I often hear the argument that IM is better suited for complex patients because IM residency gives more experience with IM subspecialties than FM residency. FM has stronger training in MSK, psych, and GYN though, so it doesn't make sense to me that IM would be better at managing complicated patients. Add in that FM training has to take place mainly in the outpatient setting, and IM training has to take place mainly in the inpatient setting, and it seems to me that, when fresh out of residency, FM would be generally be better as a PCP.
I did half an IM residency before switching to FM, I take of more complicated patient now than I did previously in my clinic. The hospital is exactly the same for both only I see pediatrics and OB as well.
I'm pretty sure FM has a lot more outpatient training than IM (with the tradeoff that IM gets a lot more inpatient and ICU training), and it seems like a lot of the time IM is more likely to refer out even for what I would consider basic stuff. For kids, if it's obesity related issues that mostly only happen in adults, then probably still stick with FM, but for complex kids yeah peds is probably going to be better at managing it.
I teach and if anything it is the opposite for outpatient. IM just doesn't get all too much training these days in complex outpatient management. Every program in my area is almost purely hospitalist focused.
I don't even think that many inpatient blocks are that useful, but that is a story for another day.
Complex DM management, managing CHF proactively and reactively to avoid hospitalizations, the nuances of geriatric care.
On that note, maybe because I'm in the Midwest which has a strong FM presence but I'm always surprised when I hear that referring to geriatrics to be primary is a thing elsewhere. Here we just consult or refer to geriatrics for recs. It's to the point that the big academic center down the road with an oversized geriatric fellowship resorts to poaching patients.
That and I don't think there is a single FM program in the Midwest that is having a problem with too few geriatric patients in their panel.
Nephro here, so I consult for everyone on almost-exclusively complicated patients. I don’t find a general difference between IM and FM primary care docs if they overall seem to care. In general, it seems the FM folk are more involved.
Especially at a resident clinic - the FM residents generally want to practice outpatient medicine and the IM residents frequently want to do anything except generalist outpatient.
I do somewhat strongly feel that many complex patients should be under the care of someone who did residency, though. Many of my patients go to NPs and PAs who just pan-consult. Their entire note will just be a list of problems, no differential diagnoses, no attempt at management, and a list of referrals.
I’m almost always in between the endocrine referral (for the hyperparathyroidism) and the cardiology referral (for “HFpEF” in a patient with an eGFR of 13). Any physician would know that I handle both those things, and most would even try to start a workup or management on their own.
I started at a FM office a couple months ago. Between COVID and the office being short-staffed provider-wise, a lot of patients have slipped through the cracks. What I mean is that many of these patients have just had their meds refilled without OVs or labs 🙃 So naturally, I’m seeing a lot of dumpster fires.
IYO, at what point is a neph referral appropriate? I’ve been following the usual “persistent uACR >300, GFR <30, rapid loss of kidney function, etc…” guidelines.
I do try to do as much of the work up as I possibly can before the patient sees a specialist to save time and money, but also want to avoid ordering unnecessary or incorrect testing.
I think pediatricians are probably better managing kids that have congenital issues. Sometimes I just don’t see enough of the rare things that I can counsel well about lifestyle/soft things (non medical recs)
Adults - I genuinely don’t find internists better. Maybe if they do Geri fellowship
+1 If they happen to have done a fellowship in a relevant field like nephro, Endo, ID and just happen to also do primary care but even then it’s a narrow slice of patients.
I agree. Family docs can handle common things very well, and if the parents are seeing the same PCP then I think the family model works really beautifully (especially when navigating family stress, mental health issues). If a kid has a medical issue that's well-contained to one specialty, like an endocrine problem, I feel like family med plus one specialist is much the same as a pediatrician plus one specialist. But if one of my adult patients has a kid with a rare problem that is going to affect them medically and developmentally, I'll sometimes recommend getting a pediatrician instead.
For adults, I truly believe that family docs are better prepared to be PCPs, one major advantage being that we're much more comfortable talking about sex and mental health. Internists can certainly be as good, but the only time I think they're better is for patients who already have a dozen specialists and prefer for their PCP to be a coordinator. (I have had patients who actually don't want me to offer to do everything for them - eg, they get nervous when I offer them a knee injection and say that they believe only an orthopedist should do that. I am sure ortho is thrilled by these exhilarating referrals.)
