White Coat Underground

Dear Dr. Pal

A young relative of mine recently asked me my thoughts about medicine as a career.   It’s a relatively common question in my mail bag, and a tough one to answer, especially when asked by strangers.  Career choices are very personal, so I don’t like to give advice as much as let people know what they can expect from a career in medicine.  Here’s one of the latest letters to show up in my inbox (edited by me for anonymity, etc.).

Dear Pal,

I’m a third year medical student at the end of my clerkships now, and I’ve found that I pretty well like everything.  I did my pediatrics rotation early and absolutely loved it, but I also really liked women’s health and it turns out that adult medicine is also pretty good.  I used to think that I want to be a super expert on one system or group of diseases, but I also like the relationships you can have with people in a primary care setting, and I find the epidemiology of preventive medicine interesting.

With this conundrum brewing as I near the point of applying to a residency, I’ve started to think about family medicine.  Could you please tell me your opinion on family medicine as a career? Do you think family practitioners provide high quality care? Or do you think that people should generally go to pediatricians, internists, and OB/gyns?  I realize that this is very highly doctor dependent.

Brutal honesty is appreciated.  Thanks, and have a good weekend.

Medical training is so prolonged, and practice so specialized, that medical students often have to choose a specialty before they’ve had the change to really explore potential careers.  This particular student is a third-year, meaning that he is done with his basic science coursework and is rotating through various clinical specialties.  As is not uncommon, this student has found that developing longitudinal relationships with patients can be both rewarding and interesting.  From the perspective of more than ten years out of medical school, it sounds like he is interested in primary care of one sort or another.

Primary care is provided by pediatricians, internists, family medicine specialists, and to a certain extent OB/Gyns.  Each of these requires a residency after medical school, typically three to four years, depending on the specialty.  It is not uncommon for a medical resident to start an internal medicine residency and decide to sub-specialize in something like cardiology or gastroenterology. 

But assuming you’ve got your heart set on primary care or OB/Gyn, there are significant differences between these specialties.  One of the more important differences is compensation.  There are numerous surveys available, and compensation is dependent on geography, hours worked, malpractice costs, and other factors. Another important factor that students often don’t think about is lifestyle and hours worked.  Some specialties lend themselves to part-time work better than others.

From a practical standpoint, each of these specialties approaches things differently.  Internal medicine covers the prevention and treatment of adult diseases.  Pediatrics, childhood health.  Pediatricians often see more patients in a day, and for less money, but tend to enjoy their work.  Their patients are not just the child, but the parents as well.  Pediatricians will often deal with difficult problems such as child abuse (for which they are mandated reporters), eating disorders, and the problems of adolescence. 

There are a number of combined internal medicine/pediatrics residencies, most of which are four year programs, a year longer than either alone.  That’s starting to sound a bit like family medicine, but family medicine has a different focus.

Specialists in family medicine usually have more training in minor, in-office procedures than other primary care specialties.  They are also trained in basic obstetrics and gynecology, but the extent to which they practice these varies based on local medical culture and custom.  The perception, which may or may not correspond to reality, is that family docs in non-rural areas don’t do a lot of obstetrics.

Obstetrics and gynecology is a difficult and rewarding specialty.  When things go well, there’s a baby at the end.  When things don’t go well, there is sometimes a dead baby and a dead woman.  The day-to-day practice of gynecology can vary from being very surgically-oriented to being primarily office-based.

And now it’s time to piss people off.  The writer asked for brutal honesty.  I have nothing useful to say about income and debt, but I can give you some very personal opinions. 

If you like working with kids and their parents, pediatrics is great.  If parents generally seem like a pain in the ass and you perceive them as “in the way”, you should consider another specialty.  If for some reason you don’t like working with the elderly, you need to know that internists usually treat a lot of older folks.  OB/Gyn is great if you like working hard, like working with your hands,  and don’t get freaked out by high-risk procedures. 

Family medicine has often suffered from being the picked-on kid at the playground.  If you like small in-office surgeries, and especially if you plan on working in an area with a shortage of physicians, such as a rural area, family medicine can be great.  But in most urban and suburban areas, family docs don’t use much of their obstetrics training—or at least that is the perception of other doctors.  Family docs are self-contained, and do great work, but unless you are interested in providing the full range of care offered by family docs, I can’t think of a compelling reason to specialize in family medicine. 

