Is it time to change Internal Medicine?

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This year I have noticed many of my classmates opting for specialties that are direct, shorter term commitments, and do not necessarily rely on a fellowship for a decent career. In fact, the majority of the most competitive specialties are direct paths: radiology, dermatology, anesthesia, EM, and all the surgical subspecialties. I feel like many of the brightest go for these fields when they could have such a substantial impact on fields like endocrinology, nephrology, heme-onc etc.

I am NOT saying internal medicine doesn't not attract the best students; this is actually far from the truth. I think they could have an even better pool to choose from if they made a few changes. Provide the option of direct subspecialty training via IM. For example, to finish as a cardiologist you apply for a combined cardiology program with 2 years IM + 3 years cardiology. It prevents the headache and uncertainty of applying for a fellowship while allowing a student to become a trained sub-specialist in 5 years. Sure these programs may become a bit more competitive but I think the advantages may outweigh the costs. Why aren't urology or ENT requiring someone to complete a surgery residency before applying for their fellowship?

If there is something I am missing here please inform me. It just seems as though medical students have already put in so much effort and time to prove they intelligent so why make those students suffer through another application if they are only interested in allergy or GI. It seems as though combined IM + subspecialty programs would benefit the student, the specialty, and subtract one year of medicare funding for fellows.

When I did my Cardiology part of my IM clerkship, the fellow made similar comments. He seemed to think that may be something coming down the pike soon. Of course, surgical specialties take ridiculous amounts of time to complete, and I don't think they're going to truncate them anytime soon. Six years to finish IM+specialty isn't an inordinate amount of time, but I do agree they could potentially shave a year off from the specialty's perspective. If they did though, where are all the senior residents that run the wards going to come from?

There are a number of fast track residency/fellowship programs around. For instance, like you mentioned with cardiology, you can also do a 2 year IM + 4 year fellowship for heme/onc. From my understanding, these programs are there primarily for future researchers and sort of incorporate a post doc into them, so I don't know if they apply to everything.

A benefit to 3 years of internal medicine, however, is that, if torn between various subspecialties, you get more time to make that decision. In that regard it doesn't seem like mandatory suffering.

Originally Posted by Dawkter

This year I have noticed many of my classmates opting for specialties that are direct, shorter term commitments, and do not necessarily rely on a fellowship for a decent career. In fact, the majority of the most competitive specialties are direct paths: radiology, dermatology, anesthesia, EM, and all the surgical subspecialties. I feel like many of the brightest go for these fields when they could have such a substantial impact on fields like endocrinology, nephrology, heme-onc etc. ...

If there is something I am missing here please inform me. It just seems as though medical students have already put in so much effort and time to prove they intelligent so why make those students suffer through another application if they are only interested in allergy or GI. It seems as though combined IM + subspecialty programs would benefit the student, the specialty, and subtract one year of medicare funding for fellows.

I'm not sure All these "direct paths" are actually shorter committments. For example, radiology has a prelim year, four years of residency, and most radiologists then must do a 1 year fellowship to get jobs (ie 6 years total post school training). And in this economy, second fellowships are not unheard of. Many surgical paths are 5 years or more and many still do a year of fellowship thereafter. By comparison some IM specalties can be done in 3 years and then another two years of fellowship -- shorter. There are no shortcuts, and it doesn't help you to whine that other fields have it better, particularly when you don't have your facts straight.

what you are saying sounds good on the surface but I think the knowledge of IM as a whole is very important for any subspecialty branching from it. IM only takes 3 years now and most fellowships are not more than 3 years. Therefore training with a fellowship averages around 5-6 years which is the same length as most every surgical field base residency.

Fields like urology usually do a surg prelim year or have to do a lot of gen surg floor work their intern year I believe. But it is not necessary for them to know the ins and outs of all in general surgery residency because they can learn in during the rest of their uro residency and if complications arise in big procedures you can always get a gen surgeon in the OR.

I think the "smarter" people on average (based on charting outcomes clearly all surgical fields are way more competitive than IM) go into surgical fields is because, well, they can. Surgery has more prestige, makes more money, and hours during residency are usually close to IM hours. Smarter people go in because the field as a whole is a lot more competitive. Lots of them also see it as being "more fun". I do not think they pursue it because of the length of training being shorter (for example, neurosurgery). Also lots of people do fellowships in gen surgery (not sure about uro) which increases the length of training by 2-3 years.

Originally Posted by docshop12

what you are saying sounds good on the surface but I think the knowledge of IM as a whole is very important for any subspecialty branching from it. IM only takes 3 years now and most fellowships are not more than 3 years. Therefore training with a fellowship averages around 5-6 years which is the same length as most every surgical field base residency.