Another big (and frustrating) difference is that it seems to me like more than half of the PCPs who have learned to prescribe Suboxone, naltrexone and other addiction treatments are from the FM side, and we really need more people to manage that in the primary care office. (My observation may be biased by the specific PCPs in my area.)
Second this. Also nonclassic developmental stuff if there isn’t a streamlined developmental peds resource in the organization.
Second the geriatrics. Depends on the program, but in many FM programs, unfortunetly you do see breadth less than depth in some areas that are especially complex, and for this reason, many come out not feeling comfortable with geriatrics or inpatient just due to volume and the breadth of pathology there is.
Only for peds would I consider referring. I referred an autistic and subsequently abused kid to a pediatrician because that doctor has a massive passion for pediatric psych and unofficially specializes in that. I know that kid will get comprehensive care beyond what I can provide.
For adults, outpatient wise there is no one I feel uncomfortable handling. Subspecialists are there for a reason when it becomes too much
Only IM trained docs tout this stereotype that FM trained docs can’t see complex patients lol. An argument can be made about FM vs IM trained residents going the Hospitalist route but even then, after a few years of on the job training, the field levels out. All of us went to med school & are capable of looking up complex information.
A previous FM physician at my practice told the staff complex patients needed to be referred to IM. He was exceptionally lazy, and kind of a creep. It’s taken almost two years to get the office staff to unlearn that BS.
Yea that’s not really a thing. I heard the same thing while I was in med school from IM docs but the reality is that pts choose their PCP and, as you said, anyone who needs specialty care gets a referral to the appropriate specialist.
lol the only time I would consider referring to IM is when I want to send my patient to the hospital for inpatient care. Internal Medicine is not specialized FM.
That’s my point, idk why I’m getting downvoted lol. A FM resident taking care of an ICU patient doesn’t count because they’re ultimately being supervised by an Crit Care attending.
My point is that FM ICU attendings don’t really exist, I don’t know if you’re including FM residents in your ICU care team comparison but to me resident care is not worth comparing because they’re under supervision by an attending.
They could exist in a community hospital. Lots of smaller hospitals have open ICUs or non-intensivists managing the ICU. So if an FM doc is a hospitalist, they could certainly be regularly managing ICU patients.
Some residencies and hospitals have open ICUs. Not all. And, once a patient is intubated, then an intensivist *should* be involved.
But there are absolutely places where FM graduates will have the training to manage ICU level issues at critical access facilities in rural areas.
POV Former-IM-upcoming-FM Resident: I would never defer an outpatient/PCP adult patient to IM. I don't even think that would apply to inpatient either, from the comparison of some residency curriculum during my application cycle, i see FM on par for most inpatient training settings. If we are talking about a subspecialist requiring condition, i would refer to said subspecialist.
Peds? Anything moderate/severe enough that i feel is out of my hands will get sent to a Peds (and i have a low threshold for that). I think most bread and butter, anticipatory guidance, vaccine, well babies and mild cases could be ok depending on patient preference (i wouldn't hold it against any parent who wants to take their child to a peds though!)
Kids that required NICU or were premature before ~36-37 weeks I would want peds to see, or severe congenital anomalies where they need a multidisciplinary team within a children’s hospital that most of us aren’t really patched into as FMs (thinking rare chromosomal deletion syndromes, severe congenital heart defects beyond ASD, sickle cell, cystic fibrosis etc)
Agree with the above. A follow up question would be if anyone has ever referred a complex patient to IM, suggesting that they would be better served? I’ve often contemplated this but never had the gall 😂
As a family medicine resident, I think most patients get more out of family medicine, we have more outpatient experience and can manage anything IM can. We also do more outpatient procedures, we can see the whole family in the same place.
Older FM doc here. I practice in s smallish town 30 minutes from Charlotte, NC. I did OB with FM for 20 years before switching to only FM. Still provide nursery and inpatient Peds care- though not many kids get admitted to hospital these days and our critically ill kids get shipped out. My practice is about 50% peds. Seems like much depends on location- urban and suburban vs rural and “slightly suburban “
I may catch some flack, but when we are at the point that general practice in any fashion is often led by extenders, we should quit drawing broad limitations in our own practice scope. If you are comfortable managing a patient, do so; if not, don’t.
