Internal Medicine v.s. Family Practice- PLEASE HELP ME!

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Can someone tell me the major difference b/w the two? Obviously, family practice is more concerned with the family as a whole, but i mean beyond that, what's the difference? Couldn't a general internist simply happen to treat many family's? I ask this b/c I have always been interested in General Internal Medicine. But now, after much research, I can't see why I shouldn't just go for Family Medicine. After all, it has the highest demand.

Intelligent answers are much appreciated, and thanks for your help.

One of the major things with Internal Medicine is the ability to specialize- cardiology, neurology, infectious disease, etc, so if you think that you would like to have that option, perhaps IM is the choice for you.

Family practice = primary-care doctor that you'd see for basic check-ups.

Internal medicine physicians will specialize in an area like cardiology, neurology, GI, or some other part of the body. They are specialists in their area of study. If you were to have a heart problem that your primary-care doc detects, he'd send you to a cardiologist for a more thorough exam. As far as I know, there is no such thing as a "general internist". They all do some sort of fellowship afterwards, otherwise, really, then you are just a family medicine doc.

Actually the number one difference is that FM doctors can practice on both children and adults. IM doctors can ONLY practice on adults. They are not trained to practice on children and cannot legally do so.

As others have said - IM CAN specialize. But FM doctors can do fellowships too its just less common.

And many IM doctors DON'T specialize. Most of my primary care practioners in my adult life have been Internal medicine docs.

Go into med school with an open mind, expect to change your desire specialty more than once. Its not something you need to stress about now. Once you've done your rotations you'll know if you like IM or FM better and which is better for your goals.

Originally Posted by TheRealMD

Family practice = primary-care doctor that you'd see for basic check-ups.

Internal medicine physicians will specialize in an area like cardiology, neurology, GI, or some other part of the body. They are specialists in their area of study. If you were to have a heart problem that your primary-care doc detects, he'd send you to a cardiologist for a more thorough exam. As far as I know, there is no such thing as a "general internist". They all do some sort of fellowship afterwards, otherwise, really, then you are just a family medicine doc.

Neurologists do residency in Neurology.

An internist who does not do a fellowship is not uncommon. Being in primary care does not equal being a FM doc. FM-trained physicians have background in peds and obstetrics that one does not get in an IM residency.

Originally Posted by TheRealMD

As far as I know, there is no such thing as a "general internist". They all do some sort of fellowship afterwards, otherwise, really, then you are just a family medicine doc.

Nope... there are general internists. That's why they classify people going into internal medicine as going into primary care... not all do, obviously, but those that don't are still involved in primary care.

Yeah, there is general internal medicine. They're called generalists or internists and specialize in IM without doing a fellowship to subspecialize in anything. I think alwaysangel is right, the main difference is IM docs only practice on adults. Aside from that big difference, I'm pretty sure there's training nuances between the two, and maybe a med student or resident can weigh in on them.

Originally Posted by alwaysaangel

Actually the number one difference is that FM doctors can practice on both children and adults. IM doctors can ONLY practice on adults. They are not trained to practice on children and cannot legally do so.

As others have said - IM CAN specialize. But FM doctors can do fellowships too its just less common.

And many IM doctors DON'T specialize. Most of my primary care practioners in my adult life have been Internal medicine docs.

Go into med school with an open mind, expect to change your desire specialty more than once. Its not something you need to stress about now. Once you've done your rotations you'll know if you like IM or FM better and which is better for your goals.

Whoa. There is no law preventing any doctor from practicing any kind of medicine if he feels comfortable doing it with the caveat that if you screw something up through negligence you will pay and pay and pay. I am in Emergency Medicine but there is nothing preventing me from going into practice as a pediatrician. I can't bill myself as "board certified" but if I can get patients there will be no problem.

The reason FM docs, for example, don't do as much surgery (yes, there was a time when Family Medicine physicians were trained to so simple surgeries like appendectomies and c-sections) is because no hospital or surgical group can afford the liability. But there's no law against it, per se.

Originally Posted by Panda Bear

The reason FM docs, for example, don't do as much surgery (yes, there was a time when Family Medicine physicians were trained to so simple surgeries like appendectomies and c-sections) is because no hospital or surgical group can afford the liability. But there's no law against it, per se.

I thought some of them were still doing these procedures way out in the boonies where there's a severe shortage of doctors?

