GI...can you still be "an internist first"?

[ucla2usc]

I am considering GI...at my institution the GI docs consult patients with the approach of a good internist, with a full H&P and a try to see the "whole" patient and disease, not just look through a scope. I admire this wholistic approach to medicine...something I had thought was shared by all subspecialties of IM. However, many people have told me that their only relationship with their gastroenterologist was through a scope, and they have never been examined or developed a relationship with them. Is this type of "procedure only" relationship really the majority of the way GI docs practice? Does the desire to be a more complete and throrough physician cost these docs lost revenue, causing their "scope only" approach to medicine? It's hard for me to believe this because at my institution they are complete docs and the kind I want to be, but is that type of approach to medicine limited to academics?

I would appreciate any discussion or experience you all have on this matter? It would be interesting if other procedural oriented IM specialities have similar dilemmas...i.e. do interventional cardiologist or EP's develop relationship and complete care for their patients, or are they in Cath lab only?

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[AJM]

I think it's entirely possible for a gastroenterologist to be an internist first, depending on what you choose to focus in. If you are a GI doc who mostly does routine outpatient screening colonoscopies, then you will not develop many longstanding relationship with your patients. There are just too many colos to do on asymptomatic patients that you will see only once every 5-10 years, that it's just not worth it to spend the extra time to "get to know them". This is the type of relationship that the majority of people in the US have with their gastroenterologists, because everyone over 50yo needs colos.

On the other hand, in virtually every other area in GI you will be able to use an internists' approach to your patients. In particular, some of the areas that come to mind that are most suitable to this approach are hepatology/liver transplants, inflammatory bowel dz, and motility disorders. But there will also be many other patients that you will see that you will develop longstanding relationships with: for example, patients with recurrent GI bleeds or recurrent esophageal strictures (among many others).

 

[novacek88]

The question I and probably every other person who read this is wondering is why would you pursue GI if you want to practice as a general internist in any manner? Based on what you are seeking, you shouldn't even consider GI. An internist does scopes and works with GI related disorders as well. People who go into GI are those who want to specialize and narrow their field of interest so they can be an expert in that particular field. Many people puruse cardiology and other subspecialties so that they don't have to burdened with practicing general internal medicine. Since you have a desire to pursue general internal medicine, my advice would be to become an internist and then focus a lot on GI. A lot of internists sort of lean toward one subspeciality without actually having completed a fellowship. I know several internists who become adept at reading echos, perform stress tests and thus function more or less as cardiologists without having completed the fellowship.

 

[AJM]

The question I and probably every other person who read this is wondering is why would you pursue GI if you want to practice as a general internist in any manner? Based on what you are seeking, you shouldn't even consider GI. An internist does scopes and works with GI related disorders as well. People who go into GI are those who want to specialize and narrow their field of interest so they can be an expert in that particular field. Many people puruse cardiology and other subspecialties so that they don't have to burdened with practicing general internal medicine. Since you have a desire to pursue general internal medicine, my advice would be to become an internist and then focus a lot on GI. A lot of internists sort of lean toward one subspeciality without actually having completed a fellowship. I know several internists who become adept at reading echos, perform stress tests and thus function more or less as cardiologists without having completed the fellowship.

While I understand what you are saying, I think you have misinterpreted the original question. There is a saying among IM subspecialists -- that they are "internists first, and subspecialists second". This stems from the fact that everyone who specializes in an IM subspecialty had to have first done an IM residency and become boarded in Internal Medicine. This kind of training creates an Internal Medicine mindset among the subspecialists in their approach to their patients - whether they are cardiologists, gastroenterologists, or rheumatologists - they all pride themselves on being able to handle very complicated patients and making use of their IM training within their subspecialty.

In other words, the saying that a subspecialist is "an internist first" does not mean that they are primarily practicing general IM with a little bit of their subspecialty mixed in, but instead it means that they are practicing their subspecialty with an IM approach -- something that most subspecialists I know strive to do.

 

[ucla2usc]

While I understand what you are saying, I think you have misinterpreted the original question. There is a saying among IM subspecialists -- that they are "internists first, and subspecialists second". This stems from the fact that everyone who specializes in an IM subspecialty had to have first done an IM residency and become boarded in Internal Medicine. This kind of training creates an Internal Medicine mindset among the subspecialists in their approach to their patients - whether they are cardiologists, gastroenterologists, or rheumatologists - they all pride themselves on being able to handle very complicated patients and making use of their IM training within their subspecialty.