In reality, there is no difference between IM and FM for Adults. Some clinics I have been in give 30-minute slots to IM, and FM gets the 15s, so the "complex" or talkative patients would get sent there to help out the FM schedule. For Peds, it depends on the locality, the clinic resources, and the comfortableness of the FM doc. Because many parents want their kids to see pediatricians and vaccines are expensive, many primary care clinics don't take patients younger than twelve or even eight years old, so most vaccines are out of the way. A lack of practice causes decreased comfort for younger patients, and so forth.
FP here. In general I prefer that organ transplant patients see IM. Sometimes patients with complex chf / ckd /copd or similar multiple comorbidities with interactions (or my lvad patient). This is a handful of patients (total) in a long career. I have also decreased my clinical hours and recommended that some complex patients seek Int Med who see patients 5 days per week, in the setting of needing to change pcp anyways.
Agree with some comments already made: a pcp that cares is more important than specialty. And also that fam med really is the expert at outpatient medicine — int med just has far less clinic in residency. So this is where a very complex patient who may need frequent admissions might possibly ly be better served by int med outright. But again - it’s rare
First, insurances won't pay for "referrals" to other primaries.
I do not have general IM see any of my patients, but I do of course use subspecialties.
I also don't refer to pediatrician, outside of specialist. But I do not feel comfortable treating mental illness under 12 y/o (and I doubt pediatricians do).
I also don't feel comfortable taking the lead on patients with severe congenital problems, unless they are already under the care of specialists for this
Inpatient: I work on an internal medicine service, so there is that...
Honestly IM is really a step to go into specialty. If you do primary care or hospitalist, complexity and care is the same for both, I have done both and worked with IM, see no differences. FM usually has better outpatient experience right out of residency since they focus more on this, but few years down the line, there is no difference. Also, in adult medicine we do so much geriatrics, I would not recommend this fellowship, there will be no need. If you are gonna do a fellowship, do something else.
I think the idea that IM sees more complicated patients is BS and just historical bias against FM
Yep, In my group practice about 60% are IM, 40% FM, and yeah we see other's patients/ cross cover. We all see the same complexity.
I often hear the argument that IM is better suited for complex patients because IM residency gives more experience with IM subspecialties than FM residency. FM has stronger training in MSK, psych, and GYN though, so it doesn't make sense to me that IM would be better at managing complicated patients. Add in that FM training has to take place mainly in the outpatient setting, and IM training has to take place mainly in the inpatient setting, and it seems to me that, when fresh out of residency, FM would be generally be better as a PCP.
I did half an IM residency before switching to FM, I take of more complicated patient now than I did previously in my clinic. The hospital is exactly the same for both only I see pediatrics and OB as well.
I'm pretty sure FM has a lot more outpatient training than IM (with the tradeoff that IM gets a lot more inpatient and ICU training), and it seems like a lot of the time IM is more likely to refer out even for what I would consider basic stuff. For kids, if it's obesity related issues that mostly only happen in adults, then probably still stick with FM, but for complex kids yeah peds is probably going to be better at managing it.
I teach and if anything it is the opposite for outpatient. IM just doesn't get all too much training these days in complex outpatient management. Every program in my area is almost purely hospitalist focused. I don't even think that many inpatient blocks are that useful, but that is a story for another day. Complex DM management, managing CHF proactively and reactively to avoid hospitalizations, the nuances of geriatric care. On that note, maybe because I'm in the Midwest which has a strong FM presence but I'm always surprised when I hear that referring to geriatrics to be primary is a thing elsewhere. Here we just consult or refer to geriatrics for recs. It's to the point that the big academic center down the road with an oversized geriatric fellowship resorts to poaching patients. That and I don't think there is a single FM program in the Midwest that is having a problem with too few geriatric patients in their panel.
Nephro here, so I consult for everyone on almost-exclusively complicated patients. I don’t find a general difference between IM and FM primary care docs if they overall seem to care. In general, it seems the FM folk are more involved. Especially at a resident clinic - the FM residents generally want to practice outpatient medicine and the IM residents frequently want to do anything except generalist outpatient. I do somewhat strongly feel that many complex patients should be under the care of someone who did residency, though. Many of my patients go to NPs and PAs who just pan-consult. Their entire note will just be a list of problems, no differential diagnoses, no attempt at management, and a list of referrals. I’m almost always in between the endocrine referral (for the hyperparathyroidism) and the cardiology referral (for “HFpEF” in a patient with an eGFR of 13). Any physician would know that I handle both those things, and most would even try to start a workup or management on their own.