Originally Posted by Auburnpremed

Can someone tell me the major difference b/w the two? Obviously, family practice is more concerned with the family as a whole, but i mean beyond that, what's the difference? Couldn't a general internist simply happen to treat many family's? I ask this b/c I have always been interested in General Internal Medicine. But now, after much research, I can't see why I shouldn't just go for Family Medicine. After all, it has the highest demand.

Intelligent answers are much appreciated, and thanks for your help.

Quick and dirty answer:

* Family med: "Cradle to grave" medicine. Can do routine OB/gyn care, and some deliver babies. Training includes a surgery rotation too.

* Internal med: "After the pediatrician." Also called "adult" medicine. Usually doesn't provide gyn or obstetrical care. No surgical training.

family med guy: is exposed to snot and feces from babies

internal med guy: is not

Originally Posted by inaminute

family med guy: is exposed to snot and feces from babies

internal med guy: is not

True. They are just exposed to snot and feces from octogenarians.

Originally Posted by lord_jeebus

An internist who does not do a fellowship is not uncommon. Being in primary care does not equal being a FM doc. FM-trained physicians have background in peds and obstetrics that one does not get in an IM residency.

Agree with this. The doctor I used to see was an internist who did IM and didn't subspecialize. Internists, hospitalists, etc all fit this mold.

Originally Posted by inaminute

family med guy: is exposed to snot and feces from babies

internal med guy: is not

I think I would mind the snot and feces from babies much less than I would the same substances coming from adults.

IM specialize in treating adults and can further specialize in specific areas like cardiology.

FP sacrifices some depth (and oppurtunity to do fellowships to go even further in depth) in exchange for treating adults, children, and OB-GYN.

Hard to compare the two because FP can vary greatly with where you practice. Some FPs do damn near a bit of everything. I spent the summer with an FP who staffed the ER, saw patients in clinical, delivered babies, and even popped into the OR for the occasional c-section or appendectomy. This was out in the boondocks though.

On the opposite end of the spectrum, there are probably plenty of FPs in the inner city who do nothing but manage HIV patients and reffer to specialists.

Personally, the question comes down to do you want variety or specilization. Seriously though, worry about getting into med-school. You've got plenty of time (and more ways of testing the water) to figure the rest out afterwards...

FM and IM are very similar, and yes General Internal Medicine is a specialty. Most people assume after your IM residency you are going to subspecialize in Gastro, Card, or something, but many physicians do remain General Internists. Being a general internist allows you to treat adults with a whole host of medical problems, much like FM docs. The main difference that I've enountered is that in FM you do treat the entire "family", and many of the cases you can handle are segmented into 25-40 diseases and conditions. That isn't to say you are incapable of tackling a complex disease as an FM doc, just that the typical conditions and presentations you'll encounter concern ear infections, arthralgia, digestive issues, etc. As a general Internist, your primary concern is that of adult diseases and disorders. The cases will, in the majority of instances, be primary care issues similar to those encountered in FM, but you do get to experience more complex issues. Plus, being a general internist gives you the option of specialization should you decide upon that path. In both FM and General IM you get to encounter conditions from the entire clinical spectrum. As a family doc you have a more personal connection with your patients. As an internist you are more of a clinical investigator. Personally, I want to go either into General IM, or General surgery. Having the option to subspecialize is always a nice addition.

Originally Posted by medguy83

FM and IM are very similar, and yes General Internal Medicine is a specialty. Most people assume after your IM residency you are going to subspecialize in Gastro, Card, or something, but many physicians do remain General Internists. Being a general internist allows you to treat adults with a whole host of medical problems, much like FM docs. The main difference that I've enountered is that in FM you do treat the entire "family", and many of the cases you can handle are segmented into 25-40 diseases and conditions. That isn't to say you are incapable of tackling a complex disease as an FM doc, just that the typical conditions and presentations you'll encounter concern ear infections, arthralgia, digestive issues, etc. As a general Internist, your primary concern is that of adult diseases and disorders. The cases will, in the majority of instances, be primary care issues similar to those encountered in FM, but you do get to experience more complex issues. Plus, being a general internist gives you the option of specialization should you decide upon that path. In both FM and General IM you get to encounter conditions from the entire clinical spectrum. As a family doc you have a more personal connection with your patients. As an internist you are more of a clinical investigator. Personally, I want to go either into General IM, or General surgery. Having the option to subspecialize is always a nice addition.

Most if not all specialties (not sure about EM/Rads/Path) allow you to subspecialize....a few that come to mind, IM, FP, Pediatrics, Anesthesiology, Surgery, OBG. That is because there are fellowships in almost every area of medicine nowadays.

