Likes and Dislikes in Family Medicine

Whew... I'm coming to the three-quarter mark of my clerkship rotation, just finishing up my Family Medicine rotation and staring down the barrel of my final rotation in Surgery. Time for another "Likes and Dislikes" post. Full disclosure - I've pretty much settled on applying to Family Medicine come CaRMS time, so this post may be a little bit biased...


1) Continuity of care is awesome
Getting to see the same patient multiple times in the same rotation is not only gratifying but great for learning. The rest of clerkship is incredibly fragmented - aside from inpatients who we see for as long as they're in hospital, clerks usually don't see a patient more than once. Here, I got to see the results of some of my diagnoses and treatment plan. It makes the experience a lot more memorable, makes care a heck of a lot easier, and makes learning that much more enjoyable.

2) Some people are a drain on healthcare resources
It should go without saying that same individuals consume more in healthcare funding than others. In family medicine, it was pretty easy to pick out the frequent visitors. If all a high-volume healthcare user does is come to their Family Physician too often, we're not in bad shape - FM visits don't cost much at all - but the spiral in costs from that point definitely adds up. Lab tests, imaging, consults...

In some cases these costs are justified and provider-driven. Someone at high risk of cardiac problems will get a lot of attention from their Family Physician and rightfully so. Some are... less beneficial. Anxiety takes a huge toll on the healthcare system in ways that have nothing to do with managing anxiety. Likewise, patients with significant social dysfunction inevitably find their way into interacting with the healthcare system for relatively non-productive reasons.

All this said, it's all too easy to blame the patients themselves for this overuse, particularly for a primary care provider dealing with the same person over and over again. These patients all have problems that deserve attention, it's just not necessarily the problem they're putting to the physician. Healthcare has its limits and in terms of improving health, it's only one part of the solution.

3) Why are regular hours a bad thing again?
I haven't worked a night for almost two months now. I have small but discrete periods of time in the morning and evening to either relax or work on side-projects. I'm getting exercise again, if only small amounts. Yet I feel like I'm learning about as much as I was during my more "intensive" rotations. This is undoubtedly where my preconceived notions come into play, but I'm still baffled why medical education is so set on the idea of long, intensive hours, particularly at this stage in the game. More experience is undoubtedly helpful, but fatigue is undoubtedly hurtful. It has been good to feel relatively rested again.

4) Rush, rush, rush
The main downside I see in Family Medicine is a strong incentive to rush patient visits. The economic constraints require seeing a lot of patients as quickly as possible in order to cover overhead. I had dreams of a practice where my patients were scheduled every 20-30 minutes and I could really take my time with my patients. Now, I don't believe that's feasible in most set-ups. Billing codes in Family Medicine are just too low to allow for deep, methodical visits like that on a regular basis.

However, they may not be necessary either. It's taking me about 30 minutes per patient right now, but that's considering I'm dealing with conditions I'm still learning about, patients I don't know, working within someone else's system, and having to review all my patient encounters. With some more knowledge, familiarity and independence, I can see 15 minute visits being enough. I wouldn't want to push it much faster than that, as I know some physicians do, but a snail's pace doesn't seem like a great idea either.

5) The Happiness Test
This question worried me a bit for this rotation because I've become fairly set on Family Medicine, but to my relief I'd say yes, they are. The paperwork seems fairly excessive and physicians who get caught up in the daily grind seem a bit disheartened, but there's room for a diverse practice to balance things out. The favourable job market and wide flexibility of location are helpful as well - where you work and who you work with matter significantly in terms of being happy at work. I think I'll welcome having a little bit of choice when I eventually establish a practice.