"Don't pick IM just for the fellowships"...T/F?

[Darrow O'Lykos]

Hi y'all,

MS3 here trying to figure out what to do with my life. I've bounced between a few different ideas since coming into med school, and currently the prospect of going the IM -> Cardiology route has me in a stranglehold. I really enjoy cardiac phys and I am set to rotate with a cardiologist in a month for my elective.

However, one thing I've heard is that you shouldn't pick IM solely for the prospect of one of the fellowship pathways, and to only pick it if you are fine with being an internist. I understand that there is never a guarantee of matching into a given fellowship (and that cardiology is particularly competitive), but how much truth is there to that advice? I get the sense that each of those careers can vary drastically from what it looks like as an internist.

Is the advice really just from a risk stratification standpoint, or is there deeper truth to saying that to enjoy those fields one should enjoy IM?

TIA

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[NewYorkDoctors]

well that's certainty one way to look at things

At the end of the day, all IM subspecialists need to have a good foundation of Internal Medicine to be a good subspecialist.

While you do not need to be a good primary care physician (that is a unique skill set needing to know quite a bit about the non-IM subspecialty fields, managing psychosocial issues, managing the worried well, and managing "healthy" patients) to be a good subspecialists, you do need to be a good Internist even to be a cardiologist (running a CCU needs to have a good base of knowledge and not just cath lab)

If you really like the heart and want to just go straight into the heart, you could always consider cardiothoracic surgery residency. But of course that is a surgical field.


The general IM advice seems to be "if you fail to match in a competitive subspecialty then you have to be okay with IM."
But every year many do not match into a competitive subspecialty. As long as the work is put in (whether during the initial application process or during a second/third try) to strength a resume, then one can definitely get subspecialty of choice. Just don't be gunning for the top fellowships at the top academic medical centers in the top most desirable places to live unless you are a top candidate yourself with top pedigree.

But if you think you might like cardiology now then pursue it and do IM. Maybe you'll find you like something else like PCCM, GI, HemeOnc, Allergy Rheum........ Nephrology (no don't! you can always do nephrology as a second fellowship if you had no debt and you really like the subject matter)

 

[Darrow O'Lykos]

you can always do nephrology as a second fellowship if you had no debt and you really like the subject matter)

I'll do cardiology and then a nephrology fellowship so that I can argue with myself even more than I do now

If you really like the heart and want to just go straight into the heart, you could always consider cardiothoracic surgery residency. But of course that is a surgical field.

I thought about this a lot during the first two years, but ultimately it boiled down to two things:
1. I think being in the same place constantly would bore me and drain me (i.e.: never leaving the OR), and;
2. After my surgery rotation, I realized I want nothing to do with general surgery, and those I-6 spots are extremely limited and highly competitive.

Whereas I think the idea of doing a variety of things (clinic 2 days a week, consults 2 days a week, imaging/reads 1 day, rotating call, etc.) would be more appealing to me in any career, thus the more weight I've given to cardiology in recent months.

At the end of the day, all IM subspecialists need to have a good foundation of Internal Medicine to be a good subspecialist.

While you do not need to be a good primary care physician (that is a unique skill set needing to know quite a bit about the non-IM subspecialty fields, managing psychosocial issues, managing the worried well, and managing "healthy" patients) to be a good subspecialists, you do need to be a good Internist even to be a cardiologist (running a CCU needs to have a good base of knowledge and not just cath lab)

The general IM advice seems to be "if you fail to match in a competitive subspecialty then you have to be okay with IM."
But every year many do not match into a competitive subspecialty. As long as the work is put in (whether during the initial application process or during a second/third try) to strength a resume, then one can definitely get subspecialty of choice. Just don't be gunning for the top fellowships at the top academic medical centers in the top most desirable places to live unless you are a top candidate yourself with top pedigree.

This is more or less what my line of thinking was as well. I understand that there are no guarantees for a fellowship in a particular field, but I'm not totally off base in thinking that I don't really like the idea of being an internist, but that in order to be a great fellowship candidate that I need to be a great IM resident and put in the work in order to get where I want to be, right?

Thanks for your input!

 

[NewYorkDoctors]

I assume you are an AMG? If so your chances are very good to get into cardiology but it is not a guarantee like a birthright or something.

Med school AMG check
Get into best IM residency you can that has a cards fellowship . This way you get exposure to cardiologists in Ccu and cards electives .

While having good clinical knowledge is good, helping the cards faculty with research (not doing clinical trials as a resident that’s not a reasonable expectation ) and anything from case manuscripts to retrospective projects to helping them write book chapters (if only editing and updating references ) to narrative reviews . Anything to get a pubmed citation for the cards faculty is the “currency “ you need on your resume . Plus that’s how you get glowing letters of recc from cards faculty .

Hence just being a good internist is a prerequisite not not the sole criterion for getting cards fellowship .