However, for those interested in academic medicine (working in a teaching hospital, teaching at a medical school), fellowships are required (heard from physicians at my school)

At both the hospital attached to where I went to medical school and also where I am training for residency now, family medicine focuses more on outpatient medicine and internal medicine focuses more on inpatient medicine. In our hospital system, probably more than half of the training family medicine gets is in various outpatient clinics. For our internal medicine training, 75% of it is inpatient on the wards or units. Also, I'm not sure if this is common elsewhere, but at the 2 institutions I have been at, there have been no inpatient family medicine attendings.

Originally Posted by Dreemer005

At both the hospital attached to where I went to medical school and also where I am training for residency now, family medicine focuses more on outpatient medicine and internal medicine focuses more on inpatient medicine. In our hospital system, probably more than half of the training family medicine gets is in various outpatient clinics. For our internal medicine training, 75% of it is inpatient on the wards or units. Also, I'm not sure if this is common elsewhere, but at the 2 institutions I have been at, there have been no inpatient family medicine attendings.

maybe this is a dumb question, but what's the advantage of inpatient vs. outpatient settings?

Originally Posted by Jolie South

maybe this is a dumb question, but what's the advantage of inpatient vs. outpatient settings?

inpatient = patients are being treated directly by the physician at the hospital, and they remain there for some duration of the treatment.

outpatient = kind of like a private doctor's office. The patient comes in w/complaint, you examine him/her, give them a treatment plan, and send them home.


I believe outpatient care is less stressful, at least timewise since the patient isn't under your direct supervision during treatment/recovery.

Originally Posted by Panda Bear

Whoa. There is no law preventing any doctor from practicing any kind of medicine if he feels comfortable doing it with the caveat that if you screw something up through negligence you will pay and pay and pay. I am in Emergency Medicine but there is nothing preventing me from going into practice as a pediatrician. I can't bill myself as "board certified" but if I can get patients there will be no problem.

The reason FM docs, for example, don't do as much surgery (yes, there was a time when Family Medicine physicians were trained to so simple surgeries like appendectomies and c-sections) is because no hospital or surgical group can afford the liability. But there's no law against it, per se.

Sorry my bad. We got a 15 yo in my free clinic once and the doctor flipped out saying she wasn't allowed to treat her because she was IM and not trained - I assumed it was a legal thing.

EDIT: Also, whether its a legal issue or not - wouldn't you be hard pressed to find malpractice insurance that covers you to treat children if you didn't do a residency that trained you for it? Maybe thats what the doctor meant - her malpractice didn't cover her to treat kids. At which point it does become a bit of a legal issue - not illegal but not smart in case you get sued...

Originally Posted by Dreemer005

At both the hospital attached to where I went to medical school and also where I am training for residency now, family medicine focuses more on outpatient medicine and internal medicine focuses more on inpatient medicine. In our hospital system, probably more than half of the training family medicine gets is in various outpatient clinics. For our internal medicine training, 75% of it is inpatient on the wards or units. Also, I'm not sure if this is common elsewhere, but at the 2 institutions I have been at, there have been no inpatient family medicine attendings.

Here both the FM and IM programs have inpatient wards staffed by residents and attendings from their respective departments. The Med wards have a lot more beds that the FM wards, though. Patients previously seen by FM (have FM PCPs, etc.) are admitted to the FM wards (usually). Everyone else goes to the Medicine team.

Originally Posted by Meatwad

True. They are just exposed to snot and feces from octogenarians.

but they can limit that exposure by being bad enough at caring for people in their seventies that they don't live til their eighties. It's all in how you manage the downside.

Originally Posted by DeadCactus

FP sacrifices some depth (and oppurtunity to do fellowships to go even further in depth) in exchange for treating adults, children, and OB-GYN.

On the opposite end of the spectrum, there are probably plenty of FPs in the inner city who do nothing but manage HIV patients and reffer to specialists.

There are some Family Med fellowships - geriatrics, adolescent medicine, and sports medicine come to mind.

Actually, in the city, many HIV patients are managed by ID. Some family med practitioners are certified in HIV medicine, and many HIV patients do see family doctors for this, but (in a city with a large academic hospital), many will be sent to see an ID doctor.

Originally Posted by medguy83

As a family doc you have a more personal connection with your patients. As an internist you are more of a clinical investigator.

Not always. Like others have said, general internists often practice primary care, and many have strong relationships with their patients.

