Residents, Students Fire Questions at New Physicians

How do you test the financial viability of a practice you want to join? Do you need an obstetrics fellowship to do OB? How do you get rid of your educational debt? Residents and students shot these questions and more at a panel of new family physicians who presented "Transitioning Into Practice" here Aug. 5 during the National Conference of Family Medicine Residents and Medical Students.

Moderator Michael Sevilla, M.D., of Salem, Ohio, told more than 100 residents and students, "Not too long ago, we were sitting where you are out there, wondering what life would be like after residency."

Details came from panelists Erika Bliss, M.D., who works in a community health center in Seattle; Ronald Labuguen, M.D., associate residency director and assistant professor at the University of Southern California, Los Angeles; and Chris Lupold, M.D., who is in private practice in Charlottesville, Va. Here is a sampling of the information exchanged.

Financial health of a practice. To confirm the fiscal viability of a practice he wanted to join (the one where he now works), Lupold reviewed the practice's tax statements and got information on income, charges, malpractice claims and liability coverage rates. "The malpractice rates to do deliveries in Pennsylvania (where Lupold did his residency) are about four times higher than where I am now in Virginia," he noted, which helped attract him to the Virginia practice.

Clues to how a practice runs. "Spend at least half a day at the practice," Lupold advised. "Hang out with the nurses and in the reception area." He also talked to people in the community, contacted a local residency to ask about the practice and called the practice as if he were a patient to see the response a new patient would get. The positive input helped reinforce his interest in the practice.

Serving the underserved. One student asked how to ensure a residency serves the underserved. Information on the percentage of Medicaid or uninsured patients the practice has may be available, said the panelists.

Bliss added, "In most family medicine residencies, you'll get experience with the underserved." For students who want to work in a community clinic, she suggested that they see whether someone from their residency faculty came from a clinic background. That person could be a likely source of information and support, said Bliss.

She also warned students that the families of many clinic patients often are very fragmented. "Sometimes you are the only person they trust, and they'll talk to you about anything." However, she added, the majority of them are appreciative of the care they receive. Clinic patients also tend to have acute illnesses and come to care late, Bliss said. "They may have eight or nine health problems. It's hard to address all those in a short visit."

Preparing for maternity care. One participant asked whether new family physicians who want to offer maternity care need to take an OB fellowship. "I didn't," said Labuguen. "My family physician colleagues and nurses have taught me more about OB than anyone else. But if you're interested in (cesarean) sections, I would recommend extra training because your comfort level will increase." He does low-risk obstetrics and focused on maternity care in residency, he said.

Breaking into academia. "If you're looking for a faculty position, two applicants being otherwise equal, they'll take a closer look at one who's done a faculty development fellowship," said Labuguen, who took that type of fellowship. In addition, "A lot of programs want faculty willing to do OB, inpatient medicine, procedures and clinical research," he noted.

Student loans. "Do you have unique ways of paying back student loans?" one participant asked. "Consolidate your loans. Get a low fixed rate," said Labuguen. "The National Health Service Corps, Indian Health Service and lots of states have programs for underserved areas where you commit to a certain number of years of service" in loan repayment programs.

Bliss encouraged students to contact financial aid offices in their medical schools and ask about loans, especially ones for students interested in primary care. "You'll double or triple your income when you get out of residency, but be careful. Buying a home may be a good idea or may not be a good idea," said Bliss.

Bonus or contract review. If you want to join a practice that advertised through an agency but you didn't use the agency, said Lupold, find out the agency's fee and ask for half of that as a signing bonus. "I got that," he said. Another thing he advised: Have a lawyer review your contract. It will be a lot different from a residency contract, said Lupold. Check with your state AFP, he advised; many use lawyers who will give members reduced rates for legal work.

Documenting procedures, patients. One resident commented, "We're documenting all our procedures and also documenting all our patients. What obstacles have you come across in getting privileges?"

"You never know what you'll need in terms of credentialing," said Labuguen. "Hospitals have asked me to submit a lot of clinical data. The procedure logs are crucial," he noted. "Lumbar punctures, central lines, they (hospitals) didn't care about them; they wanted C-sections, vacuum deliveries, circumcisions."

Bliss suggested, "When your residency tells you to keep track of your patients, ask them, 'How are you going to help me with this? Will I have a PalmPilot and enter the information when I'm in the hospital? Can the residency do it?'"

Malpractice coverage. As a fourth-year resident, in the spring, obtain documentation of your malpractice insurance coverage, said Lupold. "A practice will want to prove that you have been covered before they're willing to insure you."

Electronic health records. Ask if a residency or practice has an EHR and, if not, when the site is planning to begin using one, Bliss advised. In her case, her clinic needed someone to help implement an EHR system, and she took the lead on the project.

Hospitalists. One participant asked, "What should be your focus if you want to be a family physician hospitalist?"

Labuguen said, "Do inpatient rotations. Find family physicians who are working as hospitalists in different systems and see what their practice is like."

Lupold added, "Our hospital is now looking at family doctors to be hospitalists because they can admit all ages."

And Bliss noted, "A family doctor hospitalist is gold for a lot of areas."

Resources. The panel recommended using AAFP's electronic, interactive curriculum From Residency to Reality. In addition, AAFP collaborates with College Loan Corporation to offer a loan consolidation program.