In other words, the saying that a subspecialist is "an internist first" does not mean that they are primarily practicing general IM with a little bit of their subspecialty mixed in, but instead it means that they are practicing their subspecialty with an IM approach -- something that most subspecialists I know strive to do.

I agree with AJM, that's what draws me to IM subspecialties rather than say ENT, Ortho, Optho where you a very focused on your field, but only have a marginal understanding of how the rest of the body works. Medicine seems to tie in all organ systems, so even if you are a specialist in GI, you should understand the interactions between all other systems in the body. This is the way GI is taught at my institution, hence the whole H&P and workup with an Internist's mindset. However, rumor is that in the community you practice from a scope's eye, are consulted essentially to do the scope and no more. I'm scared this would be a unhappy reality for me if it were true.

 

[GrandMasterB]

I agree with AJM, that's what draws me to IM subspecialties rather than say ENT, Ortho, Optho where you a very focused on your field, but only have a marginal understanding of how the rest of the body works. Medicine seems to tie in all organ systems, so even if you are a specialist in GI, you should understand the interactions between all other systems in the body. This is the way GI is taught at my institution, hence the whole H&P and workup with an Internist's mindset. However, rumor is that in the community you practice from a scope's eye, are consulted essentially to do the scope and no more. I'm scared this would be a unhappy reality for me if it were true.

Hey. My internist is an GI doc, and my interactions with him have been primarily as an internist- physicals, vaccinations etc. He is a young guy, and may just be building his practice with PCP visits, while he looks for GI pts. However, at least right now- he gets to practice general internal medicine.
GMB

PS I know that my response does not address the jist of what the OP was asking. I was trying to respond to another post about how it is not-reasonable to do what my PCP does if you are going into subspecialty medicin. Another example- many ophthalmic pathologists have an active general ophtho clinical practice- and even go into the OR. IE just because you do a subspecialty- doesn't mean that you have to practice that subspecialty to the exclusion of everything else.

 

[ny skindoc]

Many top internists,chairman of Internal Mecine at med schools,hospitals etc are and have been gastroenterologists.They are certainly internists first,so it is absolutely possible to do this.Most GI docs are however only too happy to focus on procedures for primarily economic reasons.Internal medicine is also time consuming and a lot of work and very tempting to pass on to others.You can set up the practice you want.

 

[novacek88]

While I understand what you are saying, I think you have misinterpreted the original question. There is a saying among IM subspecialists -- that they are "internists first, and subspecialists second". This stems from the fact that everyone who specializes in an IM subspecialty had to have first done an IM residency and become boarded in Internal Medicine. This kind of training creates an Internal Medicine mindset among the subspecialists in their approach to their patients - whether they are cardiologists, gastroenterologists, or rheumatologists - they all pride themselves on being able to handle very complicated patients and making use of their IM training within their subspecialty.

In other words, the saying that a subspecialist is "an internist first" does not mean that they are primarily practicing general IM with a little bit of their subspecialty mixed in, but instead it means that they are practicing their subspecialty with an IM approach -- something that most subspecialists I know strive to do.

All subspecialists are internists first; that goes without saying. You couldn't even attain the level of a subspecialist without becoming a competent internist first so that point is moot. If that is the original question then I think it's a pretty silly one. It's silly to imply that a GI who does scopes all day is not an internist first or doesn't approach his or her field from an internist's perspective. You never just scope someone and leave them be. It's not like they tape your mouth shut and tell you to bend over without ever speaking to you or reading your chart. Every GI treats his or her patient from an internist's approach. Just because GI's do not give patients a full HP work up, it doesn't mean the GI is not aware of complications related to other conditions the patient might have.

And in response to different post about how one chooses to practice, I'm aware that a physician can practice however he or she sees fit. However, the question I have is why would one want to practice as an internist if they chose to subspecialize? A subspeciality is not icing on the cake; it is a lot of work. Talk to any fellow and they will tell you that there is an entire world of information that they were never exposed to as a medicine resident. Residents feel they have a pretty good grasp of field until they start fellowship and realize they didn't know as much as they thought. I spoke to a GI who has been in practice for over 20 years and he tells me there is still a lot he could learn about his field. I very seriously doubt you would have the time to practice as a general internist even if you wanted to. There is just too much information left to learn and responsibility within a subspeciality for one to focus elsewhere.