Fields like urology usually do a surg prelim year or have to do a lot of gen surg floor work their intern year I believe. But it is not necessary for them to know the ins and outs of all in general surgery residency because they can learn in during the rest of their uro residency and if complications arise in big procedures you can always get a gen surgeon in the OR.

I think the "smarter" people on average (based on charting outcomes clearly all surgical fields are way more competitive than IM) go into surgical fields is because, well, they can. Surgery has more prestige, makes more money, and hours during residency are usually close to IM hours. Smarter people go in because the field as a whole is a lot more competitive. Lots of them also see it as being "more fun". I do not think they pursue it because of the length of training being shorter (for example, neurosurgery). Also lots of people do fellowships in gen surgery (not sure about uro) which increases the length of training by 2-3 years.

You are wrong.

One more thing. Most people going into IM don't know what they want to do. How can they? It's pretty much impossible to know what's really involved with a specialty and what patients you enjoy and problems you like taking care of until you've done it for a couple years. Furthermore you don't have time in med school to do rotations on the major subspecialties in IM. Maybe they can shorten it by six months by removing some outpatient rotations? But I don't think you'll have a lot direct programs any time soon.

There are "primary care" tract programs available in IM which I think you'll likely see more of.

Originally Posted by CatFactorial

You are wrong.

oh good explanation. I believe you. Sorry and thanks for correcting my mistake.

stop trolling

Originally Posted by Law2Doc

I'm not sure All these "direct paths" are actually shorter committments. For example, radiology has a prelim year, four years of residency, and most radiologists then must do a 1 year fellowship to get jobs (ie 6 years total post school training). And in this economy, second fellowships are not unheard of. Many surgical paths are 5 years or more and many still do a year of fellowship thereafter. By comparison some IM specalties can be done in 3 years and then another two years of fellowship -- shorter. There are no shortcuts, and it doesn't help you to whine that other fields have it better, particularly when you don't have your facts straight.

A field like interventional cardiology takes up to 7 years, not to mention the worries that come with trying to get accepted into a cardiology fellowship. There is also talk that both EP and interventional will become 2 year fellowships soon requiring 8 years of training total. Not all IM subspecialties are two years.

Originally Posted by docshop12

what you are saying sounds good on the surface but I think the knowledge of IM as a whole is very important for any subspecialty branching from it. IM only takes 3 years now and most fellowships are not more than 3 years. Therefore training with a fellowship averages around 5-6 years which is the same length as most every surgical field base residency.

Fields like urology usually do a surg prelim year or have to do a lot of gen surg floor work their intern year I believe. But it is not necessary for them to know the ins and outs of all in general surgery residency because they can learn in during the rest of their uro residency and if complications arise in big procedures you can always get a gen surgeon in the OR.

I think the "smarter" people on average (based on charting outcomes clearly all surgical fields are way more competitive than IM) go into surgical fields is because, well, they can. Surgery has more prestige, makes more money, and hours during residency are usually close to IM hours. Smarter people go in because the field as a whole is a lot more competitive. Lots of them also see it as being "more fun". I do not think they pursue it because of the length of training being shorter (for example, neurosurgery). Also lots of people do fellowships in gen surgery (not sure about uro) which increases the length of training by 2-3 years.

I think theres mores smart people in IM then in surgery. IM is much bigger.

Originally Posted by docshop12

oh good explanation. I believe you. Sorry and thanks for correcting my mistake.

stop trolling

Some people don't base their careers on the latest season of Grey's Anatomy.

How the hell is that trolling? Go read a book.

Originally Posted by winkleweizen

I think theres mores smart people in IM then in surgery. IM is much bigger.

OK. Well obviously I am talking about the average IM resident vs the average surgical resident. It also depends on how one defines "smart". I was only using the word because that is what the OP said.

But let's say a "smart" resident got a >250 on step 1. In IM 358 people did so. Now combining surgical fields in charting outcomes: gen surg (81), plastic surg (37), neurosurg (50), ENT (86), ortho (154) you get a total of 408. This also does not include ophtho and uro since stats on these fields are not available. So obviously in the surgical fields those residents have higher test scores which most med students equate with being "smarter". And also all of the previous fields have higher average step 1 than IM.

By the way I am not going into a surgical field. I'm just putting down the numbers.

Originally Posted by CatFactorial

Some people don't base their careers on the latest season of Grey's Anatomy.

How the hell is that trolling? Go read a book.

all you said was "you are wrong" with no explanation. If you would have said what you said above I wouldn't have stated "stop trolling". But saying "go read a book" is sort of trolling. Have no idea where that is coming from actually.

Also I think you're wrong to say that people don't choose a surgical field for prestige. Obviously it isn't the only reason or even probably a major factor but students do take this stuff into account even only if unconsciously. Surgery has a mystique surrounding it many students find attractive.