One other possible drawback is that residents who graduate from a family medicine program will have a harder time getting into most sup-specialty programs. Family med residencies are designed to train primary care docs, not cardiologists.  If you, as a medical student, suspect you may wish to sub-specialize in nephrology, cardiology, etc., family medicine probably isn’t for you. Other primary care specialties allow a greater depth of practice, so in my opinion family medicine is at its best when practiced by doctors interested in the full  breath of patients and problems.  Like any decision, choosing a specialty opens some doors and closes others. Family medicine opens a door on complete, longitudinal continuity of care, an amazing thing to practice and an amazing gift to offer.  But it does create certain limitations as well.

Of course, internal medicine is the pinnacle of medical thinking and practice, or so we internists tend to think.  As much as I love internal medicine, though, it’s limitations are many.  If you like procedures, want to work with kids, or want to get rich without a lot of work, internal medicine is definitely out.  Internal medicine requires not only a tolerance for, but a desire to treat diseases that patients may, to a large extent, have brought on themselves.  If you are the sort who gets mad at a smoker for continuing to smoke, you’re not going to like internal medicine. 

Choosing a medical specialty is not easy, especially since you have to choose so early in your career.  Just remember: you’re going to be doing this for a very long time.  Make sure that above all else, you pick something you think you will enjoy.  That makes it a helluva lot easier to get up in the morning and answer a page in the middle of the night.

Comments

  1. #1 D. C. Sessions
    April 14, 2010

    The perception, which may or may not correspond to reality, is that family docs in non-rural areas don’t do a lot of obstetrics.

    You allude to something that I’ve gotten from some of the docs I work with in rural Arizona: you almost have to create a separate category for “non-urban medicine.” For a lot of young people, this can be totally off the table but for others it seems to be a dream come true: a chance to practice a lot of variety in medicine where physicians are desperately needed, plus (at least sometimes) some serious assistance in paying off all of those loans.

    And then there’re the locations. De gustibus non est disputandum. Who knows, you may get flight training into the bargain.

  2. #2 WcT
    April 14, 2010

    I’d just like to toss in a plug here for my own speciality:
    Emergency medicine.

    I don’t have a citation, but supposedly about 1/3 of what we do is primary care, and of the remaining two thirds, much of it is the sickest patients in the hospital. It involves a significant amount of procedural work, is relatively well compensated, and still allows one to practice a large breadth of medicine.

    The ‘downside’ (to most people also considering family medicine) is a lack of continuity of care, and the need to juggle many patients at once.

    (Downside is in quotes above because SOME people LIKE the lack of continuity of care and helping a lot of patients at once)

  3. #3 SurgPA
    April 14, 2010

    One thing to bear in mind about primary care (and perhaps many specialties) is that whatever “typical” practice looks like today, it may look completely different in 5-10 years as we struggle with an evolving health care system. I’m not sure any potential changes will affect family medicine differently from internal medicine, but some type of change seems inevitable.

  4. #4 Calli Arcale
    April 14, 2010

    I know a lot of family practice docs, and they find it very rewarding — but as you say, there isn’t a lot of opportunity for advancing into a specialty. However, it’s very steady work, and you really get to know your patients. And I don’t know how regional the OB/Gyn thing is, but at my clinic (in suburbia), about half of the family practice docs do deliver babies. (They don’t do c-sections; the OB on call does that. And if they find something suspicious in a routine pelvic exam, they refer to a gynecologist.) The beauty of this is that unlike with OB/Gyn, your prenatal doc can be your child’s pediatrician too. Family medicine is cradle-to-grave.

    A few years back, I remember my dad (family practice doc) proudly mentioning what had happened: his first third-generation patient. A couple of decades ago, as a young doctor, he’d delivered a baby girl. Now that baby was grown up, and delivered her own baby while under his care, and he was to be the child’s doctor as well. You won’t get that in another speciality. Oh, you may get situations where you get a new patient who happens to be another patient’s grandchild, but it’s not quite the same thing.

  5. #5 BB
    April 15, 2010

    When I lived in semi-rural CA, I went to a family practitioner. He was great. In many ways, he was a more thorough doc than the internist I go to now in suburban NYC.

    Your post is a thoughtful and well-written discussion of the pros and cons of primary care fields of medicine. I’ll be referring our medical students to it when the topic comes up.

