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Defining Family Practice

Family DoctorI like Dr. Rob, the one with the “distractible mind.” And although I thoroughly agree with the stance he takes in his recent post against cholesterol screening in kids, I must take issue with his opening statement:

I have a unique vantage point when it comes to the issue universal cholesterol screening in children, when compared to most pediatricians. My unique view stems from the fact that I am also an internist who deals with those children after they grow up on KFC Double Downs.

From Dictionary.com:

“Unique: existing as the only one or as the sole example; single; solitary in type or characteristics.”

Your med-peds training allows you to follow patients from birth to death (but no obstetrics or gynecology). You can care for all organ systems and all stages of disease (but without as much training in psychiatry). Congratulations! You’ve just (re)invented family practice (except for the above shortcomings). Oh, wait — that’s already a recognized specialty with its own residency programs, boards and everything like that, forty years now.

This misuse of the word “unique” is one of my pet peeves. “Unique?” I don’t think that word means what you think it means. After twenty years in practice, I agree that there probably isn’t much difference between what Dr. Rob does and what I do. After twenty years, I’m not even sure how much relevance remains from our “training.” Still, there remains a great deal of confusion about the very real differences between family practice and med-peds residencies.

For starters, med-peds doesn’t provide much in the way of psychiatry or gynecology. I suppose Dr. Rob is either comfortable referring out half his patients for the bulk of their primary care needs, or he has gleaned sufficient on-the-job training to provide office gynecology care. (I’m sure he’s perfectly competent at it by now, though I wouldn’t have wanted to be one of his early patients as he figured out how to use the speculum on his own.) As for psychiatry, I’m sure he will agree that it makes up a hefty chunk of primary care medicine. Hopefully he’s picked up enough of it over the years so that he is comfortable dealing with his patients’ psychiatric issues. So I think we can agree that the farther you get from training, the more our skill sets converge.

The main difference in the training programs is this: Med-peds residents mainly see hospital patients. Their outpatient experience is limited to one “continuity clinic” a week throughout their four years of training. First year family practice residents are also in the office (we offer continuous care by definition, so we don’t need the “continuity” modifier) one half-day per week, but this increases over the next two years so that by the third year, we spend 3 to 4 half-days a week in the office. Family practice provides specific training in outpatient medicine: How to work up problems without a hospital admission, prescribing with an eye towards compliance (and cost), basic office management — the works. My program even required that we do housecalls, which I continue to do in my own practice today.

If you’re looking for a doctor to care for your entire family and you come across someone who’s been practicing a decade or two, it probably doesn’t matter whether you find someone who calls herself a family doctor or an “internist and pediatrician,” as you’re likely to get very similar care. But if you’re looking to hire someone fresh out of training, bear in mind that the family practice-trained doctor is more likely to be able to hit the ground running in an office setting. That’s the real difference between med-peds and family practice.

*This blog post was originally published at Musings of a Dinosaur*


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