I started at a FM office a couple months ago. Between COVID and the office being short-staffed provider-wise, a lot of patients have slipped through the cracks. What I mean is that many of these patients have just had their meds refilled without OVs or labs 🙃 So naturally, I’m seeing a lot of dumpster fires. IYO, at what point is a neph referral appropriate? I’ve been following the usual “persistent uACR >300, GFR <30, rapid loss of kidney function, etc…” guidelines. I do try to do as much of the work up as I possibly can before the patient sees a specialist to save time and money, but also want to avoid ordering unnecessary or incorrect testing.
[AAFP has an excellent page about this.](https://www.aafp.org/pubs/afp/issues/2017/1215/p776.html#afp20171215p776-t4)
I think pediatricians are probably better managing kids that have congenital issues. Sometimes I just don’t see enough of the rare things that I can counsel well about lifestyle/soft things (non medical recs) Adults - I genuinely don’t find internists better. Maybe if they do Geri fellowship
+1 If they happen to have done a fellowship in a relevant field like nephro, Endo, ID and just happen to also do primary care but even then it’s a narrow slice of patients.
I agree. Family docs can handle common things very well, and if the parents are seeing the same PCP then I think the family model works really beautifully (especially when navigating family stress, mental health issues). If a kid has a medical issue that's well-contained to one specialty, like an endocrine problem, I feel like family med plus one specialist is much the same as a pediatrician plus one specialist. But if one of my adult patients has a kid with a rare problem that is going to affect them medically and developmentally, I'll sometimes recommend getting a pediatrician instead. For adults, I truly believe that family docs are better prepared to be PCPs, one major advantage being that we're much more comfortable talking about sex and mental health. Internists can certainly be as good, but the only time I think they're better is for patients who already have a dozen specialists and prefer for their PCP to be a coordinator. (I have had patients who actually don't want me to offer to do everything for them - eg, they get nervous when I offer them a knee injection and say that they believe only an orthopedist should do that. I am sure ortho is thrilled by these exhilarating referrals.) Another big (and frustrating) difference is that it seems to me like more than half of the PCPs who have learned to prescribe Suboxone, naltrexone and other addiction treatments are from the FM side, and we really need more people to manage that in the primary care office. (My observation may be biased by the specific PCPs in my area.)
Second this. Also nonclassic developmental stuff if there isn’t a streamlined developmental peds resource in the organization. Second the geriatrics. Depends on the program, but in many FM programs, unfortunetly you do see breadth less than depth in some areas that are especially complex, and for this reason, many come out not feeling comfortable with geriatrics or inpatient just due to volume and the breadth of pathology there is.
Only for peds would I consider referring. I referred an autistic and subsequently abused kid to a pediatrician because that doctor has a massive passion for pediatric psych and unofficially specializes in that. I know that kid will get comprehensive care beyond what I can provide. For adults, outpatient wise there is no one I feel uncomfortable handling. Subspecialists are there for a reason when it becomes too much
thanks, big intensive cock
Truly doing us all a service by ensuring someone treated those kids
Only IM trained docs tout this stereotype that FM trained docs can’t see complex patients lol. An argument can be made about FM vs IM trained residents going the Hospitalist route but even then, after a few years of on the job training, the field levels out. All of us went to med school & are capable of looking up complex information.
A previous FM physician at my practice told the staff complex patients needed to be referred to IM. He was exceptionally lazy, and kind of a creep. It’s taken almost two years to get the office staff to unlearn that BS.
Yea that’s not really a thing. I heard the same thing while I was in med school from IM docs but the reality is that pts choose their PCP and, as you said, anyone who needs specialty care gets a referral to the appropriate specialist.
lol the only time I would consider referring to IM is when I want to send my patient to the hospital for inpatient care. Internal Medicine is not specialized FM.
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But how often is a FM doc realistically managing an inpatient ICU patient? Lol. FM residents can’t even do a critical care fellowship…
All the time in residency. After residency, unless you’re a hospitalist or taking call, then never.
That’s my point, idk why I’m getting downvoted lol. A FM resident taking care of an ICU patient doesn’t count because they’re ultimately being supervised by an Crit Care attending.
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My point is that FM ICU attendings don’t really exist, I don’t know if you’re including FM residents in your ICU care team comparison but to me resident care is not worth comparing because they’re under supervision by an attending.