  6. #6 James Sweet
    April 15, 2010

    This probably goes without saying, but from the patient side of things, a good family practitioner is awesome. My listed PCP is still another doc, but when my son was born and we needed a pediatrician, my wife found a family practitioner and she also switched to him.

    It was a little surreal to go in for my son to have a check-up and in the same visit have him also be able to diagnose and treat my wife’s De Quervain syndrome (an unexpected-by-us but apparently fairly common result of lifting a baby over and over again). The doctor himself is just great, he always spends a lot of time with us and is very patient with questions. The receptionist is a bit flighty though… heh…

  7. #7 PalMD
    April 15, 2010

    Finding a good primary care doc is awesome. The advantages of finding someone to care for the whole family can be many.

  8. #8 gaiainc
    April 15, 2010

    Someone once described OB/GYN as a surgical subspecialty that ignores half the population. I can’t say that I disagree.

    Meds/Peds programs, unless they’ve changed, tend to be two years of pediatrics and two years of internal medicine with no specific training on how to integrate the two together.

    I do family medicine in an urban area as part of an academic department. However, my practice clinic is technically rural (about 20 miles outside of town). Right now, I have about 23 prenatal patients. Compared to some, that’s not a lot. Compared to the rest of my faculty, it’s a lot, so you can do a lot of OB in an urban area. It all depends on the area, West Coast being more family medicine friendly in general than the Northeast. We have three people on faculty who are privileged to do c-sections at the hospital and we are training a select few of our residents to do c-sections as well. My family’s doctor is one of my former residents. She assisted at my c-section and does great care for my son, my husband, and me (when I let her). I get to do things like ask her to give my husband the varicella vaccine because he’s never had it and if he had it now, it would be bad when I’m there for our son or myself.

    What I love most about my job is the variety. Recently I had a clinic day where my youngest patient was about 4 days old and my oldest patient was 86 yo. I now bunch my procedures to a particular day of the week, but that is to give my residents a time to practice their skills. I can still do a lot and take care of a lot for my patients in one visit, like freeze their warts or if needed, remove that really scary looking mole that day. I also love the relationships I have built with my patients and having them bring their loved ones to me. The more I know about where a patient comes from, the more it helps me to care for her or him. I also feel that the world can give me any patient of any gender or age and I’ll have some handle on how to manage that patient. I may not be able to figure out everything, but I also won’t go fetal at the thought of a gyn exam or knowing what to do with a pregnant woman. That sense can be particularly empowering.

    I will note to anyone interested in family medicine (or primary care even) that you will be doing a lot of psychiatry. Most insurances suck at covering mental health services, so the only way patients have for dealing with their depression and anxiety is to see their PCP. If you are not into dealing with psych, this is not the field for you.

    That said, I feel more and more that primary care is a dumping ground where we get no respect from anyone for doing anything. You are taking care of people who sometimes have no other place to go, have no motivation to make any changes, and in general want you to fix them with minimal effort or intervention on their part. You are also expect to do a lot of screening and prevention while keeping people’s diseases under control, and coordinate care between specialists that often don’t send you the information you need. There’s also the issue of having multiple specialists deciding that a patient should be on a particular medicine or go see another clinician, not caring/realizing/understanding that said therapeutic option is not covered by insurance or not affordable to the patient or too far for the patient to get to. There are also the nice letters from the pharmacy managers asking if a patient really still needs to be on his or her anti-depressant or despite the fact that the patient has been on a particular medication for years, I have to now justify why otherwise they will not cover it. There is also the mom who brought in one child for a sick visit, but couldn’t I just see the other two and oh, she’s had burning when she pees for the past few days so maybe I could just check that out for her as well.

    I also have fun with my bipolar adolescents who dislike the ONE child psychiatrist they see, so expect me to manage their psych meds. Wait… my adult patients expect me to do the same as well. Whee!

    Then there are the patients who see something on TV or hear something on the radio about something and decide to stop all their meds or a particular med that is keeping them alive because it’s supposedly bad for them. I also have patients come in telling me they really need to be on this medication or that for reasons that are not clear except they saw the commercial on TV. I’ve had one patient get mad at me because their insurance wouldn’t cover his Viagra. It also gets to be my fault because Medicare won’t cover oxygen as the patient’s O2 sat wasn’t low enough to qualify. Some days I really feel like a dumping ground for everything and anything.

