Community Health IM vs. Primary care IM vs. Family Medicine

[duanewade]

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What is the difference between an Internal Medicine (Community Health Track) specialty vs. IM (primary care track) vs. a Family Medicine specialty?
ex: Programs for example NYU seem to offer various tracks within their Internal Medicine scheme, including community health, primary care, and categorical IM. Internal Medicine Residency Tracks & Programs | NYU Langone Health

Seems like the training and end result is that you will be a community based family practitioner, so why the nuances with the names?

 

[MedicineZ0Z]

Tracks just guide your rotations/elective time to better gear you towards your end-goal.

Do you want to see adults only? Kids and adults? Outpatient procedures? How much inpatient exposure do you want? Prenatal care? Any ob? These are questions to ask to help pick your program.

If you want to see kids and adults then you do FM. If you want to do a lot of outpatient procedures, a good FM residency will be better. And tbh, a good FM residency will generally prepare you best for primary care.
If you strictly want to see adults, don't mind procedures; then I'd very much encourage IM. You'll hate the Ob stuff and seeing kids among other parts of FM.

 

[InternistDO]

Like MedicineZ0Z said, the difference between IM and FM is that IM is specifically focused on adult medicine while FM is more general and includes pediatric and obstetric training, so it's wrong to say you'll be a family physician whichever way you go--you may be a primary care physician but as an IM doctor you will not be seeing kids or pregnant women in clinic. The tradeoff is you will usually have an easier time getting inpatient (hospitalist) positions in larger cities and you retain the ability to subspecialize.

Historically the Northeast tends to have more of a focus of primary care being internists and pediatricians as opposed to family doctors (which is why there are like 30 IM programs in NYC but only about 6 FM ones), but there's nothing set in stone about this.

A primary care track IM program is one that gives you more time in the outpatient setting, usually by getting rid of some extra elective and ICU time. This can be good because many IM programs can be very inpatient heavy to the detriment of their clinic experience, meaning most of their grads don't feel as comfortable in primary care when compared to hospitalist medicine. Primary care IM is good if you have no interest in peds/OB, are considering subspecializing, or want to work in an urban area (where even FM doctors can be relegated to adults only).

The NYU community medicine track is sort of an in between track where you still do a pretty normal amount of inpatient/ICU but the clinic experience is fairly robust when compared to some other academic IM programs, and also has a focus on things that are important in urban primary care, like reproductive health, HIV treatment, and addiction medicine. They do all their outpatient didactics with the primary care track people too.

 

[MedicineZ0Z]

Like MedicineZ0Z said, the difference between IM and FM is that IM is specifically focused on adult medicine while FM is more general and includes pediatric and obstetric training, so it's wrong to say you'll be a family physician whichever way you go--you may be a primary care physician but as an IM doctor you will not be seeing kids or pregnant women in clinic. The tradeoff is you will usually have an easier time getting inpatient (hospitalist) positions in larger cities and you retain the ability to subspecialize.

Historically the Northeast tends to have more of a focus of primary care being internists and pediatricians as opposed to family doctors (which is why there are like 30 IM programs in NYC but only about 6 FM ones), but there's nothing set in stone about this.

A primary care track IM program is one that gives you more time in the outpatient setting, usually by getting rid of some extra elective and ICU time. This can be good because many IM programs can be very inpatient heavy to the detriment of their clinic experience, meaning most of their grads don't feel as comfortable in primary care when compared to hospitalist medicine. Primary care IM is good if you have no interest in peds/OB, are considering subspecializing, or want to work in an urban area (where even FM doctors can be relegated to adults only).

The NYU community medicine track is sort of an in between track where you still do a pretty normal amount of inpatient/ICU but the clinic experience is fairly robust when compared to some other academic IM programs, and also has a focus on things that are important in urban primary care, like reproductive health, HIV treatment, and addiction medicine. They do all their outpatient didactics with the primary care track people too.

Interestingly, FM has an easier time getting hospitalist positions in places where you have the least support and are in an open ICU setting with procedures/codes etc.

 

[VA Hopeful Dr]

Interestingly, FM has an easier time getting hospitalist positions in places where you have the least support and are in an open ICU setting with procedures/codes etc.

Desperation

 

[Drrrrrr. Celty]

Interestingly, FM has an easier time getting hospitalist positions in places where you have the least support and are in an open ICU setting with procedures/codes etc.

A lot of FM programs are opening up hospitalist fellowships to train for these things. But I dont think a lot of FM programs prepare you to be ready to put in central lines, or handle critical care patients. At my hospital FM doesnt have a strong inpatient foundation and as such wouldnt be able to treat a lot of common issues like A fib rvr or handle a bipaped copd without consulting.

Unopposed FM programs probably are better because they'll balance inpatient and outpatient. and there wont be an IM program that has dibs on more duties.

At the same time I think theres a stronger and more comprehensive knowledge of medicine in IM. Coming out with that will make you a better generalist and more adapt at dealing with multiple comorbidities.

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[Drrrrrr. Celty]

I kind of agree. Going to work at a hospital without significant resources such as consults and an open icu sounds like a really miserable and Gimped experience.

