I will comply with the request but I will also tell them what I expect the specialist will tell them.

I’ve been looking at the NHSC scholarship, and they distinguish between regular family practice and family practice with OB. If a FP does OB care, is the residency longer, or is that included in the regular FP residency? I don’t want to be an OB/GYN, but I’d like to do low-risk OB care along with my FP practice. -drveebs2b

 ALL family doctors are required to do a minimum number of deliveries and learn prenatal care. The minimum number of required deliveries just dropped from 50 to 25 because so many family docs end up not practicing OB once they finish residency (hence the plain FP). Some programs will offer an OB track that affords more opportunities for deliveries, OB/GYN procedures, and prenatal care training. To practice FP/OB, you do not have to have any special training beyond your normal 3 years of family medicine residency. Once you graduate, you are considered capable of managing low-risk pregnancies and deliveries. But some people WILL opt to do an extra 1 year OB fellowship after residency to get more experience and to learn to do C-sections (also, a few FP residency programs still teach C-sections). 

I really like the idea of having “long term relationships” with patients, so I’m leaning toward Family Med. BUT I also really like kids and women’s health so I guess I was wondering how often family practitioners see kids since there’s pediatrics or do lady stuff because of OB/GYN. -goldroadtonowhere

On an average day in the office, if I see 10 patients, 1 or 2 are there for an OB or GYN issue, and 2 are kids. Some days are more OB and Peds heavy than others, though. Today I saw 1 pregnant lady, 1 recently post-partum lady, 1 lady who was miscarrying, 2 kids, and 5 adults medicine patients.

Family medicine is great because you can sort of tailor your practice toward what you’re interested in and still practice broad medicine. Once you graduate, if you decide you love caring for women and children primarily (as do I), you may join a practice and make a deal that this is the population you will mostly see. Or you can just decide to accept more of a certain demographic of patient into your practice so that you can do more of the medicine you like doing. And after a few years, you’ll also develop a reputation in the community as having a certain niche, and those patients will find you. 

Family medicine residency programs also vary a lot on how much of each patient type you see. There are requirements from the accreditation organizations about how many pediatric and OB encounters and procedures you are supposed to have during your residency, so everyone has the same minimum training. But you will find that some programs are more sports medicine heavy, or geriatrics heavy, or OB heavy, for example. I liked mine because it was very solid all across the board. But if you prefer peds/OB, you may be interested to find a program that has extra strong Peds and OB teaching or even special tracks as mentioned above. 

Asker Anonymous Asks:
is family doctor the official term? or what do they call it in med school
wayfaringmd wayfaringmd Said:

The person is a Family Doctor or Family Practitioner or Family Physician.

The specialty is Family Medicine or Family Practice, which is what they call it in medical school.

Our professional organization is called the American Academy of Family Physicians.

We don’t use the term “General Practitioner,” although the term is sometimes used interchangeably with FP by laypeople. Outside of the US, a GP is probably the closest thing to a Family Doc and has a more specific meaning. Inside the US, the term GP is somewhat vague and dates back to the days before Family Medicine was a recognized specialty with its own training requirements. It described doctors who completed a rotating internship year (the mandatory minimum to practice medicine) but not a full residency program (which weren’t then and still aren’t technically required) and couldn’t claim a certain specialty. 

In the fall I’ll be a high school senior and I’m really looking to become a doctor. I know I have awhile before I have to pick my specialty but I was just wondering what you do specifically in family medicine? Do you work in a hospital? How long were you in school? Etc and how do you like if so far? - running-to-be-fit

To be a family doctor, I went to 4 years of regular college, 4 years of medical school, and now I’m in my 3rd (of 3 total) year of residency. At the end of this year I will take Family Medicine Boards, pass, and be a board certified family doctor. 

Family docs do ALL THE THINGS.

We work in hospitals, clinics, urgent cares, and ERs.

We take care of babies, pregnant ladies, kids, grown ups, and old people.

We manage contraception, pregnancy, post partum care, GYN issues, and erectile dysfunction. 

We focus on both preventive care and acute & chronic disease management.

We manage heart failure, liver failure, and kidney failure. All the failures.

We take care of patients with heart attacks and bad lung function and strokes and infections and endocrine and rheumatic disorders.

We treat psychiatric disorders, tackle complex social environments, and deal with law enforcement and social services regularly.

We cut off moles, lance abscesses, sew lacerations, remove toenails, splint breaks and sprains, inject vaccines and steroids, do Pap smears and colposcopies, and sometimes do colonoscopies and minor surgeries.

It’s hard to narrow down to specifics because family medicine is, by definition, a broad specialty. It is a super great specialty and I wouldn’t want to do any other.

Did you ever consider any other specialties? -anon

Back in the days before college even, I wanted to be a forensic pathologist. I was pretty serious about it. Went to see autopsies and errythang. You can read about what changed my mind here.   I also briefly considered infectious disease (cuz it fits with my missions aspirations), but ultimately, I’m too easily bored with seeing the same thing over and over again, and I like live patients, so I went with family medicine. 

