Question on doctor terms

[FinallyRetired]

I have a few simple questions. What does an internist specialize in and how do they differ from a GP or family doctor? And what is the difference between a resident and staff doctor? Are residents "on their own" in a hospital or do they need to be "signed off" by a staff doctor? How about surgery, can a resident do surgery? Not necessarily needing to know for myself right now but things I've wondered for a while that may become important later.

[Meadbh]

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Originally Posted by SoonToRetire I have a few simple questions. What does an internist specialize in and how do they differ from a GP or family doctor? And what is the difference between a resident and staff doctor? Are residents "on their own" in a hospital or do they need to be "signed off" by a staff doctor? How about surgery, can a resident do surgery? Not necessarily needing to know for myself right now but things I've wondered for a while that may become important later.

Good questions!

An Internist is a doctor who specializes in "internal medicine", that is, disorders of "internal" systems in the ADULT body. Those would include the cardiovascular system (heart & blood vessels), respiratory system (airway and lungs), renal system (kidneys and associated plumbing), endocrine system (glands that make hormones, such as the thyroid, pituitary, adrenal, and insulin producing cells in the pancreas). To become an internist (or any other type of specialist) after completing med school, a doctor would do a Residency in Internal Medicine. This generally takes three years in the US but longer elsewhere. Let's suppose our budding resident develops a particular interest in heart disease. Her or she could then do a Fellowship (2-3 years) in Cardiology. As an adult, if you have something wrong with you that clearly isn't surgical, and if it's beyond the expertise of your GP or Family Doctor, your GP might refer you to an Internist.

Speaking of Family Doctors or GPs, a doctor who is interested in Primary Care (looking after whoever comes in the door) will generally choose this speciality. Family Docs look after people from the cradle to the grave. They are trained in a separate residency program, and may develop particular interests, such as delivering babies, providing psychiatric consultation, doing minor surgery, delivering anesthetics (with the proper training). The good thing about having a family doc is that he or she knows you and your community very well and can deliver "continuity of care", i.e. consistency over time. Obviously, if you develop a complex illness, e.g. cancer, you will require the expertise of many specialists, such as a surgeon, oncologist (e.g. Rich in Tampa) etc. Your family doctor can help implement the plans that Rich and company think up and can look after "you", often working in a team with other health professionals such as Nurse Practitioners.

For children, the Pediatrician is the equivalent of the Internist. Some pediatricians do a lot of Primary Care for kids (see below). I am a Neonatologist, a pediatrician who has done a Fellowship in Neonatology (the care of newborn babies).

OK, on to Residents. A resident is a doctor who has graduated from medical school and who is now training in a particular specialty, which could be surgery, internal medicine, pediatrics, ob/gyn, psychiatry, family medicine, etc, etc. Depending on the specialty, residency programs take 3-5 years. Residents work very hard and do a lot of night call. They rotate to different services every month. They get a lot of teaching and mentoring and are regarded as postgrad students. Earnings range from $40-$60K where I practice. Residents have educational licences and are supervised by attendings (who have completed residencies or more). To be recognized as specalists, residents must successfully complete professional exams (such as American Boards or Canadian Fellowships) at the end of their training. Beyond residency, doctors who wish to subspecialize do Fellowships, which are generally 2-3 years in duration and have a required research component.

Can a resident "do" surgery? Yes, in a graduated way. A junior surgical resident would be expected to scrub with his/her attending and after several operations (e.g. appendicectomy) holding the retractors, would be taught to stitch up the wound, and eventually to take out the appendix. A resident should not be operating without an attending surgeon in the OR unless he or she is a senior resident and has already demonstrated competence in the procedure. Just like the coipilot flying the plane.

Rich, anything to add? Paging oncology......

[Rich_by_the_Bay]

A few differences in the states (where I practice) versus in Canada, where Meadbh practices: here, internists commonly provide primary care, while in Canada they are generally consultants. A second and growing group of internists in the states are "hospitalists" whose practice is at least 35-50% hospital based at a minimum; this is closer to what internists are in Canada or the UK.

In fact, after decades of being a primary care internist, I became a hospitalist and practice within a cancer center doing everything medical except cancer care, so officially I am not an oncologist, but rather am a general internist specializing in hospital medicine. Both Meadbh and I are in academic medicine which focuses things a bit more on referral type cases.

So, if you are looking for a good primary care doctor in the US, you'll select either an internist (adults only, more focused practice -- no OB, for example -- more training in complex or confusing diseases), a family practitioner (does a little ob, a little more ortho, minor surgery,kids, but less focused on complex or severe disease). General practitioners are very rare anymore in the states (1 year of post MD training). Last one I knew is displayed in my avatar: Marcus Welby, MD.

