why IM vs a "lifestyle specialty"?

I'm an M3 . . . and like many others i'm trying to figure out which specialty to pursue. i'm considering IM + fellowship (cards, GI) because i love the SCIENCE of IM (and these 2 fields in particular; i kid you not . . . it's not just about the $), but i'm scared that i'll end up miserable because of the sh&t involved in the CLINICAL PRACTICE OF IM (i.e., the lifestyle/hours involved, as well as the neverending paperwork, fear of malpractice, emotionally draining pts - both the overly demanding and the GOMERs, etc.).

so for those of you who could've pursued a lifestyle specialty (derm, rads, ophtho, etc.) and chose IM instead . . . what made the difference for you? i am fortunate enough to have the numbers/grades to be competitive in just about any field and am trying to understand what motivates those who chose to stay committed to IM despite the sacrifices in work/life balance?

thanks for any input.

you really need to love IM to put up with all that crap for an entire career. I too enjoyed the "science" of IM but could never deal with all the negatives you seem to be well aware of. best of luck with your decision.

I totally understand how you feel about loving the study of IM. I loved it too and thought that I would train in IM until the end of third year when I switched to Path. The reality of IM practice wore me out physically and emotionally. I just wasn't cut out for it. I've heard people say that IM docs are the "work horses" of medicine, and I do think that's true. Are you a work horse type, or will IM squish you like a bug? You'll have to figure that out.

I was also in your shoes. I really liked the idea behind the science of internal medicine. For me, I found the part that I liked best was the diagnostic aspect. The reality of day-to-day medicine, however, didn't excite me as much. Luckily for me, I liked radiology a lot when I did my rotation and knew that it was for me. It provided a lot of the diagnostic aspects of medicine, without some of the other aspects.

It seems you are getting more responses from the other side (those who didn't choose medicine). I think medicine and its subspecialties are very interesting. Every field has its problem aspects (for radiology for me its mammography, for medicine it was some of the needy chronic pain type patients). Try to decide based on what you would foresee yourself doing on a day to day basis once out of residency, not the residency itself.

dre said:

I'm an M3 . . . and like many others i'm trying to figure out which specialty to pursue. i'm considering IM + fellowship (cards, GI) because i love the SCIENCE of IM (and these 2 fields in particular; i kid you not . . . it's not just about the $), but i'm scared that i'll end up miserable because of the sh&t involved in the CLINICAL PRACTICE OF IM (i.e., the lifestyle/hours involved, as well as the neverending paperwork, fear of malpractice, emotionally draining pts - both the overly demanding and the GOMERs, etc.).

Click to expand...

Sorry to provide yet another opposite viewpoint, but that's what I have to offer. In medical school I too liked the science of medicine. I liked being perpetually challenged intellectually. All that ended in internship. IM science becomes monotonous, the challenge is getting your work done, and fighting the emotional drain of taking care of lots of patients who will never really get better. The only part I enjoy is getting to know the patients and their families, and the occasional unstable patient who makes you think on your feet. There is so much protocol in medicine you don't have a lot of wiggle room to be creative and still meet the standard of care. I would strongly advise any med student to seriously consider alternatives to IM. If you are thinking IM/fellowship, you MUST be comfortable with primary IM. Not everyone who wants one gets a fellowship. At the time when I made the decision, I wasn't entirely sure anesthesiology was exactly right for me, but now I am certain it's the best decision I've ever made!

dre said:

so for those of you who could've pursued a lifestyle specialty (derm, rads, ophtho, etc.) and chose IM instead . . . what made the difference for you?

Click to expand...

In spite of your request for comments from people who chose IM, I think all of the responses so far are from people outside of the specialty.

I considered IM, EM and GS, and I think they are all great choices. I liked diagnosing undifferentiated patients in the ED and dealing with acute issues, but I found it frustrating when patients were admitted and I was no longer part of their care. I also enjoyed GS, using my hands, and focusing on specific problems, but I found it frustrating when I had to defer my patients' other medical issues. Also, in EM and GS, you have limited practice options.

The great thing about IM is its breadth and versatility. You are a master diagnostician, often involving complex adult patient presentations with multiple organ systems. You are an expert in a variety of procedures (especially in Card, GI, Hospitalist, Intensivist). You can have long-term relationships with your patients (Primary Care) or short-term relationships (Hospitalist, Subspecialist). You can directly manage your patients' care (Primary Care, Hospitalist, Intensivist) or you can be a consultant (Subspecialist, IM consultant to other specialties). You also deal with issues of wellness and prevention, as well as treating diseases.

