Posted by: notdeaddinosaur | August 5, 2010

Family Practice Defined (Again!)

I like Dr. Rob; the one with the distractible mind. (Actually, I also like this one, as well as RFS.) And although I thoroughly agree with the stance he takes in his recent post against cholesterol screening in kids, I must take issue with his opening statement:

I have a unique vantage point when it comes to the issue universal cholesterol screening in children, when compared to most pediatricians.  My unique view stems from the fact that I am also an internist who deals with those children after they grow up on KFC Double Downs.

From Dictionary.com:

“Unique”: existing as the only one or as the sole example; single; solitary in type or characteristics

Your Med-Peds training allows you to follow patients from birth to death (but no obstetrics or gynecology). You can care for all organ systems and all stages of disease (but without as much training in psychiatry). Congratulations! You’ve just (re)invented Family Practice (except for the above shortcomings). Oh, wait: that’s already a recognized specialty with its own residency programs, boards and everything for like, forty years now.

This misuse of the word “unique” is one of my pet peeves. (Along with the use of cliches, such as “pet peeves”. Oh dear; I’m repeating myself redundantly.)

“Unique”? I do not think that word means what you think it means.

After twenty years in practice, I agree that there probably isn’t much difference between what Dr. Rob does and what I do. After twenty years, I’m not even sure how much relevance remains from our “training”. Still, there remains a great deal of confusion about the very real differences between FP and Med-Peds residencies.

For starters, Med-Peds doesn’t provide much in the way of psychiatry or gynecology. I suppose Dr. Rob is either comfortable referring out half his patients for the bulk of their primary care needs, or he has gleaned sufficient on-the-job training to provide office gynecology care. (I’m sure he’s perfectly competent at it by now, though I wouldn’t have wanted to be one of his early patients as he figured out how to use the speculum on his own.) As for psychiatry, I’m sure he will agree that it makes up a hefty chunk of primary care medicine. Hopefully he’s picked up enough of it over the years so that he is comfortable dealing with his patients’ psychiatric issues. So I think we can agree that the farther you get from training, the more our skill sets converge.

The main difference in the training programs is this: Med-Peds residents mainly see hospital patients. Their outpatient experience is limited to one “continuity clinic” a week throughout their four years of training. First year Family Practice residents are also in the office (we offer continuous care by definition, so we don’t need the “continuity” modifier) one half-day per week, but this increases over the next two years so that by the third year, we spend 3-4 half-days a week in the office. Family Practice provides specific training in outpatient medicine: how to work up problems without a hospital admission; prescribing with an eye towards compliance (and cost); basic office management; the works. My program even required that we do house calls, which I continue to do in my own practice today.

If you’re looking for a doctor to care for your entire family and you come across someone who’s been practicing a decade or two, it probably doesn’t matter whether you find someone who calls herself a Family Doctor or an “Internist and Pediatrician,” as you’re likely to get very similar care. But if you’re looking to hire someone fresh out of training, bear in mind that the FP-trained doc is more likely to be able to hit the ground running in an office setting. That’s the real difference between Med-Peds and Family Practice.

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Responses

  1. I like you too.

    We have FP’s in our office (3 of them) along with me and onther Med-Peds. It’s great to have both, as our training has different focus. The FP’s have a broader training, better outpatient psych, do more procedures, are way better at derm, but are otherwise a lot like Med-Peds. The main advantage of Med-Peds is that we are more intensive in Peds training. The FP’s in our office had to get used to the number of kids we see, and we still see higher acuity with the chronically sick babies. It’s actually great having both in our office.

    The reason I said what I said was just to emphasize the different thinking I have than my pediatric colleagues, who will check cholesterol not thinking of the long-term.

  2. I like your post (and I love your blog), but let me bitch at you just a teensy bit. You have your professional-turf issues and I (a clin. psych. doctoral student) have mine.

    You would not have wanted to be among Dr. Rob’s first few tries at the speculum, but you allow that he might be not too deadly with it by now. (Let’s hope. I’ve seen my wife on the receiving end of an expertly-wielded speculum and even that didn’t look like much fun.) On the other hand, you seem to be suggesting that psychiatry is something people can sort of pick up as they go along.

    Having so far worked a few cases, and sat in on a bunch of others in supervision, where one of the major obstacles to helping the patient was the completely stupid history of off-the-cuff, evidence-free diagnoses, and even stupider two-page list of contradictory and often crippling psych meds, often provided by an M.D. — in many cases, sadly, a full-fledged psychiatrist — I’m not convinced that psychiatry is something you can pick up as you go along. I feel like a lot of us non-prescribers (at least in my town) spend a lot of time cleaning up the messes left behind by M.D.s and APRNs.

    I am perfectly aware that my viewpoint arises from a biased sample. We don’t see, and/or I may not recall so quickly, the patients who are very well served by psychiatric providers — but I don’t want to forget about the ones who aren’t. This is a really tricky game and I don’t endorse the idea that it can be picked up as one goes along.

  3. I keep reminding people they’re unique – just like everyone else 🙂

    BTW – I love your blog. I work as a clinic manager in a one-doc shop and can’t help but giggle at all the things that happen in your office. Of course, oftentimes similar things happen here too, but I can’t put it into words the way you do so “uniquely.” 🙂

  4. Gee, if psych is such a tricky game and ought to be practiced only by psychologist/psychiatrists why the *&^% can’t I get one when somebody’s having an overdose/manic episode/other psych emergency. Believe me, a lot of FPs would much rather hand this stuff off to the psychs but cna’t find anybody who’ll go to the hospital/take Medicare-caid patients/answer the freakin’ phone of the weekend. So we end up doing it, by default because there is no one else to do it. And a lot of us are pretty darn good at it.

  5. Thank you for this. I’ve wondered at the difference between FP & Med-Peds.


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