Originally Posted by docshop12

One more thing. Most people going into IM don't know what they want to do. How can they? It's pretty much impossible to know what's really involved with a specialty and what patients you enjoy and problems you like taking care of until you've done it for a couple years. Furthermore you don't have time in med school to do rotations on the major subspecialties in IM. Maybe they can shorten it by six months by removing some outpatient rotations? But I don't think you'll have a lot direct programs any time soon.

There are "primary care" tract programs available in IM which I think you'll likely see more of.

It's not as impossible as you say. You can have an interest in a particular field without having done it before. Hypothetical example--a research assistant in a sarcoidosis lab eventually wants to be a pulmonologist. IM + pulmonology fellowship, bam.

Originally Posted by docshop12

OK. Well obviously I am talking about the average IM resident vs the average surgical resident. It also depends on how one defines "smart". I was only using the word because that is what the OP said.

But let's say a "smart" resident got a >250 on step 1. In IM 358 people did so. Now combining surgical fields in charting outcomes: gen surg (81), plastic surg (37), neurosurg (50), ENT (86), ortho (154) you get a total of 408. This also does not include ophtho and uro since stats on these fields are not available. So obviously in the surgical fields those residents have higher test scores which most med students equate with being "smarter". And also all of the previous fields have higher average step 1 than IM.

By the way I am not going into a surgical field. I'm just putting down the numbers.

What nonsense. After you match into a program you want, who really cares about step scores? What physician bases his/her career reputation on medical school performance?

Originally Posted by docshop12

I think the "smarter" people on average go into surgical fields is because, well, they can.

lol

Originally Posted by CatFactorial

It's not as impossible as you say. You can have an interest in a particular field without having done it before. Hypothetical example--a research assistant in a sarcoidosis lab eventually wants to be a pulmonologist. IM + pulmonology fellowship, bam.

most med students don't do this. I haven't done IM residency nor do I know enough about its set up to see what could be cut but I think if a person has a particular interest then the person could do more electives in that field. Programs may be able to shorten their duration by 6 months for residents like that perhaps as well. But I think a great majority of IM residents do not know what fellowship if any they would like to pursue before they even start.

What nonsense. After you match into a program you want, who really cares about step scores? What physician bases his/her career reputation on medical school performance?

well I don't necessarily agree with using step scores to show how smart a person is but there really isn't any other meaningful objective measurement. I would say step scores show knowledge at that particular time. It isn't applicable by the time you are well into residency. However all students take these tests so all students can be compared to one another and on average surgical residents had higher scores as students than IM residents.

Originally Posted by Dawkter

A field like interventional cardiology takes up to 7 years, not to mention the worries that come with trying to get accepted into a cardiology fellowship. There is also talk that both EP and interventional will become 2 year fellowships soon requiring 8 years of training total. Not all IM subspecialties are two years.

Meh, six years for radiology, seven for cards, it's a pretty irrelevant difference. My point is that you seemed to be suggesting these direct paths were all like three and out, which isn't the case.

most med students don't do this. I haven't done IM residency nor do I know enough about its set up to see what could be cut but I think if a person has a particular interest then the person could do more electives in that field. Programs may be able to shorten their duration by 6 months for residents like that perhaps as well. But I think a great majority of IM residents do not know what fellowship if any they would like to pursue before they even start.

How exactly do you know what most medical students do or don't do? Do you speak from experience? Substituting a different disease and IM subspecialty, that scenario describes my interests pretty well. And by no means am I unique.


well I don't necessarily agree with using step scores to show how smart a person is but there really isn't any other meaningful objective measurement. I would say step scores show knowledge at that particular time. It isn't applicable by the time you are well into residency. However all students take these tests so all students can be compared to one another and on average surgical residents had higher scores as students than IM residents.




It's just absurd to think that any medical student would go through the rigors of medical school, figure out what s/he likes and dislikes, and then bail for [insert high step score field here] "just because he can."

Originally Posted by Law2Doc

Meh, six years for radiology, seven for cards, it's a pretty irrelevant difference. My point is that you seemed to be suggesting these direct paths were all like three and out, which isn't the case.

What? Doing interventional cards means you apply for two fellowships and put in seven years. I'm saying put in 6 years and apply for one interventional fellowship by making IM plus cards 5 years combined.

Originally Posted by docshop12

But let's say a "smart" resident got a >250 on step 1. In IM 358 people did so. Now combining surgical fields in charting outcomes: gen surg (81), plastic surg (37), neurosurg (50), ENT (86), ortho (154) you get a total of 408. This also does not include ophtho and uro since stats on these fields are not available. So obviously in the surgical fields those residents have higher test scores which most med students equate with being "smarter". And also all of the previous fields have higher average step 1 than IM.