Maybe once you do IM and do micu you might like critical care pulm . Pulm is analogous to cards in many ways . Like to read echoes and stress tests ? I read PFTs and CPEts . Like to do invasive procedures ? There is bronchoscopy and EBUS . Like Ccu patients ? Micu had you covered too . Like pulm HTN ? You can manage from either subspecialty (though pulm does class 1 ,3,4 ,5 while cards does 1,2)

General pulm can manage osa and ordering sleep tests just fine . Sleep medicine is for opening your own sleep lab and managing narcolepsy and those less common issues .

You can get critical care US certified through big pccm programs and be proficient in point of care echo and US of the entire body and also do TEEs for critical care patients as well .

 

[NITRAS]

I went through residency fulling planning on doing fellowship. At some point, I liked what I was doing that I didn’t want to go through fellowship. Most places treat fellows worse than residents. I’d at least be ok with the idea of being an internist. General medicine can be practiced in such broad and different ways. . it is hard to imagine not being able to do something with the training.

 

[AlbinoHawk DO]

Hi y'all,

MS3 here trying to figure out what to do with my life. I've bounced between a few different ideas since coming into med school, and currently the prospect of going the IM -> Cardiology route has me in a stranglehold. I really enjoy cardiac phys and I am set to rotate with a cardiologist in a month for my elective.

However, one thing I've heard is that you shouldn't pick IM solely for the prospect of one of the fellowship pathways, and to only pick it if you are fine with being an internist. I understand that there is never a guarantee of matching into a given fellowship (and that cardiology is particularly competitive), but how much truth is there to that advice? I get the sense that each of those careers can vary drastically from what it looks like as an internist.

Is the advice really just from a risk stratification standpoint, or is there deeper truth to saying that to enjoy those fields one should enjoy IM?

TIA

I don't agree with this advice. How else do you become a cardiologist if you don't do IM first? Are you going to pick your 2nd or third choice and lament all your life that you didn't try for what you wanted? Besides, I don't know any IM doctor that doesn't do some "Cardiology" as part of treating patients

 

[NewYorkDoctors]

This is more or less what my line of thinking was as well. I understand that there are no guarantees for a fellowship in a particular field, but I'm not totally off base in thinking that I don't really like the idea of being an internist, but that in order to be a great fellowship candidate that I need to be a great IM resident and put in the work in order to get where I want to be, right?

nah a lot of people like Internal Medicine but loathe the thought of being a hospitalist or primary care physician. this is probably some combination of perceived lower pay, perceived lower prestige, perceived more difficult patients, perceived [insert whatever].

you're not alone. just don't wear that on your shoulder or else you'll get a lot of people not liking you. while you need not make doctor friends in life (I know I dont lol), you do not want to make enemies / rivals / critics in residency or that might put a big red flag onto your resume for cards fellowship later on.

 

[rokshana]

Hi y'all,

MS3 here trying to figure out what to do with my life. I've bounced between a few different ideas since coming into med school, and currently the prospect of going the IM -> Cardiology route has me in a stranglehold. I really enjoy cardiac phys and I am set to rotate with a cardiologist in a month for my elective.

However, one thing I've heard is that you shouldn't pick IM solely for the prospect of one of the fellowship pathways, and to only pick it if you are fine with being an internist. I understand that there is never a guarantee of matching into a given fellowship (and that cardiology is particularly competitive), but how much truth is there to that advice? I get the sense that each of those careers can vary drastically from what it looks like as an internist.

Is the advice really just from a risk stratification standpoint, or is there deeper truth to saying that to enjoy those fields one should enjoy IM?

TIA

i think the point is that dont pick a residency if you dont want to do the core specialty if you dont get the fellowship.

I came into medical school, thinking to do REI...my graduate degree and research was in reproductive biology...figured i would do ob/gyn and then rei...which is the path for rei...come 3rd yr had to decide if wanted to do REI vs Gen endocrine because the path split...REI have to do ob/gyn residency vs gen endo goes through IM residency...decided to go through IM and do endocrine...why? because REI was (and still is) very competitive (it is to OB what GI is to IM), favors AMGs (I'm IMG) and there were only about 60 spots at the time ...while gen endo is less competitive and there are more spots...~ 250 at the time...i did a endocrine rotation at the very beginning of 4th year to see if it was even of interest and then asked myself if i would be ok with being a gen ob/gyn vs gen IM if i didn't get the fellowship...i went IM to Endo, because i just couldn't see myself doing gen ob/gyn (prolly didn't help that ob/gyn was my first rotation as a 3rd year) and i'm happy with my decision ...i actually worked as a hospitalist for a couple of years in-between residency and fellowship and would have been ok with continuing down that path if i hadn't matched in endo.

