can specialists act as General internists?

[surgeon_hopeful]

Hey,

Does anyone know of any specialists in one area of IM that also practice as general internists?

Also, what exactly does an internist do? How are they different from normal doctors?

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[ABPA]

Hey,

Does anyone know of any specialists in one area of IM that also practice as general internists?

Also, what exactly does an internist do? How are they different from normal doctors?

I didn't know internists weren't 'normal doctors'

 

[Igor]

Don't understand your "normal doctors" question.

I know a few subspecialists who will "take over" the patients' care. It's most common in patients with a transplant (where all the standard rules don't apply). It is sometimes done with patients that have advanced disease (stage 4 CHF or satge 4 cancer, for example) who are not expected to live very long.

Years ago it used to be fairly common that nephrologists acted the primary for dialysis patients; this is becomming less common now.

Most subspecialists prefer to care for diseases and problems within their area of expertise; it's uncommon to find cardiologists who want to deal with diarrhea or GI docs who like to treat angina.

 

[core0]

Don't understand your "normal doctors" question.

I know a few subspecialists who will "take over" the patients' care. It's most common in patients with a transplant (where all the standard rules don't apply). It is sometimes done with patients that have advanced disease (stage 4 CHF or satge 4 cancer, for example) who are not expected to live very long.

Years ago it used to be fairly common that nephrologists acted the primary for dialysis patients; this is becomming less common now.

Most subspecialists prefer to care for diseases and problems within their area of expertise; it's uncommon to find cardiologists who want to deal with diarrhea or GI docs who like to treat angina.

There are still specialists out there that do IM and their specialty. They are becoming rarer and rarer. In our practice we have a small number of patients left over from the days when some of our doc's did IM and GI. They are all in their 80's or 90's now but one of our doc's still follows them. I also see some pulmonologists that work as hospitalists in addition to critical care so this is somewhat IM'ish.

David Carpenter, PA-C

 

[purpleham]

At my school several rheumatologists act as attendings on general medicine teams 1-3 months/year.

 

[fantasty]

At my school several rheumatologists act as attendings on general medicine teams 1-3 months/year.

Yeah, I asked about this recently too. Our hospital has pulm and rheum covering general medicine often as well.

According to one general internist I asked, he said that some of the specialties (specifically, the two Igor cited - cards and GI) tend to only want to tell with their area of expertise. I kinda like rheum and ID because it seems like you could still stay pretty close to gen medicine if you wanted (and I imagine pulm and nephrology would be like that as well). One ID doc I know (in a community setting) insists on acting as the primary doc for his HIV patients (since many of the other local docs do not have the expertise to handle them comprehensively).

 

[Adcadet]

I was told that at our VA all IM sub-specialists have to spend at least 2 weeks per year leading an inpatient general IM team. I personally saw attendings working with medicine teams from ID, geri, neph, pulm, and of course hospitalists and general IM. I get the impression that in general there are definitely some IM sub-specialists who do this more (ID, rheum, sports medicine, even pulm/cc acting as hospitalist) than other (cardiology, GI).

 

[internist88]

so basically it seems that people who go into rheum or endocrine can do both, but it is not very frequent is what I'm understanding from reading this. Wouldn't a specialist who does this earn more money depending on the volume of patients simply becuase they will probably have to work more?

Also, would you have to do even more training/tests so that people can deem you worthy of doing both?

sorry to hijack the thread surgeon...

 

[Adcadet]

so basically it seems that people who go into rheum or endocrine can do both, but it is not very frequent is what I'm understanding from reading this. Wouldn't a specialist who does this earn more money depending on the volume of patients simply becuase they will probably have to work more?

Also, would you have to do even more training/tests so that people can deem you worthy of doing both?

sorry to hijack the thread surgeon...

I'll take a crack at this since I've discussed it before with a few attendings. If anybody disagrees, by all means correct me.

After your IM residency you can sit for your IM boards to become a board certified (general) internist. The certification is time limited, and is currently 10 years long. During fellowship and beyond you can choose to maintain your internal medicine board certification or not. Some do, some don't. I get the impression that those who really practice in a very specialized sub-specialty (thinking like electrophysiology-cardiology) rarely maintain their IM boards, whereas those who practice more general medicine, and specifically those who do attend on general medicine services, are more likely to keep up their IM boards. I know of some people boarded in pulmonary and critical care medicine (which is typically a 3-year residency combining these two specialties) who also maintain their IM boards, so they must maintain 3 certifications. One has pointed out that he does this because he feels that a very solid grasp of general IM is needed for his pulmonary practice and critical care competency.