Originally Posted by Jolie South

maybe this is a dumb question, but what's the advantage of inpatient vs. outpatient settings?

Originally Posted by baylormed

I believe outpatient care is less stressful, at least timewise since the patient isn't under your direct supervision during treatment/recovery.

Outpatient can be MORE stressful (although can sometimes be less time consuming for the doctor). Outpatient really relies on the patient actually coming into your office - which is not a sure thing. When you do your 3rd year rotations, it's not unusual for your outpatient clinic schedule to be jam-packed - because only about 60% of patients will actually show up for their appointments. For most patients, it's not a huge deal - but for some patients (i.e. people following up after a positive HIV test or after they've been initially treated for an ectopic pregnancy), you spend considerable mental time praying that they'll come back.

Some people also hate outpatient because they feel like a large portion of the time is spent doing social work-type stuff, or with wrestling with insurance companies.

I know this is going to sound stupid, but is it common for an Internal Medicine physician to specialize in oncology or pathology?

Originally Posted by LaDaLa

I know this is going to sound stupid, but is it common for an Internal Medicine physician to specialize in oncology or pathology?

Pathology is its own separate specialty (just like Radiology, Anesthesia, etc).

Originally Posted by baylormed

Most if not all specialties (not sure about EM/Rads/Path) allow you to subspecialize....a few that come to mind, IM, FP, Pediatrics, Anesthesiology, Surgery, OBG. That is because there are fellowships in almost every area of medicine nowadays.

However, for those interested in academic medicine (working in a teaching hospital, teaching at a medical school), fellowships are required (heard from physicians at my school)

Just for future reference, Rads has some subs and Path has a really nice selection as well.

Path: blood banking, chemical path, cytopath, forensics, hematology, immunopath, medical micro, neuropath, peds path

Rads: abdominal, cardiothoracic, endovascular surg neurorad, MSK rad, neurorad, nuclear, peds, vascular & interventional

Originally Posted by LaDaLa

I know this is going to sound stupid, but is it common for an Internal Medicine physician to specialize in oncology or pathology?

Also (at least in my region) it's rare to find a pure Oncologist. Most are trained in both Hematology/Oncology, even if their practice is almost entirely one or the other.

Originally Posted by PeepshowJohnny

Also (at least in my region) it's rare to find a pure Oncologist. Most are trained in both Hematology/Oncology, even if their practice is almost entirely one or the other.

Yeah, it doesn't make much sense to do just one or the other. Heme is 2 years, Onc is 2 years, and Heme/Onc is 3 years. Might as well give yourself more latitude with only 1 extra year of training.

Check out the official ACGME website for a listing of the residencies you can apply to after med school, and which fellowships fall under the certain specialties. This should clear up any confusion about what docs can and cannot become board certified in. Follow this url and click on the "List Programs by Specialty" on the left margin. http://www.acgme.org/adspublic/

It's a great reference for pre-meds too. It's definitely good to keep an open mind about the different specialties as you go through med school, but I've found that it's advantageous to be educated on what your options are as you're applying to med school as well. During two of my interviews I was asked if I had any thoughts on what I wanted to do, and it's good to know the system of residencies to form a competent answer. You don't want to say something like 'I definitely want to do General Family Practice to start, then subspecialize in Urology after a few years' (two completely different residencies). Also, notice the overlap of sub-specialties, such as Pain Medicine fellowships for Anesthesiology, Physical Medicine, Neurology, and Psychiatry. NEAT!!!

OK so just to clarify...a primary care physician CAN be a family practice doctor? but not necessarily, right?

Originally Posted by sultana

OK so just to clarify...a primary care physician CAN be a family practice doctor? but not necessarily, right?

a primary care physician is the guy/gal you go to for your routine check up. typically, that's family practice or internal medicine.

to the op, just get to medical school and let things sort themselves out.

fp has a smattering of medicine, pediatrics, ob/gyn, & general surgery.

i thought about fp, but ending up doing medicine, as i learned that i did not like treating kids (more because of the parents), wasn't too fond of the obstetric side of ob/gyn, didn't like general surgery. so, that cancelled out a lot of what makes up fp!

interestingly enough, i know a few fp residents who don't plan on pursuing any portion of ob/gyn after residency, nor any surgery... which sort of makes me wonder why they didn't just do med-peds residency in the first place. ah well.

Originally Posted by alwaysaangel

Actually the number one difference is that FM doctors can practice on both children and adults. IM doctors can ONLY practice on adults. They are not trained to practice on children and cannot legally do so.