    And that’s my two cents, for what they are worth.

  9. #9 PalMD
    April 15, 2010

    And that’s my two cents, for what they are worth.

    It’s worth a lot more than you’ll get paid for it. I appreciate it.

  10. #10 D. C. Sessions
    April 15, 2010

    Two cents? You sure you won’t take chocolate?

    I’m beginning to understand why my PCP likes to just chat for a bit when I’m in for my annual lube-and-oil-change. Too bad he doesn’t ski or I’d dump a bunch of freebies on him.

  11. #11 gaiainc
    April 16, 2010

    DC Sessions, I’ll always take chocolate, particularly the dark kind. Mmmm… chocolate…

  12. #12 Dianne
    April 16, 2010

    Too bad he doesn’t ski or I’d dump a bunch of freebies on him.

    I ski. Got any hematologic problems? (Not that I could take freebies from a patient anyway…or would given that the patient population at the institution where I work tends to have trouble raising bus fare to get to appointments much less presents. But it’s a nice thought…)

  13. #13 Liz H
    April 17, 2010

    I grew up in urban and suburban places, and our family practitioner always dealt with my mom and I’s ob/gyn stuff. Which was a godsend when it came time for my first pap. Yes, it was a new thing, and I’d heard all sorts of “this is an evil torture exam” stuff. But because I knew the person doing it, had been seeing them for years, I wasn’t all freaked out, so it was seriously a non-event.

    My younger brother and his wife made the same decision when they had my nephew, which turned out to be a godsend because then the person who worked with my sister-in-law was also the person who delivered my nephew, is also the person caring for him. So when she said “my neighbor is anti-vaccine, [Liz] says she’s crazy, what do you think?” she trusted him enough to listen when he told her that, yes, her neighbor was being irrational.

    etc. I can imagine being a family practitioner is seriously hard, but there’s something to be said for seeing the whole family.

  14. #14 D. C. Sessions
    April 19, 2010

    Dianne:

    I ski. Got any hematologic problems?

    Not unless Gilbert’s syndrome counts. Besides, the area is closed now until December. On the other hand, if you’re in Arizona or New Mexico next winter ping me.

  15. #15 Pascale
    April 20, 2010

    I’m one of those who gets pissed when smokers continue to smoke, so internal medicine would have been difficult. Of course, most of the students in my class who thought about pediatrics could not do it; They were unable to poke a kid with a needle when push came to shove. Me, I had no problem with it. And kids get really interesting stuff.
    I would like to put in a plug for academic medicine. While not as well-paid as private practice, you get to do a lot more than see patients. Training the next generation and developing new ways to make people better is cool. And the ivory tower often allows more schedule flexibility than other practice settings.
    You still have to figure out what specialty grabs you, but even primary care can be done academically. And it often makes practice even more rewarding.

  16. #16 pttugas
    May 4, 2010

    The key is telling your body there won’t be any more famines. There are two primary ways of doing this:

    1. Eat real food. When you’re eating quality food and it’s assimilated efficiently, the body begins to receive what it needs to function at its best. This is one very important step in turning off the famine response. The presence of nutrient-dense food in the diet signals to the body that there is plenty of food available and there’s no need to pile on fat stores. Digestion is also an important part of this equation because you want to make sure the real food you eat is assimilated properly. Including raw and cultured foods in your diet on a regular basis can improve your digestive health and ensure you’re getting the most out of your food.

    2. Reduce stress. Another folly of modern society is the intense level of stress most of us are exposed to, often since very early childhood. Stress induces the famine response as much as dieting. After all, the body doesn’t distinguish between types of stresses; the same biochemical reactions occur whether you’re stressed by your work, a difficult marriage, lack of real food, poor sleep habits or any number of stressors. So it’s very important to address this and take the appropriate steps to reducing and managing the stress in your life. Read more about the stress connection to weight loss here and here and here.

    Without addressing these two components, a healthy body composition is virtually impossible to achieve. Plus, healthy food choices reduce stress, and reducing stress makes it easier to choose healthier food. So making one small change at a time really can add up, and the right choices will come more naturally over time. Granted, this involves patience and won’t produce results like “Lose 10 pounds in one week!” But it will set you on the path to lasting health.

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