I am a recently-trained Family Physican in rural central New York. In our 40 or so bed hospital, we have 1 pediatrician (nearing retirement), 4 internists and 7 FP's. The FP's by far have the broadest practices, from ICU care (ie. vents, MI's, etc.) to neonatal resucitation. Many residency programs teach stress testing and endoscopy, and if there's an individual procedure you'd like to become proficient in (not offered @ your program) most residency directors are networked enough that they can set up an elective for you.

In our town, which houses the only hospital in a county of 54,000 (landwise probably 2 hour car drive from end to end) the internists seem to do mostly geriatrics, while the FP's take care of the kids, babies, younger families and of course, geriatrics. Many families like the fact that they can bring their entire family to the FP, and knowing the family helps us provide better care to each individual.

Hope this helps!

Derek--

As a family physician in an isolated town in Northern Minnesota, I say FP all the way. You need to be able to deal with kids, pregnant patients, gynecology, social isssues, community education, physchiatry, emergencies, trauma. Pick the program that offers to teach you the widest variety of skill. I trained in Duluth MN. They have been having more difficulty filling because the program is more rigorous than others in the area ...but it trained me to be out here 100 plus miles from anywhere else

Derek,

Twenty years ago when I was a student I had a great deal of difficulty deciding what specialty to pursue. I wasn't even committed to primary care at the time. The one thing I was certain of was that I wanted to live in a small community. So after a prolonged introspective process I woke up one day with the realization that if I was to live in a small community, I would be called on to take care of everything from cardiac arrest to acne, so I'd better go where the training was broadest - and that was Family Medicine.

I've not regretted it a bit. A pregnancy and delivery is a much better way to get to know a family than a chronic or terminal illness. Every specialty (and every program for that matter) has its holes. Internal medicine (in addition to the obvious limit of age) tends not to teach much Gyn, ortho, sportsmedicine, or office procedures (though in trade you do get more inpatient and ICU). Peds tend not to want to do procedures at all. From a "health services" standpoint, an FP can practice almost anywhere - even without a hospital, though I personally wouldn't want to. Because our age limited primary care colleagues have to have colleagues of similar scope to share call with, AND have to have complementary primary care specialists for the patients they do not cover, it is rare for the Peds-Ob-IM model to work well in catchment areas of less than 18 to 25 thousand. And at the lower end of those numbers it is very difficult for Peds-Ob! -IM to coexist with Family Practice.

Arthur Freeland   Kirksville Missouri    Arthurfree@aol.com

Generally the house of internal medicine remains committed to the support of its well developed specialist system. Quote from recent student interest group in IM which I attended, "By doing Medicine you leave your choices open for subspecialty practice later." If this resonates with you , stop reading here.

Unfortunately for medical students, medical educators have a vested interest in persuading[not educating] persuading young people that their specialty is the best one to choose. Any student that is not recruited heavily probably has some obvious flaw of intellect or character. Therefore a disclaimer is hereby inserted.

One of my claims to fame is the fact that I have been certified by several boards on both sides of the fence you currently straddle. Also I have practiced in the trenches and I have been part of the ivory tower. One of my recently published studies dealt with the market realities of community based practice. In this study, I attemped to take a specialty neutral view of services. J Am Board Fam Practice 2002;May :191-200. A specialty neutral view is essential because of the fact that the "guild " mentality will forbid most general internists and many family physicians form obtaining the skills you mentioned.

The guild mentality is brutally simple. A powerful minority are paid extremely well to maintain a teaching cartel which , in turn, produces an economic monopoly on lucrative services in a multi billion dollar per year industry.

The downside of Family Medicine is the the fact that a third of the residencies are opposed to teaching the things that procedurally inclined young physicians seek. Another third are lukewarm in their support or politically contested. Here the student doesn't suffer from the guild mentality, rather the student may naively choose a program that promises the moon but delivers far less. By the way , strong OB role models in an FP faculty are predictors for procedural truth in advertising.

Certainly the skills you mentioned are scientifically valid and , in some cases, life saving. But there is no reward and no requirement that residency faculty teach them. It was for this reason that practicing physicians, not academic physicians, created most of the effective "how to do it" courses of the last 30 years. ACLS, ATLS, ALSO, and the competency based testing modules In GI endoscopy as offered by the AAFP. Overall the academic health centers have continued to request more and more years to teach increasingly specialized bits of clinical skill. This fact requires trend analysis<yawn>

Derek,

I am a rural FP, 70% of the PC in my community is FP, the other is IM. We can't seem to hold onto to peds for more than a year or two. IM takes care  of the "REALLY" sick pts (sometimes). Many of them don't do gyn care at all(and I refuse to see their pts just for paps); one of them tries to occasionally treat peds (which makes me groan). Quite a number of pts  transfer to me so they can have "one stop shopping" for grandma, themselves and the kids--ultimate FP and a real insight into many health problems. I take hospital call, do ICU and used to do OB. I do minor surgery in the office. another FP does a lot of endoscopy, and some do alot of first assist--depends on your interest and abitlity to say NO.  Good luck!