There are a wide variety of practice models. The scope of practice involves treating patients in the clinic, hospital ward, intensive care unit, hospice, the patient's own home, or a nursing home. You can be the primary physician for your patients (Primary Care) or you can seek patients by referrals (Subspecialist). You can work in direct patient care, you can work in academic medicine (teacher, researcher), or you can be a consultant in the private sector (pharmaceuticals, biomedical engineering, medical informatics). The www.ACPOnline.org has a continuing series on practice models for IM.

There are also a wide variety of business models, some of which offer you a significant amount of autonomy. You can work as a solo physician, as part of a physician group, as an employee of a corporate entitity, or as a consultant. You can accept a large number of patients or you can set up a boutique practice. You can set your own hours in private practice or you can do shift work as a hospitalist. You can work in the private sector and have no patients at all. You can accept insurance payments or you can set up a cash-only practice.

For me, IM was a great choice. I plan to practice and also be involved in medical informatics (www.amia.org). Of course, IM isn't for everyone. But if you're interested, you might want to check out the following organizations.

• The Society of Hospital Medicine www.hospitalmedicine.org
• The American College of Physicians www.acponline.org
• Doctors for Adults www.doctorsforadults.com

PM me if you want to talk about anything in detail.

Any other comments in support of IM? 😕

As a medical student, I was deciding between IM and anesthesia, came very close to going the anesthesia route, then decided on IM. Actually, some of the anesthesia attendings that I keep in touch with are still trying to convince me to do anesthesia - when I remind them that I'm almost done with my IM residency, they promptly tell me that some of their best anesthesiologists are double boarded in IM/anesthesia.... tempting, but even after almost 3 years of IM, I still would choose IM over gas.

There are many reasons why I chose IM. I'll mention just a few here.

1. First and foremost, I enjoy building longstanding relationships with my patients. You cannot do that in almost any of the lifestyle specialties. I couldn't accept that if I did gas, all of my patients would only know me as "the anesthesiologist" -- it would make me feel like some anonymous member of the medical system. In contrast, in IM and the subspecialties, your patients get to know and trust you. I've had patients during their clinic visits bring me things such as fresh vegetables from their gardens, or BBQ ribs, as "thank you's" -- you don't get that kind of gratitude from your patients (or that yummy food!) in the lifestyle specialties.

2. I like being in control of my own schedule. As far as day-to-day activities are concerned, I want to be able to decide what I want to do and when. Again, you can't do that in gas - you are bound to the almighty OR schedule. Sure, IM has the almighty clinic schedule, but the difference is that as an attending you are the one who decides how much clinic, if any, you want to do (hospitalists and some subspecialists don't have clinic). You can also decide how many patients you will see, what hours your clinic will go from, etc. Personally, I need variation in my day - given the flexibility of venues in IM, it keeps me on my toes so that I don't get bored.

3. I enjoy the academic challenge of IM. While anesthesia is challenging in it's own right, the academics of it are mostly limited to physiology and pharmacology. They don't deal as much with pathology and diagnostics. While I like physiology, I really enjoy diagnosing and dealing with the weird/funky diseases -- IM and the subspecialties IMHO are the best fields to get that kind of experience. Whenever a physician can't figure out what's going on with a patient, they call the medicine consult or the appropriate IM subspecialist to sort things out.

There was a previous comment on this thread that "IM is monotonous" -- that is definitely an experience that interns face. Heck, I thought so when I was an intern, too. But most of that experience is because of internship, not because of IM in general. After internship, things get a lot better -- as a 2nd and 3rd year resident, you learn SO much more about IM, and that's when you start to deal with all the interesting stuff. For interns, nothing ever seems interesting, because they are so overworked. Just keep in mind that internship does not reflect real life medical practice, so take what interns say with a grain of salt.

Last - I hope I don't sound like I'm bashing anesthesia. It's definitely a great field - I just like IM better. In fact, I'm still at times toying with the idea of doing an anesthesia residency, because it would help to enhance my intended area of practice. But I'm going to be doing a 4-year subspecialty fellowship, and after that I'll probably want to just move on rather than doing another 3 years of training... at some point I have to make a living, right? 🙂