Sometimes you're going to have sick patients that need early consults. And sometimes itll change their hospital course significantly.

Desperation

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[MedicineZ0Z]

Desperation

That's true for any underserved area job.

A lot of FM programs are opening up hospitalist fellowships to train for these things. But I dont think a lot of FM programs prepare you to be ready to put in central lines, or handle critical care patients. At my hospital FM doesnt have a strong inpatient foundation and as such wouldnt be able to treat a lot of common issues like A fib rvr or handle a bipaped copd without consulting.

Unopposed FM programs probably are better because they'll balance inpatient and outpatient. and there wont be an IM program that has dibs on more duties.

At the same time I think theres a stronger and more comprehensive knowledge of medicine in IM. Coming out with that will make you a better generalist and more adapt at dealing with multiple comorbidities.

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Our PGY2s can handle afib rvr without consults. We also do manage other things on the floor routinely, dka, starting amio drips etc. This will be very residency dependent as many just don't have good pathology and volume (opposed or unopposed) to provide the inpatient training.
On the contrary, my residency is opposed and we manage some crazy pathology/zebras everyday and interested residents get the exposure to lines etc. As an intern, having 10 medically active patients is the norm and only ~2 are at most routine pneumonia/copd type admits. And so we have residents graduate who then work in places with minimal resources.

 

[VA Hopeful Dr]

That's true for any underserved area job.

Yep, it wasn't a value judgment

 

[Drrrrrr. Celty]

Our PGY2s can handle afib rvr without consults. We also do manage other things on the floor routinely, dka, starting amio drips etc. This will be very residency dependent as many just don't have good pathology and volume (opposed or unopposed) to provide the inpatient training.
On the contrary, my residency is opposed and we manage some crazy pathology/zebras everyday and interested residents get the exposure to lines etc. As an intern, having 10 medically active patients is the norm and only ~2 are at most routine pneumonia/copd type admits. And so we have residents graduate who then work in places with minimal resources.

Yah, that's not how most residencies are. But I also don't really know what you're really seeing at your hospital that makes routine patients not the most common denominator except on consult services, which generally FM residents don't participate in.

 

[MedicineZ0Z]

Yah, that's not how most residencies are. But I also don't really know what you're really seeing at your hospital that makes routine patients not the most common denominator except on consult services, which generally FM residents don't participate in.

What do you mean? We admit everything up to transplant patients (with a dozen serious comorbidities) as the primary. The patient population is just very sick and complex as a whole.
Consult services - we do inpatient cardio, surgery, medical icu, surgical icu, cardiac icu, PICU, inpatient peds.

FM is also the dominant force here in primary care.


Also, why isn't FM managing afib rvr; nowhere where you are?

 

[Drrrrrr. Celty]

What do you mean? We admit everything up to transplant patients (with a dozen serious comorbidities) as the primary. The patient population is just very sick and complex as a whole.
Consult services - we do inpatient cardio, surgery, medical icu, surgical icu, cardiac icu, PICU, inpatient peds.

FM is also the dominant force here in primary care.


Also, why isn't FM managing afib rvr; nowhere where you are?

Yah. 90% of FM programs aren't like that. My FM program is pretty much exclusively built around outpatient. They do like 4 months of inpatient intern year. A couple of surgery months where I don't really think they actually do much. The rest is split between outpatient type of rotations. They do one month of adult MICU.

IM basically does all of those above. Minus the peds and surgery. FM isn't involved in any of that.

Yes, they're managing it. There's a difference between starting IV cardizem and continuing something another physician or the ED started. FM is comfortable continuing something with adequate consults. I am comfortable initiating drips. They are not.

Like don't get me wrong. It sounds like you're at some extremely high powered quartenary care center and frankly one that has got to be so big that it can spread out their IM house staff and still have room for the above. I'm in a relatively established community hospital with 3 different sites. The IM program is king and sucks up all the resources.

 

[MedicineZ0Z]

Yah. 90% of FM programs aren't like that. My FM program is pretty much exclusively built around outpatient. They do like 4 months of inpatient intern year. A couple of surgery months where I don't really think they actually do much. The rest is split between outpatient type of rotations. They do one month of adult MICU.

IM basically does all of those above. Minus the peds and surgery. FM isn't involved in any of that.

Yes, they're managing it. There's a difference between starting IV cardizem and continuing something another physician or the ED started. FM is comfortable continuing something with adequate consults. I am comfortable initiating drips. They are not.

Like don't get me wrong. It sounds like you're at some extremely high powered quartenary care center and frankly one that has got to be so big that it can spread out their IM house staff and still have room for the above. I'm in a relatively established community hospital with 3 different sites. The IM program is king and sucks up all the resources.

4 months of inpatient in intern year isn't bad if they do more in pgy2 and pgy3 (which they obviously are) but the key thing is - what are they managing? Treating CAP is very easy. what's the census like? how many per intern? call schedule? night float? autonomy?
10 medically active patients per intern who are almost all ultra complex provides a lott more learning in just 1 week than a full month does of managing 4-5 patients.

And no I meant starting it yourself. Even without any FM attending (let alone consultant) input if it occurs overnight/on call for example.