Derek, I trained in LaCrosse,WI. Since we were the only residency, there were no "turf" wars and the attendings were happy to have a resident around. I knew that I wanted to do D&C's, so I frequently scrubbed them over the noon hour with the gyn's when I was on other rotations. The best thing to do is ask and realize that you only have three years to learn what you want, so go get it. I practice in a rural community, 7000 and the county seat for 14000, 45 minutes south of the University of Iowa Hospital. A perfect distance to not be limited in my scope of practice but driving distance for my patients who need to 'go north'. The idea of family systems - that the illnesses of one effects the many- is a cornerstone of family medicine. I also see no training for orthopedics, psychiatry, chemical dependency, as well as the interaction of all these specialties in IM. My favorite example patient was pregnant with depression in the years before Prozac. She needed hyperal for her hyperemesis, psychiatry for her depression, obstetrics for her pregnancy, internal medicine to manage her gestational diabetes and chronic hypertension, as well as a pediatrician to help her first child adjust to a new sibling at home. Luckily, I was a resident and had the time and access to guide her care. I can only imagine her fragmented care if she had started with an Ob/Gyn. We have two internists in town and they also do mostly geriatrics and take care of people with 15 drugs on their list. I also have a few of these folks, but not all day. Doing well child checks the day after you attend a funeral is a reassurance that life goes on. I am happy that I could provide Ob/Gyn care to the neighbor girl whom I started caring for when she was 13. Sorry about the rant, but rural medicine really does rock!

Lynette, This is far from a rant. It is a wonderful testimony that I will share with medical students and residents. Rural medicine really does rock!

I worked for 20 years in a small town with an internist and other family physicians. Currently I direct a community based family practice residency that prepares graduates for rural practice. The basic problem is that even with well trained internists, there is no support element for them for call. Family Physicians care for children, neonates, deliver babies, do colonoscopies, do emergency room care, suture their patients, provide gynecologic care, and set fractures among other things. The internist, with rare exceptions, is not trained to do so wide an array of scope of practice, thus producing a real problem unless there is enough practice for 2 to 3 internists.

Family Physicians are particularly trained to provide care in small and rural sites as opposed to the training of internists which is considerably reduced to outfit them for rural/remote care.

Dennis LaRavia, MD

Professor and Director

Brazos Family Medicine Residency

(979)862-4465 dlaravia@medicine.tamu.edu

Derek,

It appears you dropped a bombshell and now have all of us rabid about FP touting how great our specialty is. From the about 10 responses I have read so far, a lot of the differences have been addressed. Enjoying the challenge of diversity is critical to enjoying rural FP. If you thrive on variety to your life go FP. If you like the security of limiting your practice to older adults than go IM.

However, for many rural sites, IM or Peds end up doing OB, Ortho, Gyn, Surg etc, that they were never trained to do. Talk about stress! What some may say is an advantage to IM would be hospital and critical care advantages to IM training, is not an issue in that FP's throughout the country do most of the Intensive care for their communities. Also ER's in rural sites are covered mostly by FP's.

In Alaska you can add, veterinary and dentistry to your needed talents. A summary of a day in Kodiak, may give you an idea of why FP fit best the needs of rural America.

7am Arrive in hospital for a scheduled repeat cesarean. I am to do the newborn care. However, my partner who was to assist on the cesarean, asks me to go do a vaginal delivery for him that was to deliver in the next 30 minutes. He would handle the newborn and someone else would assist on the cesarean. The delivery resulted in a horrendous shoulder dystocia, successfully delivered using techniques taught in Advanced Live Support for Obstetrics. Resuscitated the baby successfully.

9am Start clinic with a variety of urgent care walk-ins, since I am also on-call for the ER.

10am A 20 y/o comes in with Diabetic Ketoacidosis, new diabetic diagnosis. Spend the next 12 hours admitting her and managing her sugars, and low potassium, while doing other duties. Our ICU was the room that we moved the crash cart into.

1pm The local priest comes in with deep venous thrombosis is admitted.

2pm Return to clinic and handle a variety of other patients.