People have a right to be confused. Some groups (the biggest internal medicine organization, for example) have been calling internists "doctors for adults." I always say that a general internist (US) is to adults what a pediatrician is to kids.

[Meadbh]

Pardon me Rich, I assumed you were an Oncologist. I'm interested to know your perspective on the pros and cons of primary care versus hospitalist medicine. Send me a PM so we won't bore the others!

Meadbh

[Sue J]

Please continue the discussion here. I'm probably not the only one who thinks this is very interesting.

[Trek]

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Originally Posted by Sue J Please continue the discussion here. I'm probably not the only one who thinks this is very interesting.

Please do 'cause all the semantics leave me not knowing what someone like Rich does other than work as a primary doctor at a hospital sometimes.

[Ed_The_Gypsy]

Ditto. I have body parts in both countries.

[Meadbh]

While we're at it, maybe Moemg can explain the difference between a Clinical Nurse Specialist, a Nurse Practitioner, and all those other terms that my Nursing colleagues are so picky about. Paging nursing.....

[Rich_by_the_Bay]

OK, I'll take a crack at it, but you asked for it...

I'm a hospitalist. I trained in internal medicine (4 years beyond medical school). I practiced primary care (personal care for adults, doctor of first contact) for 25 years, mostly in academic places (university hospitals, etc.). Eventually, largely because of academic opportunities, I drifted into hospital medicine just as it was taking hold as a legitimate specialty in the states. I spend my time caring for very, very sick patients which is both rewarding and at times draining.

I loved doing primary care but must admit that bureaucratic and financial considerations had eroded my enjoyment over the years. Yet, I still have a small primary care practice now, mostly colleagues, nurses, doctors, "friends" (read big donors referred to me by the hospital VIPs). My hope for FIRE is to return to part time primary care. Enough about my career.

Hospital medicine is like primary care for inpatients; episodic, but I still coordinate care among subspecialists, usually am the first responder for true emergencies, etc. As an academician, much of my time is spent overseeing residents (MDs 1-3 years beyond medical school). Here you have to strike a balance between allowing the residents to have controlled independence while still assuring that the care of the patients is not compromised. Usually I do this in stealth mode, but they hear from me if a care plan deviates too far from what is best.

Residents are not on their own if the attending physician is doing his or her job well. This includes surgery where, yes, the residents do participate in graded degrees under the very close supervision of the attending physician. But this includes allowing them to perform quite independently if you have previously assured yourself that they have proven themselves in such situations to your satisfaction. There are occasional lapses, but not many. Despite the outcry, young physicians are typically very smart, sincere have survived an incredibly competitive preparation, and do a great job. Working as part of a team also keeps the errors down.

Meadbh, both primary care and hospitalism have been right for me at their respective stages of my career. If I had to limit myself to one only, it would probably be primary care since I so enjoyed the longterm relationships, taking care of the kids and even grandkids of my earliest patients. There's a special satisfaction successfully diagnosing and managing the undifferentiated patient... and protecting them from overzealous care by referring thoughtfully. But I'm glad to have done both.

[Meadbh and I share an interest in evidence-based medicine, pioneered in Canada and the UK -- I did my EBM training at McMaster in Ontario. EBM is the practice of finding and assessing the best research evidence for solving a patient problem, and using the right decision tools to apply when necessary. Sounds vague, but think of it like investing: you can research the stocks and funds, know the proven theories, diversify, be disciplined and patient and employ the best tools available (EBM) or you can listen to your barber and bet on the latest tips or whatever lucky experience you may have had before (non-EBM).]

Still sure you don't want us to go offline ?

[FinallyRetired]

Thanks, everyone, for very complete and informative answers. I'm much better informed now, and hopefully can make better choices and decisions for my health care and those of my family. I respect and admire everyone who works in the medical field and who have dedicated their professional life to helping those in need.

[Meadbh]

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Originally Posted by Rich_in_Tampa [Meadbh and I share an interest in evidence-based medicine, pioneered in Canada and the UK -- I did my EBM training at McMaster in Ontario. EBM is the practice of finding and assessing the best research evidence for solving a patient problem, and using the right decision tools to apply when necessary. Sounds vague, but think of it like investing: you can research the stocks and funds, know the proven theories, diversify, be disciplined and patient and employ the best tools available (EBM) or you can listen to your barber and bet on the latest tips or whatever lucky experience you may have had before (non-EBM).]