After completing only a single year of internship, in any field, it would be legal for you to perform open heart surgery on a neonate.

Getting hospital privligedes to do so might be another matter.

you probably shouldnt be worrying about your specialty this early in the game

To all the pre-meds out there: If you clearly dont know what you are talking about don't respond like you do.

Don't worry, L2D and Panda police this site like it's their job and they'll post the correct answer.

Originally Posted by Instatewaiter

To all the pre-meds out there: If you clearly dont know what you are talking about don't respond like you do.

Don't worry, L2D and Panda police this site like it's their job and they'll post the correct answer.

What am I...Chopped Liver???...LOL As an FP in PRIVATE PRACTICE who AUTHORED the Family Medicine FAQ...This is my perspective of the differences between FP and IM (Taken from the FAQ).

================================
What is the difference between family medicine and internal medicine?

The main difference is that internal medicine is the specialty that deals with ADULT disease and treatment ONLY. Nobody under 18 (generally), and no OB. Family medicine deals with adult medicine, but also includes all other age groups (from newborn to elderly) and may or may not include an OB component (depending on region and personal preference of the practitioner). First, let me compare the residency training.

For IM residents, ALL rotations are in adult medicine and subspecialties. There is NO OB or peds. The only interaction with pregnant patients will be as a consultant for women in labor & delivery who develop a medical problem on top of their pregnancy (e.g., out-of-control diabetes, cardiac problems, etc.). As an IM resident, you will get more ICU exposure then the FM residents, and you will get to do more of certain procedures then the FM residents (central lines, Swan-Ganz catheters, etc.)

FM residents not only do adult medicine rotations, but pediatric rotations as well. They also have to do certain months of Labor & Delivery, where they not only play an active role in delivery and management of pregnant women, but also the management of medical conditions on top of the pregnancy that may occur (with the appropriate consultations, of course). Another difference is what occurs after residency. IM residents can do a fellowship in the various subspecialties, whereas FM has a limited number of fellowships. These have been described earlier in this document.

Here is the interesting twist...
In the world of PRIVATE PRACTICE, these differences are not as profound as in residency. The reason being is that as a private practitioner, your malpractice insurance as well as your hospital privileges WILL NOT cover the broad range of things you once did as a resident, especially when there are enough specialists around to do them. YES, an IM resident has put in more central lines than an FM resident, and floated more Swans, etc., but in private practice, you will be HARD PRESSED to find ANY private practice general internist who does those things for the reasons described above.
In a nutshell, when it comes to the private practice world of an IM doc vs. an FP, basically BOTH FPs and IMs on a daily basis handle the SAME bread & butter type of adult cases (hypertension, diabetes, thyroid disorders, upper respiratory infections, gastroenteritis, heart disease, rashes, etc. - which will make up 90+% of your office day), and are reimbursed the SAME from Medicare and managed care insurance companies. A level 3 outpatient visit (there are 5 possible levels) - (a.k.a. 99213) is reimbursed the SAME whether you are an internist or an FP. Anything beyond bread & butter management is referred out for the SAME reasons as I described in my peds vs. FM comparison.

When it comes to inpatient medicine in the PRIVATE PRACTICE world, FM and IM function the same way as well. Both handle bread & butter admissions (exacerbation of CHF, chest pain-r/o MI, sepsis, MI, altered mental status, pneumonia, nursing home "trainwrecks", etc.) and BOTH will obtain the appropriate consults when warranted - no difference. Did the internist get more experience managing a vent in residency? YES, but again, you are going to have a VERY hard time finding an internist in private practice who manages his own vents without calling pulmonology consult, because if there is a bad outcome because you didn't get a consult, you WILL get nailed!

FM and IM are both employed interchangeably by hospital staffs as well as managed care companies. ONE exception is in places that do not have any IM sub-specialists (cardiology, pulmonology, gastroenterology, etc.), the local internist may be the one who has to do certain procedures (reading echocardiograms, placing central lines, floating Swan-Ganz cathethers, stress tests, bone marrow biopsies, etc.), primarily because there is no one else around to do it. This phenomenon exists primarily in small towns with NO sub-specialists.

What is the difference between FM residency and Med/Peds residency, and what is the significance in private practice?