4pm Return to the ER to care for a alcoholic patient with an UGI bleed, sepsis, blown pupil that with CT scanner that we have in Kodiak ruled out  a subdural hematoma and later would find out that the blown pupil was old. After transfusing him with 2 of the 4 units of O- blood that we had and starting IV antibiotics, we transferred him to Anchorage.

5pm Got supper before the next ER patient arrived.

7pm Get a radio call about an accident with 2-3 victims. Over the next 2 hours would get conflicting reports via radio on number of victims. One was dead, and one they couldn't find. Ended up being a couple had accidently driven off a 400 ft cliff the previous evening. The driver died. The passenger was thrown from the vehicle half way down. After spending the night on the side of the cliff, she crawled down the cliff with a broken femur to the ocean found her boyfriend dead and then spent the next 12 hours trying to crawl in and out of surf to a house about 2 miles down the bay. She ended up after crawling one mile before being able to attract the attention of a fisherman who splinted her leg, radioed for help and then transported her to Kodiak. It took them 2 hours to get to the boat harbor. She was hypothermic, and had a broken femur. After taking a few hours evaluating and getting xrays, I transported her to Anchorage, for Orthopedic care.

1 am go to bed for 2 hours before the next patient arrives.

8 am the next exciting FP day starts.

Derek, neither an internist nor pediatrician could have handled that day. I felt good. I saved 4 lives that day. One baby, a 17 year new mother, a 20 year old new diabetic, and a 15 year old girl with a femur fx and hypothermia. I had a multitude of ordinary cases that every FP deals with on a daily basis.

Only FP trains you to be the jack-of-all-trades for the rural town. Many towns can only afford 1-4 doctors. FP just makes the most sense if you really want to be of true use to your community. You can make more money in other specialties, however, when you go to retire do you want $$ ? or do you want to know that you made a difference for your rural community. It really comes down to individual value systems.

Derek,

As a Family Physician practicing in a small rural community it is my totally biased opinion that you must become a Family Physician if you really want to serve in a small town ( or any size town for that matter). The editorial in the Des Moines Register is excellent. We as F.P. docs must maintain our scope of practice in order to provide our patients with 95% of their care. If one F.P. does not provide a service we should try to find an F.P. in our area that does and send the case to them so they can maintain their numbers i.e.. colonoscopy, EGD, OB , etc.. This family practice approach, will give the patient better access close to home and help decrease or slow the sky-rocketing cost of healthcare.

As far as training, there are many excellent residencies that will allow you to receive the procedural training necessary to practice in a rural area. Actually the training is good enough to practice anywhere but that is a different fight. Some programs can give this training in 3 years, others may require a fellowship year.

If you have further questions please let me know.

By the way, I do OB including surgical, colonoscopy, EGD, ER, etc.. I am also a member of the Committee on Rural Health of the AAFP.

PS We do not have any IM docs in the rural communities in our area. Of course, different people differ on their definition of rural.

Subject: Re: [rural] Rural practice, financial incentives, etc

Sent: 7/1/2002 10:45 AM

To: Rural Health, rural@mail.aafp.org

I've read with some interest the ongoing debate about why one should be an FP if going into rural practice and was pleased to see the  testimonials of such dedicated and skilled physicians. I think the arguments have been one sided, but what one would hope to see posted on an FP site.

So I won't debate the FP vs internal medicine in a rural location.

FP's have a distinct advantage in these areas and just need to receive adequate ICU exposure in residency to equal there IM peers in complex medical cases.

I will take umbrage with the assertion that to be a rural physician one must take a vow of poverty. I opened a solo medical practice  straight out of residency in a town of 3000 service area of 8000. The area is predominantly medicare, medicaid, and uninsured. I'm always busy, I do a lot of procedures, I cover the ER, and I earn way more than the average family physician.

To earn a good living you obviously need to be busy, but you also need to be actively involved in your business. Know to the penny how  much money is coming in and out. Know what you get paid for and what you don't. You have to make the hard decisions about sending patients to collections for unpaid bills or not participating with a poorly paying insurance program, but these are the aspects that need to be attended to in a well run practice. If you do it well you get some leeway, to give away your services to those who can't afford them, or purchase that new piece of equipment which will increase the available services in your town. In the end I often find that the people or institutions that give me the biggest headache are also the ones that don't follow financial agreements. To clear away the financial deadwood frequently clears administrative logjams and allows me to focus on more important issues and ill patients.

Rural docs see more patients per year than there urban colleagues, hopefully we are also paid more.

Joe Black  tidepool@harborside.com