By the way I am not going into a surgical field. I'm just putting down the numbers.

Why are you comparing every surgical specialty to IM? The correct comparison would be general surgery to internal medicine.

There are also very different beasts of IM programs out there. Many IM programs offer their graduates little to no chance of getting into a good fellowship - of course these do not attract top applicants.

The people applying to the big academic programs often are much more impressive than your typical gen surgery applicant, and lumping them in with FMGs fighting for small community IM programs is silly.

Anyone arguing that IM docs are less cerebral than surgeons has clearly not spent a second on the wards. Are you in medical school yet?

Originally Posted by docshop12

most med students don't do this. I haven't done IM residency nor do I know enough about its set up to see what could be cut but I think if a person has a particular interest then the person could do more electives in that field. Programs may be able to shorten their duration by 6 months for residents like that perhaps as well. But I think a great majority of IM residents do not know what fellowship if any they would like to pursue before they even start.

If you think you have more elective time in residency than in medical school, you clearly don't know why you're talking about...

Medical students are often naive about the realities of being a doctor, but it's far easier to get exposure to new subspecialties in medical school than residency.

Most residents aiming for competitive specialties know what they want going in to residency or at the latest by the end of their first year (and you have to apply end of your second year). Electives are spent building credentials and making connections, not window-shopping - that's what medical school is for...

Originally Posted by docshop12

what you are saying sounds good on the surface but I think the knowledge of IM as a whole is very important for any subspecialty branching from it. IM only takes 3 years now and most fellowships are not more than 3 years. Therefore training with a fellowship averages around 5-6 years which is the same length as most every surgical field base residency.

Fields like urology usually do a surg prelim year or have to do a lot of gen surg floor work their intern year I believe. But it is not necessary for them to know the ins and outs of all in general surgery residency because they can learn in during the rest of their uro residency and if complications arise in big procedures you can always get a gen surgeon in the OR.

I think the "smarter" people on average (based on charting outcomes clearly all surgical fields are way more competitive than IM) go into surgical fields is because, well, they can. Surgery has more prestige, makes more money, and hours during residency are usually close to IM hours. Smarter people go in because the field as a whole is a lot more competitive. Lots of them also see it as being "more fun". I do not think they pursue it because of the length of training being shorter (for example, neurosurgery). Also lots of people do fellowships in gen surgery (not sure about uro) which increases the length of training by 2-3 years.

what an relevant point you make. such a meaningful contribution to this discussion. /sarcasm

Originally Posted by johnnydrama

Anyone arguing that IM docs are less cerebral than surgeons has clearly not spent a second on the wards. Are you in medical school yet?

I did not argue that or mention it at all...

I am lumping them together because those fields and doctors training in them are "surgeons". And you are simply wrong about IM interns knowing exactly what subspecialty they want to pursue. I go to a huge academic program and most all I spoke with do not have a definite fellowship in mind. Also I never said you had more elective time in residency. But there are elective months you can take and over a 3 year period this is more than the 4th year electives in med school. Also as a resident your role is different and your knowledge is greater so you can make a more informed decision on what fellowship you want to pursue. Finally half of US grads IM residents don't do a fellowship.

I will put this in terms you will understand since you're doing radiology. A lot of med students I have talked to who like radiology want to solely do it for IR. These students have 2 logical fallacies. 1. They do not know the scope and knowledge of IR at the resident/fellow level nor does a student have any responsibilities and 2. students don't know hardly any diagnostic radiology and all that is involved with the field or other subspecialties like nuclear medicine. So after a few years in rads residency a person may learn they really like neuroradiology or abdominal.

Same goes for IM. People may go in with a fellowship in mind but might change once they learn more of what other fields have to offer.

Same argument is made against dedicated thoracic surgery programs. I know a CT surgeon on the board at my program who didn't like the idea of fast tract thoracic surgery because he just didn't think it was possible for a med student to know he/she want to only do thoracic surgery without seeing any general surgery.

So again you try to berate a poster and come up empty. It's getting old.

Originally Posted by RandomHero117

what an relevant point you make. such a meaningful contribution to this discussion. /sarcasm

way to read the first post where the OP says he thinks the best and brightest choose surgical fields. I was just using the same terminology.

A troll post is defined as a post which is off topic (yours) and provides no meaningful contribution to the discussion (yours).

Originally Posted by Law2Doc

I'm not sure All these "direct paths" are actually shorter committments. For example, radiology has a prelim year, four years of residency, and most radiologists then must do a 1 year fellowship to get jobs (ie 6 years total post school training). And in this economy, second fellowships are not unheard of. Many surgical paths are 5 years or more and many still do a year of fellowship thereafter. By comparison some IM specalties can be done in 3 years and then another two years of fellowship -- shorter. There are no shortcuts, and it doesn't help you to whine that other fields have it better, particularly when you don't have your facts straight.