 

[mustangsally65]

I hope no one minds my intrusion here. I'm pre-med but was referred to a gastroenterologist just this morning and I have an entirely new perspective on the field after seeing him.

I had a colonoscopy in January and I was sent to a large group practice with their own endoscopy center and about 15 physicians. It was kind of an assembly line thing, my pre-op appointment was with a nurse to get my history, current meds, and prep/instructions. The day of the procedure I showed up, changed into a gown, had my IV started, and was already on my left side before I ever saw the physician. He was great, but there was minimal contact (no pun intended) except for the procedure that had been ordered.

Today I went to see a young physician with his own office in a tiny town where I live. He spent two hours with me. I was quite shocked when he gave me a sheet and told me to take off my shirt and pants, and even more surprised when he did a rectal exam. I didn't know GI docs did things like that until today.

And it made a huge difference. I felt quite special and like my concerns and problems were being heard and seriously considered. I've had ongoing GI problems for years, and no cause or treatment has yet to be determined. It felt really good today to be taken so seriously and to have every little symptom acknowledged. I'm strongly considering family practice (if I ever get into med school!) but today really made me think about IM/GI.

 

[novacek88]

I hope no one minds my intrusion here. I'm pre-med but was referred to a gastroenterologist just this morning and I have an entirely new perspective on the field after seeing him.

I had a colonoscopy in January and I was sent to a large group practice with their own endoscopy center and about 15 physicians. It was kind of an assembly line thing, my pre-op appointment was with a nurse to get my history, current meds, and prep/instructions. The day of the procedure I showed up, changed into a gown, had my IV started, and was already on my left side before I ever saw the physician. He was great, but there was minimal contact (no pun intended) except for the procedure that had been ordered.

Today I went to see a young physician with his own office in a tiny town where I live. He spent two hours with me. I was quite shocked when he gave me a sheet and told me to take off my shirt and pants, and even more surprised when he did a rectal exam. I didn't know GI docs did things like that until today.

And it made a huge difference. I felt quite special and like my concerns and problems were being heard and seriously considered. I've had ongoing GI problems for years, and no cause or treatment has yet to be determined. It felt really good today to be taken so seriously and to have every little symptom acknowledged. I'm strongly considering family practice (if I ever get into med school!) but today really made me think about IM/GI.

Your story brings up another interesting point: small town medicine vs. big city medicine. I think a lot of physicians overlook practicing in less populated areas and fail to realize the benefits they have. Honestly, your physician would never be able to practice this way in a larger more dense population. Spending 2 hours with a patient is simply not feasible in a larger city in which your expenses and patient population would be high. If you were known to spend 2 hours per patient, the group that hired you would likely not extend your contract. And if you decided to open your own practice and see patients in this manner, you would go broke in no time. If you enjoyed your experience with your physician, I strongly encourage you to practice within your small town because in a larger city, you would never be able to devote this much time to a patient without incurring major costs. And based on your account, I would strongly enourage to consider family practice or even med/peds because these positions truly allow you to get to know your patients in a way that subspecialists don't.

 

[mustangsally65]

Your story brings up another interesting point: small town medicine vs. big city medicine. I think a lot of physicians overlook practicing in less populated areas and fail to realize the benefits they have. Honestly, your physician would never be able to practice this way in a larger more dense population. Spending 2 hours with a patient is simply not feasible in a larger city in which your expenses and patient population would be high. If you were known to spend 2 hours per patient, the group that hired you would likely not extend your contract. And if you decided to open your own practice and see patients in this manner, you would go broke in no time. If you enjoyed your experience with your physician, I strongly encourage you to practice within your small town because in a larger city, you would never be able to devote this much time to a patient without incurring major costs. And based on your account, I would strongly enourage to consider family practice or even med/peds because these positions truly allow you to get to know your patients in a way that subspecialists don't.

Thanks for your insight. I know small town medicine is for me, but I'd never considered a field outside of primary care so I was very intrigued by this gastroenterologist's style. I'm still pretty sure I'm going to do family medicine but it was refreshing to see that even subspecialists can be IMs too.