Did you have to decide between two areas of medicine, for example pediatrics vs. surgery? If so how did you make that decision? -anon

Unlike many med students, my specialty decision was pretty easy for me. When I’m making big decisions, I tend to think in very black and white terms, so I didn’t have a lot of internal struggle about my specialty choice. Surgery was never a consideration for me because I enjoy sleep and my personality wasn’t right for surgery. I enjoy peds but also really like adult medicine —the pathology is very different. I like peds enough to do it as a family doc, but not enough to be a pediatrician. Basically, I like a little bit of everything, so I chose the specialty that lets me do a little of everything. 

EDIT: 

If you’re trying to decide between 2 specialties, make a list of all the things you love and don’t-so-much love about each. Fast forward 15 or 20 years. Will those same things you enjoy sustain you, or do you think you’ll get tired of them? Are the dislikes minor or are they potential deal breakers? Also think about the practice setting options each will offer and the lifestyle each can afford. Think about your own personality and compare it to the personalities of attendings you have seen in each specialty. Which fits you more? Explain the differences to your significant other; which specialty fits the life that the two of you wish to have? 

And if you still can’t decide, apply and interview at both. Your interview process may help you decide. 

Asker geetles Asks:
Hey! So my med school gave me the opportunity to go to Kenya as a medicine elective. We had a free clinic in the slums and saw thousands of patients and it basically was the greatest experience of my life so far. I, like you, would love to do international medicine and missions in the future. I really enjoy primary care and I'm going for the 15 match. Do you think FM is the best way to go? How do you plan on continuing for international medicine post-residency? Thanks!
wayfaringmd wayfaringmd Said:

I think Family med, internal med, peds, OB/GYN, general surgery, or emergency medicine would all be very useful in full-time missions, and pretty much any specialty can be used on short term (at minimum). Family medicine covers the widest range of ages and conditions, so it works perfectly for missions. Plus family docs (and pediatricians) tend to put a lot of emphasis on prevention and continuity of care, which typically have not been strong in countries with developing or under-developed medical systems, though it is improving in some places. 

Above all, the best specialty for you is the one that you enjoy most. You can use any specialty on the mission field if you are motivated. But I have to push family med a little, right?

I encourage you in the next few years (yes, even residency) to try to find opportunities in hospitals or clinics overseas that are doing continuity care and are working to improve the access to healthcare in their region. Or you can work with your school to try to start some sort of stable continual project where you can help provide people with primary care, rather than have them depend on mobile clinics to hand out short-term supplies of meds. You can help improve the health literacy of the community, train local health workers, nurses, and even doctors, and improve sanitation and clean water supplies in a region. That’s real primary care. 

As for me, I’m applying for a 2 year Christian-affiliated post residency medical missions program, which I will talk about more in detail in a few months once I find out if I’ve been accepted. There are several secular and religious affiliated programs out there that are available for further training during or after residency. 

Asker Anonymous Asks:
It seems like internal medicine and family medicine have a significant amount of overlap. When you're covering the hospital, what's the difference between cases assigned to family medicine vs. internal medicine?
wayfaringmd wayfaringmd Said:

In my program, we have separate pediatric, OB, and internal medicine services that are all staffed by family doctors and residents. Our internal medicine service admits adult patients from our family medicine clinic. We also take “unassigned” patients who do not have doctors or whose doctors do not admit to the hospital. This unassigned pool is the same pool the internal medicine hospitalists admit from. So it’s the same population. We also admit to both the floor and the ICU, so the acuity of the patients’ conditions is similar as well.

The overlap between family and internal medicine ends when you consider that we admit kids and pregnant ladies as well, which internists do not. We also do not rotate through as many sub-specialties, and we focus a bit more on the outpatient setting than internists do. 

Asker Anonymous Asks:
Hey! Here's my question. I want to be a doctor more than anything (I can't really see myself doing anything else). However, I also plan on having a family someday and I want to be a big part of their lives. I have an interest in primary care. Can I be a primary care physician and still have a home life? What are some other specialties to look into that can give me this sort of balance?
wayfaringmd wayfaringmd Said:

Yo, primary care is the best. You can ABSOLUTELY have a home life as a primary doc. Primary care can really be as consuming and busy or as chill as you want to make it. I know family docs who work 60-80 hours a week, and docs who only work 3-4 days a week. It’s very flexible.

The easy ROAD specialties are also known for providing a nice home life. 

Asker Anonymous Asks:
Just finish first year med student, always wanted to do family medicine, but now I started taking an interest about ROAD specialties. Any medblr opinions and interesting firsthand experiences with these practitioners that I should know outside my shadowing experiences?
wayfaringmd wayfaringmd Said:

Don’t give up on or settle on ANY specialty before you’ve started your clinical rotations. First year is really too early to make any big decisions. And I mean, hey, I’m pretty biased when it comes to family medicine. I’d be interested to know what you liked about FM and your reasons for thinking maybe the “easy ROAD” is for you now. 