I can't speak for the OP's overall intention, but I think you're missing the more important issue he/she raised, which is the issue of tying in the sub-specialty training to the initial residency placement. Even if it's kept at 3+3, a linked 6 year IM/Subspecialty program would be immensely more attractive to me at least, and likely to many others. I think it's a bit insulting to characterize the OP as "whining" when he/she is doing nothing of the sort. And you're focusing on the smaller picture from the OP's post and ostensibly missing the larger one.

Originally Posted by Dawkter

What? Doing interventional cards means you apply for two fellowships and put in seven years. I'm saying put in 6 years and apply for one interventional fellowship by making IM plus cards 5 years combined.

I think it's easy to say 7 years is too long as a student since it seems so far away. But a surgeon I spoke with who trained a total (with 2 years research) of 9 years says he does not regret in the least the amount of training he did. I'm sure not all feel that way but I agree with that opinion. It doesn't seem as a student that interventional cards should require 7 years after med school since all they seem to do is send a cath into the coronaries and put in stents. But I think we only think that because we just don't know all that is involved with the field.

Cardiology is a huge field in and of itself. It has interventional, EP (which is mostly procedures), imaging, inpatient, outpatient, etc. It's larger and more diverse than lots of other subspecialities in IM out there. Perhaps in the future when/if cards becomes even more complex that it requires more training then programs will start to pop up that will expedite training. But I think that limit is around 8 years (the length of things like endovascular neurosurgery/interventional neuro - another field that if you look at it from the student perspective doesn't seem like it should take that long but the fellows don't complain when you talk to them).

it is also my opinion that if a 3rd/4th year student is dead set on something very specialized like interventional cards then that student is very naive. No way that student can make a informed decision like that so early in his/her training.

Originally Posted by johnnydrama

Anyone arguing that IM docs are less cerebral than surgeons has clearly not spent a second on the wards. Are you in medical school yet?

I think you need to be very clear on your definition of cerebral and definition of intelligence. If your forte is to spend 20 minutes per patient waxing intellectual about the sensitivity and specificity of a scoring system for predicting the duration of community acquired pneumonia, does that make you smart?

Originally Posted by docshop12

I did not argue that or mention it at all...

I am lumping them together because those fields and doctors training in them are "surgeons". And you are simply wrong about IM interns knowing exactly what subspecialty they want to pursue. I go to a huge academic program and most all I spoke with do not have a definite fellowship in mind. Also I never said you had more elective time in residency. But there are elective months you can take and over a 3 year period this is more than the 4th year electives in med school. Also as a resident your role is different and your knowledge is greater so you can make a more informed decision on what fellowship you want to pursue. Finally half of US grads IM residents don't do a fellowship.

Several friends of mine are going through the fellowship process now. Many people choose IM because they are undecided, that is true, but anyone going into a competitive subspecialty needs to decide early, and many decide before they get there.

Either they go for a chief year, or they have to apply at the end of second year. That doesn't leave much room for error, and only a few months total of elective time to figure things out. For less competitive specialties, people can do things like take a hospitality (autocorrect doesn't like hospitalists apparently) year, etc etc before applying.

I will put this in terms you will understand since you're doing radiology. A lot of med students I have talked to who like radiology want to solely do it for IR. These students have 2 logical fallacies. 1. They do not know the scope and knowledge of IR at the resident/fellow level nor does a student have any responsibilities and 2. students don't know hardly any diagnostic radiology and all that is involved with the field or other subspecialties like nuclear medicine. So after a few years in rads residency a person may learn they really like neuroradiology or abdominal.

Your English is horrible. I hope it isn't your first language.

I seriously considered IM - I really liked both cardiology and oncology.

Flexibility to change one's mind is great, but pushing the decision point back further isn't really an advantage.

If I could have applied directly to cardiology, I might have considered it more seriously, but the idea of that level of uncertainty about getting the specialty I want in a location I would want that much later in life was not appealing.

And I'd argue that the biggest factor making residents change their minds about fellowships isn't due to a fundamentally new understanding of the material, but more about practical matters like the job market and what life would be like actually working in that specialty.

For your example, residents generally don't change their minds about IR because they suddenly "know the scope and knowledge", it's because they realize that they don't want the unpredictable lifestyle associated with it.

Same goes for IM. People may go in with a fellowship in mind but might change once they learn more of what other fields have to offer.

Same argument is made against dedicated thoracic surgery programs. I know a CT surgeon on the board at my program who didn't like the idea of fast tract thoracic surgery because he just didn't think it was possible for a med student to know he/she want to only do thoracic surgery without seeing any general surgery.

