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Tuesday Jan 16, 2018

Your Family Medicine Practice Is Whatever You Make It

The American Board of Family Medicine and the Association of Family Medicine Residency Directors recently surveyed practicing physicians who are three years out of residency to understand the scope of medical practice among these family physicians(www.annfammed.org) and improve residency education.

[multidirection street sign with red arrows]

For me, taking the survey was a reflective and somewhat nostalgic exercise. It made me immensely proud of the broad scope of training I received. I remembered placing chest tubes in the trauma bay, having end-of-life conversations with families in the ICU, delivering babies, early morning rounding on patients on the floor and using nested order sets in the ER.

But those are all just memories now. I exclusively practice outpatient family medicine, and my career feels just as rich. A recent day started with a 4-day-old newborn. Then I saw a 76-year-old man who was just released from the hospital after having a stroke. The rest of my day included a pregnant patient with a sore throat, a patient with multiple chronic diseases, and a transgender patient who needed help managing her hormones.

I'm also the district medical director of our innovative primary care organization, a role that includes growing our patient population, driving quality improvement initiatives and fostering community partnerships.

The survey led to a conversation with my fellow bloggers and family physician peers. Their practices are incredibly diverse; some do inpatient, obstetrics, sports medicine, a range of procedures and so much more.

So what, exactly, is the scope of a family physician? Well, that's the fantastic part of family medicine. We get to be the physicians our communities need. And we get to practice the type of medicine we want. Regardless of the setting, it's a rewarding career.

Natasha Bhuyan, M.D., Phoenix

Direct Primary Care

One of the most underappreciated aspects of providing a deeper level of care is time itself. I quickly discovered in my training that many health issues do not fit well into the 10- to 15-minute office visit, so I looked for a practice model that helps solve the common problem of lack of time in primary care visits.

I pursued a direct primary care practice in large part to regain that time, and thus the ability to care for more complex problems and patients. I have found that many of my new patients with chronic diseases have been largely managed by a menagerie of subspecialists and hospitalists. With adequate time, I often can reduce the need for subspecialty care and restore the primacy of primary care.

Ryan Neuhofel, D.O., M.P.H., Lawrence, Kan.

Caring for Vulnerable Populations

Family medicine opens doors for students committed to human rights and social justice issues, and opens many more for people seeking doctors with these competencies. As a family doc who started a clinic for people who have experienced human trafficking(www.facebook.com) and other forms of human rights and sexual abuses, I am grateful that family medicine training has facilitated ways for me to continuously find new ways to advocate on behalf of patients.

My path included training from Physicians for Human Rights(physiciansforhumanrights.org) during residency to conduct evaluations for asylum seekers. More recently, I completed a mini-fellowship in child and adolescent psychiatry because of the shortage of health care professionals who provide mental health evaluations for asylum seekers. In addition, completing an HIV Intensive Preceptorship Program and training to be a sexual assault forensic examiner are examples of the many post-residency training opportunities I have pursued as a family physician, guided by the needs of patients and community partners.

The breadth of our family medicine training includes women's health, pediatrics and mental health, so we are uniquely positioned to be of service at these intersections of health and human rights. I hope medical students who share this passion will also find their future in our specialty.

Anita Ravi, M.D., M.P.H., M.S.H.P., New York City

Rural Medicine

When I realized I was going to practice rural family medicine, I knew I was going to need a residency program that prepared me for this type of practice. That meant looking for a place that trained in full-scope family medicine, with the option for rural rotations to gain more experience. I wanted the opportunity to learn and experience all aspects of family medicine, because how else would I know what I wanted my practice to look like?

I knew many rural physicians and had the opportunity to talk with them about how their practices were structured and what they did and did not do. If you had asked me in medical school if I would do colonoscopy and endoscopy I would have said, "Yes! I'm going to offer everything!" What I learned was that scopes did not come naturally to me (I know I could have worked to hone this skill, but I just didn't play enough video games growing up) and they weren't something I was interested in, so I didn't pursue more training.

For the first five years of practice, I routinely covered the ER on call. Now with a robust obstetrics panel and lots of nights delivering babies, that is no longer part of my routine. Tailoring your practice to what works for you is one of the beautiful aspects of family medicine. I would encourage students and residents to take the time to learn a wide range of skills so you can find out what most inspires and interests you.

Beth Oller, M.D., Stockton, Kan.

Evolving Your Practice

Through college and most of medical school, I thought I was destined to be a general surgeon. My first physician mentor was a surgeon, and my first medical job was as a perioperative aide. I was attracted to the sterile environment and the meticulous, hands-on nature of the surgeon life. However, my med school surgical rotation quickly dissuaded me from that career path. I was turned off by the years of scut work that preceded metamorphosis into a true master of the operating theater. Also, I wasn't thrilled about the prospect of debriding painful festering wounds as an obligatory part of the job.

All it took was one family medicine rotation for me to immediately be drawn in by the diverse scope of practice this specialty offered. I love the fact that during any given day I could be performing procedures or sitting at the bedside of an ailing nursing home patient. I took my current hospital job straight out of residency. With our second child on the way, I passed up a geriatrics fellowship in exchange for a practice that allowed me to do inpatient, outpatient, and long-term care from day one. I was thrilled about the proposed flexibility of the position and the fact that I could essentially mold my practice as I saw fit.

Although I have since relinquished my inpatient duties to the hospitalist team, I have added addiction recovery and weight management to my practice. I hope to add naturopathic and integrative medicine skills to my repertoire to better promote general patient wellness and overall body-mind-spirit wholeness.

I love that as a family physician, no day is exactly like the last, and I can continuously grow and evolve my practice into one that meets my interests and my patients' needs.

Kurt Bravata, M.D., Buffalo, Mo.

Community Health

I thought I was going to have to get a second residency. I have long wanted to pair family medicine and community development, and for the past three years, my plan had been to finish up family medicine residency and start a preventive medicine residency right afterward. I thought that to get the job I wanted, I would need the credentials from both training tracks. An advisor encouraged me to just ask around before signing up for another two years, so I made a few inquiries.

As it turns out, family medicine is more than enough. I spend three-fourths of my time in clinic and I work on special projects about one day each week. Thus far, I have been tasked with starting group visits, telemedicine and working with the city council to improve bike path connectivity.

My hospital has seen the value in a focus on preventive medicine and trusts me to maximize our outreach and impact. Importantly, I didn't think this was an option to me initially, until I started asking for what I wanted. Thus, more important than what any of us say is within the scope of family medicine is the knowledge that just about anything can be within the scope, provided you ask for what you want.

Stewart Decker, M.D., Klamath Falls, Ore.

Posted at 02:23PM Jan 16, 2018 by Natasha Bhuyan, M.D.

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