 

[NewYorkDoctors]

I don't agree with this advice. How else do you become a cardiologist if you don't do IM first? Are you going to pick your 2nd or third choice and lament all your life that you didn't try for what you wanted? Besides, I don't know any IM doctor that doesn't do some "Cardiology" as part of treating patients

agreed
everyone INternist can order EKG, echos, and some PCPs get CT calcium scoring and CTCA based on insurance coverage

moreover, I do plenty of cardiology workup myself. When a patient is referred to me for dyspnea / chest pain first (before cardiology. it happens).

I do my usual pulmonary workup : physical exam, CXR, CTC (if applicable), PFTs, FENO, 6MWT, relevant labwork, bronchoprovocation testing, sleep studies.

but if that is unrevealing (or if they have COPD, asthma, IPF, etc... but still have symptoms of ischemic heart disease) or I hear a distinct 3/6 murmur consistent with AS, MR, TR (yes I do listen... to the heart... i record it also with the EKO Core 500 stethoscope to get a phonocardiogram and three lead ECG as well), I do the CPET/EKG stress test (recall Internists in the boonies do treadmill EKG stress tests out of necessity in light of absence of resources) and order TTEs (I have a mobile ultrasound company borrow space in my office for a monthly rental fee from them and they can do TTEs which are intrepreted by cardiologists. i get the report and images / videos on a portal) and CTCAs myself.

Usually if I find a problem, I refer straight to my interventional cardiology colleague. He appreciates jumping straight to LHC.

I seldom see a need to refer a patient of mine to general cardiology. Sure I could "get the patient out of my hair" but the "internist in me" wants to finish the job.

so the OP, you could always do pulmonary and have a grand time dabbling in some general cardiology as well unless your goal is structural, interventional, EP, or CHF/transplant.

 

[mszzeta]

Hi y'all,

MS3 here trying to figure out what to do with my life. I've bounced between a few different ideas since coming into med school, and currently the prospect of going the IM -> Cardiology route has me in a stranglehold. I really enjoy cardiac phys and I am set to rotate with a cardiologist in a month for my elective.

However, one thing I've heard is that you shouldn't pick IM solely for the prospect of one of the fellowship pathways, and to only pick it if you are fine with being an internist. I understand that there is never a guarantee of matching into a given fellowship (and that cardiology is particularly competitive), but how much truth is there to that advice? I get the sense that each of those careers can vary drastically from what it looks like as an internist.

Is the advice really just from a risk stratification standpoint, or is there deeper truth to saying that to enjoy those fields one should enjoy IM?

TIA

I don't know where this statement is from, but it is totally fine to pick IM solely for a subspeciality. This is what most people end up with their life anyway. The only caveat is that for patients' best interest, you need to be a excellent internist in addition to be a good cardiologist. Otherwise when you patient get dyspnea and everything in your brain is literally cardiology, you may make mistakes for missing other IM DDx...

 

[TaroBubbleTea]

There are lots of people who plan on doing fellowship but for one reason or another don’t end up applying, whether it be they get tired of training or realize they don’t like the field as much as they thought. You should do IM if you think you’ll be ok doing general medicine in case you don’t subspecialize.

 

[NewYorkDoctors]

I don't know where this statement is from, but it is totally fine to pick IM solely for a subspeciality. This is what most people end up with their life anyway. The only caveat is that for patients' best interest, you need to be a excellent internist in addition to be a good cardiologist. Otherwise when you patient get dyspnea and everything in your brain is literally cardiology, you may make mistakes for missing other IM DDx...

its not too hard though. do every cardiac test out there then send to me for pulmonary evaluation

then I get my pulmonary history, do PFTs and CPET up front (in an attempt not to just CT scan everything unless there is a clear CXR indication or its for lung cancer screening in a smoker) to get to the bottom of the dyspnea, assess for OSA and then tell them they are deconditioned and then try to get them onto a step count exercise program... and then most never follow up with me again and no show future visits because I prescribed exercise.

 

[Gastrapathy]

F

 

[Señor S]

In my experience it's very rare for a US MD not to get a fellowship in whatever field they want...as in, I've never actually seen it happen. Maybe they have to apply a couple of times but they eventually break through. Doing IM with the plan of doing a fellowship after is the norm and most residents at most academic programs end up doing just that. If Cardiology is what you want then do IM. Don't plan for failure.

 

[Drrrrrr. Celty]

In my experience it's very rare for a US MD not to get a fellowship in whatever field they want...as in, I've never actually seen it happen. Maybe they have to apply a couple of times but they eventually break through. Doing IM with the plan of doing a fellowship after is the norm and most residents at most academic programs end up doing just that. If Cardiology is what you want then do IM. Don't plan for failure.

In my experience good residents also get tired, get pregnant, and decide they are done with training.

People go into resident with the desire to be a cardiology fellow. They do a few call shifts in internal medicine and then see the cardiology fellows looking like death. And by the time they're in their 2nd and 3rd year realize it's not worth it.