So again you try to berate a poster and come up empty. It's getting old.

Most CT surgeons are against CT surgery tracks because their scope of practice has decreased to almost nil thanks to interventional cardiology.

Are you really a student? I find this hard to believe.

As someone who is going to do internal medicine, judging intelligence by average step score across all specialtis in surg vs medicine is a stupid comparison for reasons that really should be obvious to anyone who's been through ms3 year. If your internist tells you he can remove your appendix, run for the hills. If your surgeon thinks he can manage your vasculitis, run for the hills. Does it take more smarts to treat vasculitis than do an appendectomy? Depends on who you ask and how much experience they have with either. Based on your argument, dermatologists are the "smartest specialty"

Also stop double posting

I think the real point is that smarter people can choose to go into whatever field they want to, whereas those who are not as smart are shoehorned into less competitive specialties. That said, you can find intelligent people in all specialties.

Originally Posted by phenylacetone

I think you need to be very clear on your definition of cerebral and definition of intelligence. If your forte is to spend 20 minutes per patient waxing intellectual about the sensitivity and specificity of a scoring system for predicting the duration of community acquired pneumonia, does that make you smart?

I chose the word "cerebral" very carefully.

I was definitely not saying surgeons are dumber than IM people (have known some brilliant surgeons/surgery residents). They're prone to far less mental master baiting though, that's for sure.

Originally Posted by DrSnips

I think the real point is that smarter people can choose to go into whatever field they want to, whereas those who are not as smart are shoehorned into less competitive specialties. That said, you can find intelligent people in all specialties.

Ding ding ding

To my best estimation, the 'smartest' person from my class from a top 25 med school went into Psych...Kudos to her.

In other news, reading this tread dropped my IQ by at least 3 points.

Originally Posted by johnnydrama

Are you really a student? I find this hard to believe.

well this is the last time I'm replying to any of your posts on any thread ever. You call other people trolls but you come here and bash everyone in a disrespectful manner because you disagree with them. btw so glad you did not choose IM. Rads is perfect for you.

All hail johnnydrama. He knows all about everything!

Originally Posted by docshop12

All hail johnnydrama. He knows all about everything!

At last! Some recognition.

I don't call everyone trolls, only a few who deserve it.

Truthers, steroid-fueled Canadians, and you my dear chum.

Originally Posted by GuyWhoDoesStuff

I can't speak for the OP's overall intention, but I think you're missing the more important issue he/she raised, which is the issue of tying in the sub-specialty training to the initial residency placement. Even if it's kept at 3+3, a linked 6 year IM/Subspecialty program would be immensely more attractive to me at least, and likely to many others. I think it's a bit insulting to characterize the OP as "whining" when he/she is doing nothing of the sort. And you're focusing on the smaller picture from the OP's post and ostensibly missing the larger one.

No, I got that. But even the ROAD specialties require a prelim year before you can sub specialize. There is a notion that you can never really be a good specialist unless you have adequate generalist foundation. It's really the same principle here.

Also with the cuts to duty hours a stronger argument could probably be made to lengthen a lot of residency paths, not abridge them. Anyone who is late in residency can tell you that although it's a long arduous path, you only feel partly prepared for what comes next as is. And you start worrying that you really won't have seen and done everything that might be professionally helpful. Shortening the path sounds a lot better to those who haven't started down this rabbit hole yet. As a med student you are focused on the years you have to go and the hours you need to work. About midway during residency this focus is going to shift and your lack of time to accomplish certain things is going to be the real stressor.

Originally Posted by Phyozo

As someone who is going to do internal medicine, judging intelligence by average step score across all specialtis in surg vs medicine is a stupid comparison for reasons that really should be obvious to anyone who's been through ms3 year. If your internist tells you he can remove your appendix, run for the hills. If your surgeon thinks he can manage your vasculitis, run for the hills. Does it take more smarts to treat vasculitis than do an appendectomy? Depends on who you ask and how much experience they have with either. Based on your argument, dermatologists are the "smartest specialty"

Also stop double posting

While you will find very smart people in every specialty (including lower down specialties), on average the competitive specialties have smarter people in them vs. less competitive. And among the competitive specialties are surgical specialties.

Originally Posted by sportsperson

While you will find very smart people in every specialty (including lower down specialties), on average the competitive specialties have smarter people in them vs. less competitive. And among the competitive specialties are surgical specialties.

My point is that even if you're the most brilliant person in the world but you've spent the last 5 years doing appys and choles in surgery, no way you will know how to manage a patient with semi-complicated diabetes. Your point about generalizing specialties based on usmle step scores as a surrogate marker for intelligence is not only ridiculous but irrelevant.