FM is dominant here given how enormous and complex our patient population is. IM does well too, but FM is very well respected by almost every department. I do agree that this is unique for academic centers. But I would also disagree that unopposed programs provide better inpatient training all the time. Many have staff who are uncomfortable with many things. Or the volume per resident and total pathology may not be there.

 

[Drrrrrr. Celty]

4 months of inpatient in intern year isn't bad if they do more in pgy2 and pgy3 (which they obviously are) but the key thing is - what are they managing? Treating CAP is very easy. what's the census like? how many per intern? call schedule? night float? autonomy?
10 medically active patients per intern who are almost all ultra complex provides a lott more learning in just 1 week than a full month does of managing 4-5 patients.

And no I meant starting it yourself. Even without any FM attending (let alone consultant) input if it occurs overnight/on call for example.

FM is dominant here given how enormous and complex our patient population is. IM does well too, but FM is very well respected by almost every department. I do agree that this is unique for academic centers. But I would also disagree that unopposed programs provide better inpatient training all the time. Many have staff who are uncomfortable with many things. Or the volume per resident and total pathology may not be there.

I think it's rare to have patients who generally aren't medically complex... Like when I'm on the floor/wards rotations my problem list is rarely less than 8 active things. But again, I'm not entirely sure what you're trying to say here. Are you under the impression that a person walks into the hospital with one discrete problem? Like you're always going to get tons of pts who have added problem: either uncontrolled diabetes, alcohol withdrawal, etc.

Yah, our FM people don't have call. IM does all the call.

Yah, I don't think your FM program really is reflective of most FM programs. There are probably only 10 programs in the country like that, one of which is probably UNC where I recall thinking their program is more an IM program than a FM program.

 

[MedicineZ0Z]

I think it's rare to have patients who generally aren't medically complex... Like when I'm on the floor/wards rotations my problem list is rarely less than 8 active things. But again, I'm not entirely sure what you're trying to say here. Are you under the impression that a person walks into the hospital with one discrete problem? Like you're always going to get tons of pts who have added problem: either uncontrolled diabetes, alcohol withdrawal, etc.

Yah, our FM people don't have call. IM does all the call.

Yah, I don't think your FM program really is reflective of most FM programs. There are probably only 10 programs in the country like that, one of which is probably UNC where I recall thinking their program is more an IM program than a FM program.

No I meant multiple active issues at once in the same patient.

There are definitely a lot more than 10 lol. I interviewed at 18 places and all of them were inpatient heavy with call and I didn't go to any of the "big name" ones like JPS or UNC.

 

[rokshana]

What do you mean? We admit everything up to transplant patients (with a dozen serious comorbidities) as the primary. The patient population is just very sick and complex as a whole.
Consult services - we do inpatient cardio, surgery, medical icu, surgical icu, cardiac icu, PICU, inpatient peds.

FM is also the dominant force here in primary care.


Also, why isn't FM managing afib rvr; nowhere where you are?

So you are House?

 

[Drrrrrr. Celty]

So you are House?

I'm not really sure he gets that what he describes is basically most inpatient medicine services. If you have one problem you probably don't need to go to the hospital. It's the decompensated problem which set off multiple organ injury that ends up at the hospital.

But I also don't fully comprehend what kind of a training program he is describing. Our FM people are busy as hell getting their numbers in for clinic and doing their own things. How are they supposed to also be doing what is effectively an IM residency too?

 

[MedicineZ0Z]

I'm not really sure he gets that what he describes is basically most inpatient medicine services. If you have one problem you probably don't need to go to the hospital. It's the decompensated problem which set off multiple organ injury that ends up at the hospital.

But I also don't fully comprehend what kind of a training program he is describing. Our FM people are busy as hell getting their numbers in for clinic and doing their own things. How are they supposed to also be doing what is effectively an IM residency too?

We escalate our patients per clinic session numbers very quickly and have a low no-show rate.
I can't comprehend a type of program where FM doesn't do inpatient call. How do you have an FM inpatient service then?

 

[Drrrrrr. Celty]

We escalate our patients per clinic session numbers very quickly and have a low no-show rate.
I can't comprehend a type of program where FM doesn't do inpatient call. How do you have an FM inpatient service then?

We do their night admissions during our nights. Our IM program does our call in MICU and is rapid/code team. Which is more stressful but gets us better procedure numbers and more autonomy with critical and complex patients ex. SICU/MICU.

I suspect our FM program is very outpatient focused program. But i've seen a lot of FM programs that are like this. And most FM ppl exclusively want outpatient so it works out for them.

 

[MedicineZ0Z]

We do their night admissions during our nights. Our IM program does our call in MICU and is rapid/code team. Which is more stressful but gets us better procedure numbers and more autonomy with critical and complex patients ex. SICU/MICU.

I suspect our FM program is very outpatient focused program. But i've seen a lot of FM programs that are like this. And most FM ppl exclusively want outpatient so it works out for them.

Yeah Idk everywhere I interviewed, the inpatient service was 24/7 100% FM run only. But I suppose it makes sense if you just want to do outpatient only to be where you are.