Radiology, Ophtho, Anesthesia, and Derm all seemed painfully boring to me. I didn’t want to spend my days doing the same thing over and over and over, even if it meant tons of money and a decent work schedule. But some people like the security of knowing a lot about a narrower area of medicine. Me, I like variety and the big picture stuff. Others pick those specialties just because of the lifestyle they afford. 

Do you think you could maybe comment a bit on OB/GYN vs. family medicine as well?
wayfaringmd wayfaringmd Said:

OB/GYN is all hoo-has all the time.

Family is all the other parts plus hoo-has. 

OB is half surgery/procedures, half outpatient care.

Traditional outpatient family medicine is about 90-95% non-procedural. Except for the few family docs still out there who perform C-sections. 

OB is a 4 year residency. Family medicine is 3.

OB/GYN is a lot more than delivering babies. It includes infertility care, contraception management, urogynecology, maternal-fetal medicine, reproductive endocrinology, GYN oncology, managing dysfunctional bleeding and STIs, hysterectomies,  and tons more. 

Family docs overlap some of this, as we manage contraception, STIs, dysfunctional bleeding (non-surgical), basic gynecology, and low-risk obstetrical care. 

Asker Anonymous Asks:
Why chose family medicine over the others? I thought emergency, paediatric and neuro would be interesting.
wayfaringmd wayfaringmd Said:

Why do family medicine, uh, probably because it’s awesome. I wrote a post waaaaay back in 2011 about why I picked Family medicine. As I review those reasons again, now 2 and a half years later, they’re still accurate for me. But here’s some general reasons why lots of people choose family medicine:

  1. Flexibility of work environments - clinics, urgent cares, ERs, hospitalist work, nursing homes, medical missions, public health, research, rural, urban, whatever. All are possible with Family Medicine
  2. Broad spectrum of pathology and variety in daily patient load- ortho, psych, OB, peds, geriatrics, preventive medicine, we do it all.
  3. Continuity of care
  4. Ability to still have a life - with all the different work environment possibilities, you can have as much time for family as you want
  5. High demand for primary care docs makes finding jobs easy
  6. Easily bored - don’t care to know a lot about a narrow range of subjects
  7. Focus on prevention and whole-person care
  8. opportunities to enhance your primary care skills with fellowships in Geriatrics, Palliative Care/Hospice, Integrative Medicine, Obstetrics, Sports Medicine, and others.

Reasons I personally didn’t like the other specialties you mentioned:

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How did you decide on your Family Medicine residency? I'm a third year med student and I want to do Family Medicine. I'm trying to figure out what I want in a residency program. Thanks!
wayfaringmd wayfaringmd Said:

Well first off, YAY family medicine! I hope your rotations during third and fourth year don’t turn you astray ;). Like you, I knew pretty early on what I wanted to do specialty wise, so here’s how I found my program.

1. Start with Geography. I knew I wanted to stay in the south unless I could find a program that really amazed me outside that area, so I went to the AAFP's website and pulled up all the programs in about 9 states. They have a pretty great Residency Directory you can search that will tell you most basic info about the programs.

2.  Considered my special interests. I want to do mission work, so I searched for programs that allowed international rotations and added those to my list.  

3. Narrow by program type. Think about whether you want an unopposed program (tip: you do) or an opposed program (ahem, you don’t.). Benefits of unopposed programs include higher acuity patients (because they’re not being passed on to other specialty residencies or fellows), more variety, better continuity of care experience, and more respect from colleagues of other specialties. I’ve been in both type of program, so I can explain more if needed.

4. Narrow by curriculum. Family medicine covers a lot, and many programs are skewed a bit towards one area of interest or another. If you love geriatrics, you should probably go to a geri-heavy program with a geriatrics or palliative care fellowship option. If you love OB or sports medicine, search for programs with tracks that offer more training in these areas. 

5. Narrow by extras. Check out the town. Figure out if you could actually enjoy your admittedly limited free time in residency. Check out their benefits options, schools, housing market, and job options for your significant other.

6. DO AWAY ROTATIONS. I scheduled aways at my top 3 programs on paper and ended up having to cancel one. My #1 program pre-rotation ended up being very low on my list because I didn’t like the location and didn’t think I fit well with the residents there. My #3 ended up becoming my #1. Away rotations are huge. Every program, like every Tumblr, has a certain feel or personality to it. Make sure your #1 actually fits you.

Are unopposed FM residency programs only at community hospitals?
wayfaringmd wayfaringmd Said:

Not necessarily. Most are, but you can find unopposed programs in big cities too. Usually they’re at smaller hospitals in those cities though. Just know that the most complex cases in the big cities are going to go to the place with all the specialists.