Originally Posted by Phyozo

Does it take more smarts to treat vasculitis than do an appendectomy? Depends on who you ask and how much experience they have with either. Based on your argument, dermatologists are the "smartest specialty."

Well, to be fair, in addition to being one of the more competitive specialties, we do routinely treat vasculitis AND do surgery.

Originally Posted by Phyozo

My point is that even if you're the most brilliant person in the world but you've spent the last 5 years doing appys and choles in surgery, no way you will know how to manage a patient with semi-complicated diabetes....

you don't think complicated diabetics get appendicitis or cholecystitis and linger on on surgical services now and then? The SICU is full of them. The surgery residents manage them at their sickest, when they have other comorbidities.

Girls, girls! You're all smart and you're all pretty! Stop fighting.

Originally Posted by johnnydrama

Girls, girls! You're all smart and you're all pretty! Stop fighting.

Pshhh. if they're in med school some how I doubt they're all pretty

Originally Posted by Law2Doc

you don't think complicated diabetics get appendicitis or cholecystitis and linger on on surgical services now and then? The SICU is full of them. The surgery residents manage them at their sickest, when they have other comorbidities.

Oh bish please.

You're still going on about this. The mere fact patients make it in and out of a SICU is a miracle and has little to do with that the "awesome" management by the surgeons.

If I had a dollar for the number of time the surgeons tried to "kill" a patient of mine by ignoring or not paying attention to things in the SICU, I could buy us a good meal. And invariably what always happens is they dick around for two maybe three days, and then decide that it's hard or they are bored and transfer the patient to the MICU like should have happened in the first place.

And you're not "managing diabetes" by putting a patient on an insulin gtt. The nurse manages your blood sugar, and keeps your sugars between 150-200. Don't hurt you shoulder, anyone, trying to pay yourself on the back with the "complex and complicated" diabetes management in the ICU.

Originally Posted by Law2Doc

No, I got that. But even the ROAD specialties require a prelim year before you can sub specialize. There is a notion that you can never really be a good specialist unless you have adequate generalist foundation. It's really the same principle here.

Also with the cuts to duty hours a stronger argument could probably be made to lengthen a lot of residency paths, not abridge them. Anyone who is late in residency can tell you that although it's a long arduous path, you only feel partly prepared for what comes next as is. And you start worrying that you really won't have seen and done everything that might be professionally helpful. Shortening the path sounds a lot better to those who haven't started down this rabbit hole yet. As a med student you are focused on the years you have to go and the hours you need to work. About midway during residency this focus is going to shift and your lack of time to accomplish certain things is going to be the real stressor.

I agree with this, but again it dodges the other big point I think the OP was trying to make (and if he was not, allow me to introduce it as a novel idea): linking the application process somehow so that you are "matching into" cardiology, heme/onc, GI, etc right out of med school. The residency/fellowship lengths would still be identical, as would the content and progression of said content. I do realize there are inherent hurdles to this, but the positive would be eliminating the huge amount of uncertainty for students hoping to match into competitive fellowships. In a sense, their stock may be pretty darn high coming out of medical school (great Step I/Step II scores, honors in clinical rotations, solid research, etc), and when the choice is between "gambling" with the internal medicine route and hoping they continue to remain the "cream of the crop" during residency (for someone hoping to match,say, cards or GI) or snagging a residency that's already by definition more specialized (and inherently more lucrative) than internal medicine such as derm, rads, gas, etc, it's easy to see why some might abandon the former. I'm not arguing this is the norm by any means, but I do think that there is that bit of deterrent that exists.

I fully support (well, for most cases) a year of general medicine prelim year/TY for these "already subspecialized" fields, on that we agree entirely. But I think the extra hoops to jump through to obtain the IM subspecialties can be a headache for some. As a personal anecdote (the value of which are always limited), I have two classmates/friends who were excellent students (one AOA, one probably should've been, both Step I >240) and thinking IM (one wanted cards, the other I'm not sure), but both ended up in other fields (rads and gas) primarily because they deemed it "too risky" to assume they'd be in strong shape to match into top fellowships in a couple more years. Again, I'm not advocating anyone switch their life plans based on this factor, but it seems that some people do.

Originally Posted by GuyWhoDoesStuff

But I think the extra hoops to jump through to obtain the IM subspecialties can be a headache for some. As a personal anecdote (the value of which are always limited), I have two classmates/friends who were excellent students (one AOA, one probably should've been, both Step I >240) and thinking IM (one wanted cards, the other I'm not sure), but both ended up in other fields (rads and gas) primarily because they deemed it "too risky" to assume they'd be in strong shape to match into top fellowships in a couple more years. Again, I'm not advocating anyone switch their life plans based on this factor, but it seems that some people do.