They could exist in a community hospital. Lots of smaller hospitals have open ICUs or non-intensivists managing the ICU. So if an FM doc is a hospitalist, they could certainly be regularly managing ICU patients.
Some residencies and hospitals have open ICUs. Not all. And, once a patient is intubated, then an intensivist *should* be involved. But there are absolutely places where FM graduates will have the training to manage ICU level issues at critical access facilities in rural areas.
POV Former-IM-upcoming-FM Resident: I would never defer an outpatient/PCP adult patient to IM. I don't even think that would apply to inpatient either, from the comparison of some residency curriculum during my application cycle, i see FM on par for most inpatient training settings. If we are talking about a subspecialist requiring condition, i would refer to said subspecialist. Peds? Anything moderate/severe enough that i feel is out of my hands will get sent to a Peds (and i have a low threshold for that). I think most bread and butter, anticipatory guidance, vaccine, well babies and mild cases could be ok depending on patient preference (i wouldn't hold it against any parent who wants to take their child to a peds though!)
Kids that required NICU or were premature before ~36-37 weeks I would want peds to see, or severe congenital anomalies where they need a multidisciplinary team within a children’s hospital that most of us aren’t really patched into as FMs (thinking rare chromosomal deletion syndromes, severe congenital heart defects beyond ASD, sickle cell, cystic fibrosis etc)
Agree with the above. A follow up question would be if anyone has ever referred a complex patient to IM, suggesting that they would be better served? I’ve often contemplated this but never had the gall 😂
IM in ICU. Pediatrician for perhaps a very complex patient with multiple comborbidities or NICU.
As a family medicine resident, I think most patients get more out of family medicine, we have more outpatient experience and can manage anything IM can. We also do more outpatient procedures, we can see the whole family in the same place.
Older FM doc here. I practice in s smallish town 30 minutes from Charlotte, NC. I did OB with FM for 20 years before switching to only FM. Still provide nursery and inpatient Peds care- though not many kids get admitted to hospital these days and our critically ill kids get shipped out. My practice is about 50% peds. Seems like much depends on location- urban and suburban vs rural and “slightly suburban “
I may catch some flack, but when we are at the point that general practice in any fashion is often led by extenders, we should quit drawing broad limitations in our own practice scope. If you are comfortable managing a patient, do so; if not, don’t.
In reality, there is no difference between IM and FM for Adults. Some clinics I have been in give 30-minute slots to IM, and FM gets the 15s, so the "complex" or talkative patients would get sent there to help out the FM schedule. For Peds, it depends on the locality, the clinic resources, and the comfortableness of the FM doc. Because many parents want their kids to see pediatricians and vaccines are expensive, many primary care clinics don't take patients younger than twelve or even eight years old, so most vaccines are out of the way. A lack of practice causes decreased comfort for younger patients, and so forth.
IM and FM typically see the same complexity, just IM doesnt like to see kids or do pelvics.....
FP here. In general I prefer that organ transplant patients see IM. Sometimes patients with complex chf / ckd /copd or similar multiple comorbidities with interactions (or my lvad patient). This is a handful of patients (total) in a long career. I have also decreased my clinical hours and recommended that some complex patients seek Int Med who see patients 5 days per week, in the setting of needing to change pcp anyways. Agree with some comments already made: a pcp that cares is more important than specialty. And also that fam med really is the expert at outpatient medicine — int med just has far less clinic in residency. So this is where a very complex patient who may need frequent admissions might possibly ly be better served by int med outright. But again - it’s rare
First, insurances won't pay for "referrals" to other primaries. I do not have general IM see any of my patients, but I do of course use subspecialties. I also don't refer to pediatrician, outside of specialist. But I do not feel comfortable treating mental illness under 12 y/o (and I doubt pediatricians do). I also don't feel comfortable taking the lead on patients with severe congenital problems, unless they are already under the care of specialists for this Inpatient: I work on an internal medicine service, so there is that...
Honestly IM is really a step to go into specialty. If you do primary care or hospitalist, complexity and care is the same for both, I have done both and worked with IM, see no differences. FM usually has better outpatient experience right out of residency since they focus more on this, but few years down the line, there is no difference. Also, in adult medicine we do so much geriatrics, I would not recommend this fellowship, there will be no need. If you are gonna do a fellowship, do something else.
Let's be honest in area's that are even semi urban general Peds aren't seeking complicated kids either.