As far as money is concerned....well, I'm sure it depends on your employment situation and the number of hours you're willing to work. If you're compensated proportionally for the revenue that you generate, then I'm sure some of the high paying subspecialists take a "pay cut" to spend time doing general IM in place of their specialty. Would a private practice interventional cardiologist making $400,000/year (for full time interventional work) choose to give up some of his/her cath lab time to work as a general internist who makes $160,000/year (for full time work)? Meanwhile, I'm sure for ID and rheum it's a toss up as from what I can tell ID and rheum pays about as well as general IM. If you want to work more hours to make more money, I'm sure you could work as a subspecialist and moonlight on the side as a general internist - heck, internal medicine subspecialty fellows and some residents do this all the time.

 

[Chulito]

Hmmm, that's very interesting and encouraging. I've recently had conversations about this matter with two different interviewers who challenged me about my single-minded focus on primary care and public health, so I brought it up with the medical director at the community clinic where I work. Unfortunately I haven't really gotten much clarity on the matter. I've been hell bent on family medicine for a long time, partly because primary care appeals to me as a practice, but also in part because of the population that I want to serve and their need for primary care. But we have a great deal of difficulty in our clinic getting specialty care for our patients (mostly uninsured or government insured) as well, and I have an intellectual interest in cardiology, so I've been wondering about the notion of practicing both primary care and cardiology, but both for the same population. Unfortunately, unless you want to go into private practice (where you can serve whomever you want and accept whatever modes of reimbursement you like), it seems that one of the biggest problems is finding a hospital setting that will allow a cardiologist to see patients who are all uninsured or only insured by Basic Health/Medicaire/Medicaid. Has anyone had experience doing this sort of thing or known anyone who has done it? Any relevant anecdotal reflections would be *greatly* appreciated.

 

[Mayhem]

At my school specialists run one of the Gen Med teams for a month each year. During my rotation we had a neurologist on Gen Med A and a cardiologist on Gen Med B.

 

[im do 08]

When i was rotating through Frankford Bucks in PA, there was a team of cardiologists (5 of them) and they took turns to be in the hospital. Whoever was in the hospital though would cover the GMF, ICU, and tele floors.

The others would either be in the cath lab, doing TEEs and otherwise in their practice.

One of the partners actually spends more time than the rest in the hospital... he's there the most, up to 4 days a week, and I assume that he just likes it better in the hospital, but its clear that they're all certified in internal as well.

Dunno if this helps but there's my two cents...

 

[ThinkingIM]

At my school specialists run one of the Gen Med teams for a month each year. During my rotation we had a neurologist on Gen Med A and a cardiologist on Gen Med B.

A cardiologist (or any other IM subspecialist for that matter) should be able to handle bread and butter gen med cases. A neurologist acting as medicine attending, however, is downright scary. As an antecdote: when I was on neuro and one of our patients cane down with a nosocomial pnuemo the whole team (residents and attending alike) nearly went into full blown panic attacks about how this pt. needs to be transferred to medicine immediately. It was actually the med students and psych intern who assured the rest of the team we could probably take care of this relatively easy.....even though we went through all the right steps and got the guy on the right Abx, the attending still demanded an ID consult (the result of which was: agree with current tx plan)

 

[salmonella]

A cardiologist (or any other IM subspecialist for that matter) should be able to handle bread and butter gen med cases. A neurologist acting as medicine attending, however, is downright scary. As an antecdote: when I was on neuro and one of our patients cane down with a nosocomial pnuemo the whole team (residents and attending alike) nearly went into full blown panic attacks about how this pt. needs to be transferred to medicine immediately. It was actually the med students and psych intern who assured the rest of the team we could probably take care of this relatively easy.....even though we went through all the right steps and got the guy on the right Abx, the attending still demanded an ID consult (the result of which was: agree with current tx plan)

Well, don't forget a lot of neurologists, especially the older generation, are doubled boarded in internal medicine and neurology. They are well versed in general medicine issues most of the time.

 

[Mayhem]

Yeah my bad. This doctor had done IM first. I think he used to be head of medicine too