Matching into fellowship is not that big of a deal - matching into residency was much more important step. Another point many people do not understand is what is meant by "top fellowships" - most of your "top" fellowships are "top" because of the research you're able to do there; ie. they have money to pay fellows to do research and start to make an acedmic name and career for themselves. If all you want to do is learn clinical sub-specialty medicine in one of the IM sub-specialty areas it's not that hard to find a spot somewhere as long as you're flexible.

As far as shortening IM training. I don't think it's a good idea. Hell, I think the three years we get now is like borderline adequate and that's for the people who were paying attention. As was mentioned earlier being a good sub-specialist requires you to have a solid foundation in internal medicine or you're kind of useless outside your area. Think of the surgical sub-specialists, good at what they do, but completely useless outside of that, which they can get away with because they are largely procedural. However, when you're dealing with medical issues where you're seeing one part of what is quite often a systemic problem and you're wanting to use medicine that can interfere in other areas of the body or with other medications, you need to know good solid IM.

You could still learn general medicine in a subspecialty track.

If Cardiology were a 5 year residency with a separate intern year, the first two could be spent as general IM and they'd get the same training as now.

Even with the three years general IM, many IM subspecialists lose track of things outside their specialty - that's just human nature. The relevant stuff is kept, the less relevant stuff becomes fuzzy.

And it's far easier to get into an IM residency than a cardiology fellowship (using your standard of just getting in somewhere). Most people have higher standards than that and might also want to stay in a particular region, etc. Top programs aren't just about research - that's a foolish statement. The training you get at a major center will be much different than that at a barebones community hospital in the middle of nowhere.

Originally Posted by jdh71

...

If I had a dollar for the number of time the surgeons tried to "kill" a patient of mine by ignoring or not paying attention to things in the SICU, I could buy us a good meal...

there are plenty of surgeons who wouldn't mind a dollar for every time the medicine folks try to "kill" patients with surgical issues as well. Good meals all around. Don't be silly. My response was to a naive comment that only medical patients have complex medical issues, which simply isn't the case.

In fact, I'd say the main argument against subspecialty tracks would be that people who aren't competitive enough to get a spot at a top program in cardiology could still get an IM spot at that program for better basic training before going somewhere worse for fellowship.

Originally Posted by Law2Doc

there are plenty of surgeons who wouldn't mind a dollar for every time the medicine folks try to "kill" patients with surgical issues as well. Good meals all around. Don't be silly. My response was to a naive comment that only medical patients have complex medical issues, which simply isn't the case.

Don't expect too much rationality - he's a 9/11 Truther.

Originally Posted by GuyWhoDoesStuff

I agree with this, but again it dodges the other big point I think the OP was trying to make (and if he was not, allow me to introduce it as a novel idea): linking the application process somehow so that you are "matching into" cardiology, heme/onc, GI, etc right out of med school. The residency/fellowship lengths would still be identical, as would the content and progression of said content. I do realize there are inherent hurdles to this, but the positive would be eliminating the huge amount of uncertainty for students hoping to match into competitive fellowships. In a sense, their stock may be pretty darn high coming out of medical school (great Step I/Step II scores, honors in clinical rotations, solid research, etc), and when the choice is between "gambling" with the internal medicine route and hoping they continue to remain the "cream of the crop" during residency (for someone hoping to match,say, cards or GI) or snagging a residency that's already by definition more specialized (and inherently more lucrative) than internal medicine such as derm, rads, gas, etc, it's easy to see why some might abandon the former. I'm not arguing this is the norm by any means, but I do think that there is that bit of deterrent that exists.

I fully support (well, for most cases) a year of general medicine prelim year/TY for these "already subspecialized" fields, on that we agree entirely. But I think the extra hoops to jump through to obtain the IM subspecialties can be a headache for some. As a personal anecdote (the value of which are always limited), I have two classmates/friends who were excellent students (one AOA, one probably should've been, both Step I >240) and thinking IM (one wanted cards, the other I'm not sure), but both ended up in other fields (rads and gas) primarily because they deemed it "too risky" to assume they'd be in strong shape to match into top fellowships in a couple more years. Again, I'm not advocating anyone switch their life plans based on this factor, but it seems that some people do.

Taking uncertainty out of the system has some negative consequences, that I think outweigh the positives. First, it shortens the time people have to decide what they want to do with their life, which is ever a good thing.Somee people know early on what they want, others need the extra time to solidify things., and second, it creates a closed mind view for a lot of people who start to take the attitude that "I don't really need to know this well, because I won't ever use it again". (sort of like the prelim interns sometimes have). Both are the bad consequences of locking folks into their paths early. I simply don't see much benefit in letting someone know they got cards a few years earlier, it doesn't change much except give someone a bad attitude when having to deal with non-cardiology issues during the early years as a pointless "chore".