Basically, Med/Peds is a combination residency that combines IM and peds into a 4-year residency (half medicine rotations, half peds rotations). These programs do not include OB rotations or general surgery. At the end, one must obtain and maintain board certification in BOTH specialties (that means 2 separate exams, plus CME and recertification). In FM, there is just ONE board certification to maintain. For Med/Peds, after residency, one may elect to do a fellowship in either an adult, pediatric, or a combined adult/peds subspecialty. In FM, there are limited fellowships which have already been described.

Here is where the differences end. In the world of private practice, BOTH function the same. The only difference is IF the FP decides to include OB in his/her practice, then the med/peds doc cannot cross-cover. BOTH groups will handle the same type of bread & butter adult and peds cases with the APPROPRIATE referrals to specialists when warranted. There is no difference in insurance reimbursement between the two for a particular case. ALSO, if you are Med-Peds, you must take 2 BOARD EXAMS once you are finished with residency, and must RECERTIFY BOTH BOARDS every 10 years. When you are a busy private practicioner, keeping up with 2 boards becomes a MAJOR PAIN IN THE ASS...Whereas in FP, there is only ONE board exam to keep up with every 10 years (use to be 7).

Hope this helps.

-Derek Sampson, MD

Originally Posted by Instatewaiter

To all the pre-meds out there: If you clearly dont know what you are talking about don't respond like you do.

No kidding...reading some of these answers makes me nervous about some of the other advice I have been given on here!

Originally Posted by baylormed

Most if not all specialties (not sure about EM/Rads/Path) allow you to subspecialize....a few that come to mind, IM, FP, Pediatrics, Anesthesiology, Surgery, OBG. That is because there are fellowships in almost every area of medicine nowadays.

However, for those interested in academic medicine (working in a teaching hospital, teaching at a medical school), fellowships are required (heard from physicians at my school)

EM can do toxicology, peds EM maybe some others
Derm path is open to both path and derm as a fellowship I think.
+ the comprehensive list someone else wrote.

Is there any specialty that can't subspecialize?

Originally Posted by elwademd

interestingly enough, i know a few fp residents who don't plan on pursuing any portion of ob/gyn after residency, nor any surgery... which sort of makes me wonder why they didn't just do med-peds residency in the first place. ah well.

My guess is because med-peds is a 4 year program and is more intense than family practice. The training also focuses more on the inpatient versus the outpatient setting, so if you are sure you want to do outpatient medicine (like FP), I would think it makes less sense to do a residency which is heavier on inpatient.

Originally Posted by Drogba

EM can do toxicology, peds EM maybe some others

There are about 20 fellowships for EM.

http://www.saem.org/saemdnn/Home/Com...8/Default.aspx

Originally Posted by tkim

There are about 20 fellowships for EM.

http://www.saem.org/saemdnn/Home/Com...8/Default.aspx

I was just referring to subspecialization that would earn you board certification, of which there only seem to be four areas. Thank you for the list of fellowships though. Do these actually have any worht to justify the extra years of training and lost income? If you wanted to practice wilderness medicine would you really need to complete extra training for example.

Originally Posted by BlackSails

After completing only a single year of internship, in any field, it would be legal for you to perform open heart surgery on a neonate.

Getting hospital privligedes to do so might be another matter.

So if you operate on a neonate today (assuming you're pre-med) then that's illegal and you could go to jail... but if you're done w/ one year of internship then you could legally operate on the neonate's heart from a criminal standpoint... but you'd still be totally sued to sh*t in civil court right? Negligence, etc? I mean unless it went PERFECTLY, you're totally hosed right?

Somebody give me some insight on this... L2D I'm lookin' at you...

Originally Posted by Drogba

I was just referring to subspecialization that would earn you board certification, of which there only seem to be four areas. Thank you for the list of fellowships though. Do these actually have any worht to justify the extra years of training and lost income? If you wanted to practice wilderness medicine would you really need to complete extra training for example.

That's a great question. Fellowship training in the case of EM would make that person more marketable to academic or competitive positions that one might not otherwise get. Being ultrasound trained means that you should have the skills to set up an ultrasound training program for not just EM residencies, but to train other attendings in non-academic EDs.

For toxicology, you could run a Poison Control center, or be 'the tox guy' at a residency.

There is the consideration of lost income, as stipends are either commensurate with the PGY level of fellowship training, or some fixed amount. But since you are essentially a junior attending, with some minimum shift responsibility, moonlighting covers some of that shortfall.

The long term outlook is that fellowships will make you more desireable and generally increase your pay scale. So the extra year or two in fellowship would be compensated by either better pay or opportunities.