Thanks Rich for sharing your personal perspective as a practitioner. I'm also interested in your observations about the quality of care that patients get when treated by a hospitalist versus being admitted to hospital under the care of a physician in private practice. For example, is variation reduced? Are hospital stays more efficient? Are EBM tools (e.g. care pathways) more likely to be used effectively?

For everybody else, you should know that traditionally, medicine was seen as an "art" and there are a number of studies out there that show that 100 experts in, say, colon cancer, will read the same literature and provide care in 100 different ways, and not just because the patient wants it that way. In other words, there was a great deal of variation driven by the whim of the physician. As we get more scientific about this, it's becoming clearer that there are advantages to treating common problems in standard ways (including reducing the risk of errors), while of course recognizing that every patient is unique. The question is: what model of care is most conducive to implementing EBM and patient safety? Should physicians be "company men/women" on salary, or should they be "lone rangers"?

Of course, EBM has another meaning in my specialty: expressed breast milk!

[Rich_by_the_Bay]

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Originally Posted by Meadbh I'm also interested in your observations about the quality of care that patients get when treated by a hospitalist versus being admitted to hospital under the care of a physician in private practice. For example, is variation reduced? Are hospital stays more efficient? Are EBM tools (e.g. care pathways) more likely to be used effectively?

Well, we've got to turn to the evidence . Patient satisfaction appears to be a bit higher with hospitalists. Adherence to guidelines, advantage hospitalists in some observational studies. Length of stay - close call. Outcomes? That's the big one and for most diseases there simply is no valid evidence -- yet.

Personally, I think it is a better model. I am more up to date and comfortable with the latest treatments for common inpatient diseases. I am there when the family flies in at 4 pm (not in my office up to my neck with patients and paperwork). I know the hospital routine, the nursing staff, and the subspecialists better. The surgeons rely on us regularly to bail out surgical patients who developed nonsurgical problems during their stay. And we can offer some protection from referral-rrhea (where a surgical patient ends up with 4 medical subspecialty consultants for various problems, where a single hospitalist consult would have been just fine).

Time will tell.

[Nords]

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Originally Posted by Rich_in_Tampa referral-rrhea

Good one!

I've never even heard of a hospitalist before this post. Your educational efforts are making us all more dangerous informed consumers, Rich...

[Meadbh]

I like it when consumers are informed and participate actively in their own care. One day on rounds, a Dad was reading through a 900 page internet search he had run on his baby's illness, which was rare and serious. Each member of the team presented his/her input. I turned to the Dad and asked for his. He said: "Well, based on my review of the available literature, I think the prognosis for my baby's condition is uncertain and that we may never know what caused this problem". I couldn't have put it any better!

[Achiever51]

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Originally Posted by Sue J Please continue the discussion here. I'm probably not the only one who thinks this is very interesting.

Yes, please share! This is interesting stuff -- and may help more of us understand the whole health care discussion.

[kjrn]

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Originally Posted by Rich_in_Tampa Personally, I think it is a better model. I am more up to date and comfortable with the latest treatments for common inpatient diseases. I am there when the family flies in at 4 pm (not in my office up to my neck with patients and paperwork). I know the hospital routine, the nursing staff, and the subspecialists better. The surgeons rely on us regularly to bail out surgical patients who developed nonsurgical problems during their stay. And we can offer some protection from referral-rrhea (where a surgical patient ends up with 4 medical subspecialty consultants for various problems, where a single hospitalist consult would have been just fine).

One vote in agreement from the nursing section!

Having worked both with and without an Intensivist in the unit, I can say without a doubt that I WANT that dedicated doc there. There's a huge list of benefits (as Rich listed). For us there were added benefits of actual practice of evidence-based medicine, consistency of care, timely targeted response to pending emergencies, and an opportunity (for all) to contribute to the improvement of patient outcomes as a team.

The increasing weight being placed on the healthcare system will force change. Fortunately, the use of hospitalists would seem to be a very positive one.

[Meadbh]

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Originally Posted by kjrn One vote in agreement from the nursing section! Having worked both with and without an Intensivist in the unit, I can say without a doubt that I WANT that dedicated doc there. There's a huge list of benefits (as Rich listed). For us there were added benefits of actual practice of evidence-based medicine, consistency of care, timely targeted response to pending emergencies, and an opportunity (for all) to contribute to the improvement of patient outcomes as a team. The increasing weight being placed on the healthcare system will force change. Fortunately, the use of hospitalists would seem to be a very positive one.

Agreed! From the intensivist in the unit.....