• Fresh Perspectives

    Yes, You Can Practice Full-scope Family Medicine

    A residency colleague once told me, "MaryAnn, you're just not going to be able to do it all. You'll have to give things up."

    I'll tell you how she was right, but not until I explain all the ways she was wrong.

    When I finished training in 2016, I was dual boarded in family medicine and HIV medicine. I had just completed a fellowship in surgical and high-risk obstetrics. I loved all of it, and I had no intention of giving anything up. I already had my two children and a supportive husband. The world was a giant open door.

    But the data paint a different picture. Only 7% of family physicians practice obstetrics, despite the fact that more than 20% of us intend to do OB when we graduate. Only 46% of recent family medicine graduates practice inpatient medicine, compared to 78% of graduates prior to 2010. I remember an attending OB telling me during my fellowship that there was no reason for OB/Gyn generalists, that the American College of Obstetricians and Gynecologists should split that specialty.

    There were two assumptions made by my colleague and my attending: 1) that there are always enough specialized physicians for all patients, and 2) that physician satisfaction should come from specialization, not breadth. We already know that No. 1 is not true. There is a dire shortage of family physicians; there is a shortage of obstetrical providers; and patients do not have adequate access to specialized care, not only in rural communities but even in our city centers. We also know that physician burnout is a real thing, and that fulfilling physician satisfaction is key to maintaining our workforce. It's important to know that survey data actually reveals family physicians with broad-scope practice actually have better odds of avoiding burnout.

    Now back to my story. The data about residency graduates staying at their first jobs is not hopeful. Data shows 40% to 70% of residency graduates leave their first jobs within five years, and more than half of those who leave do so after only one or two years.

    I remember my "first job" interviews.

    "What is your ideal practice?"

    "What are you looking for?"

    My weary fellowship brain mustered thoughts of "sleep … meals … laundry."

    Of course, I created something else as an answer, something based on zero experience in real medicine. Something based on human rights, equity and women's health. I wasn't quite sure what distribution of inpatient, outpatient and procedures I wanted. I had no idea what different models of outpatient family medicine could look like.

    What lured me to my first job, honestly, were that I had a friend who worked there, I genuinely liked the people I met and it was a significant academic center. The pay wasn't bad, and I believed I could use almost all my skills in the same place.

    I was wrong.

    My first job was, in professional terms, a bad fit. I had the training to do HIV medicine, OB medicine, inpatient medicine, outpatient medicine, but I had none of the clout or support needed to actually do it all. I was the first family physician with my scope to be hired in many years. No other family doc there was doing cesarean sections, HIV work or family planning. I hadn't met all of my supervisors before starting, and the director of OB wanted nothing to do with me. Our community hospital's HIV doctor was so excited I'd arrived (when he found out about me nine months into my work there), but they were already closing the hospital and moving the residency, so it didn't matter much.

    The job didn't offer the tools to keep all my wheels on track. I tried to create a support system on my own. I worked with local OBs to continue practicing OB. I was able to practice ample inpatient medicine. The system was Catholic, which I realized greatly curtailed my ability to practice women's health procedures (or even talk with patients about them).

    I made good friends there, and I loved teaching the residents. I applied for other jobs. I worked hard enough and came out with strong recommendations.

    What did I learn from my fumble?

    • I learned to make sure to interview with all my potential supervisors. (And as a full-scope family medicine doctor, I have many supervisors!)
    • I learned that sign-on bonuses often have strings attached, and most sign-on bonuses are actually retention bonuses. Employers may pay you when you sign, but you will have to pay them back if you don't stay. And bigger retention bonuses may mean it's harder for certain employers to retain clinicians.
    • I learned the hard way what it's like to pay back an already spent retention bonus and moving across the country with two kids and a partner in tow. I have made expensive mistakes.

    Now I'm at my second job, and I'm happy professionally. I have a practice that includes full-spectrum women's health, pediatrics, LGBTQ care and addiction care. On any given day I speak two or three languages. I work inpatient medicine, and I work labor and delivery. I perform surgery, including a large scope of procedures. I talk about sex, identity and safety -- my favorite professional topics. I care for entire families. I care for the very young and the very old.

    I have let my HIV board go. It's something I consider adding back often, but I just haven't been able to give it the necessary time recently.

    I talk to many family medicine residents. They find me on Twitter, on Facebook and on this blog. They ask me how to do obstetrics, how to balance all their work interests. I am always both realistic and encouraging. As family physicians, we can and often do have adequate training for a large breadth of practice. There is such an incredible need for well-trained, full-scope family physicians. This pandemic has highlighted that even more.  

    At Boston Medical Center, family physicians were on the palliative care teams, inpatient COVID-19 teams, labor-and-delivery teams, at the front and center of surge planning, in the communities creating and staffing public testing sites, and working with nursing homes. Our broad training is not running out of time nor going out of style. Our training is as vital as it ever has been. And though we may fumble, if we persist, we will find our place in systems that allow for our breadth of expertise and find ways to benefit from it.

    MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is an assistant professor at Boston Medical Center. She is also women's health director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.

    Read other posts by this blogger.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.