As an endo fellow I found fellowship to be worse than residency. For cardiology fellows I think it's not even comparable in the same sentence. But most of them really love the field and really want to master it.

In short, don't go into IM without the realization that you may realize cardiology is not what you want to do or that you realize that doing a 3 year fellowship followed by multiple years of actively building your practice, being on call, etc is not conducive to your lifestyle goals.

 

[Señor S]

In my experience good residents also get tired, get pregnant, and decide they are done with training.

People go into resident with the desire to be a cardiology fellow. They do a few call shifts in internal medicine and then see the cardiology fellows looking like death. And by the time they're in their 2nd and 3rd year realize it's not worth it.

As an endo fellow I found fellowship to be worse than residency. For cardiology fellows I think it's not even comparable in the same sentence. But most of them really love the field and really want to master it.

In short, don't go into IM without the realization that you may realize cardiology is not what you want to do or that you realize that doing a 3 year fellowship followed by multiple years of actively building your practice, being on call, etc is not conducive to your lifestyle goals.

Not even applying for a fellowship is a choice people make, and obviously you only make that choice if you find the idea of hospitalist or primary care appealing or at least tolerable. Most subspecialists I know tell me they find the idea of being a hospitalist nauseating; doesn't mean it was a mistake for them to match into IM. Training is a means to an end and trainees' experiences are often not representative of "real world" practice (in ways both positive and negative). If somebody wants to be a Cardiologist then they should do Internal Medicine; they should absolutely not give up on that dream because there's some catastrophic worst-case scenario where they end up as a generalist (what is the alternative pathway for this person anyways?).

 

[Espressso]

I think it's totally reasonable to go into IM knowing you want to do x fellowship. How else can you go into x fellowship without doing IM? However by the same token, it's important to remember that fellowship is not guarenteed and you may not match. On top of that, no matter what fellowship you choose, cardiology, gi, heme/onc, pccm, etc, you should still want to master IM first. All incredible subspecialists were great internists first.

 

[Prehealth1011]

Since you only have 2 years to rack up research, if your goal is cardio/GI/onc/pccm, you have to start early. Having a specific specialty in mind might be beneficial because you can start sooner rather than later.

 

[NewYorkDoctors]

I think it's totally reasonable to go into IM knowing you want to do x fellowship. How else can you go into x fellowship without doing IM? However by the same token, it's important to remember that fellowship is not guarenteed and you may not match. On top of that, no matter what fellowship you choose, cardiology, gi, heme/onc, pccm, etc, you should still want to master IM first. All incredible subspecialists were great internists first.

good advice agreed

but I want to provide the caveat that being "great internist" in this case means in residency you want to be known as a hard worker from the hospitalists and GIM faculty and having good knowledge base by reading MKSAP but you do NOT want to dedicate too much time actually becoming a super well rounded internist who does all the quality improvement stuff and hand holding stuff

you want to be known as a great worker with good knowledge base. but you want to spend most of your spare time doing clinical research or other scholarly activity for the subspecialist faculty to get their reviews and letters in. this latter part is the key to getting (competitive) fellowship

 

[Prehealth1011]

good advice agreed

but I want to provide the caveat that being "great internist" in this case means in residency you want to be known as a hard worker from the hospitalists and GIM faculty and having good knowledge base by reading MKSAP but you do NOT want to dedicate too much time actually becoming a super well rounded internist who does all the quality improvement stuff and hand holding stuff

you want to be known as a great worker with good knowledge base. but you want to spend most of your spare time doing clinical research or other scholarly activity for the subspecialist faculty to get their reviews and letters in. this latter part is the key to getting (competitive) fellowship

This is true. We had co-residents who were busy volunteering, changing policies, wellness-ing, quality-improving, showing interest in teaching, and being well-liked by everyone. No tangible research. Didn't match.

 

[TexasMed22]

This is true. We had co-residents who were busy volunteering, changing policies, wellness-ing, quality-improving, showing interest in teaching, and being well-liked by everyone. No tangible research. Didn't match.

great system we have

 

[NewYorkDoctors]

This is true. We had co-residents who were busy volunteering, changing policies, wellness-ing, quality-improving, showing interest in teaching, and being well-liked by everyone. No tangible research. Didn't match.

the way i can conceivably see this route working is doing this route to become Chief Resident as PGY4. Then certain institutions want to keep that chief resident in house for any fellowship of your choice regardless of "pedigree." Automatic competitive fellowship in house of your choice regardless of how much research and PubMedding was actually done

 

[HemeOncHopeful19]

i think the point is that dont pick a residency if you dont want to do the core specialty if you dont get the fellowship.

I came into medical school, thinking to do REI...my graduate degree and research was in reproductive biology...figured i would do ob/gyn and then rei...which is the path for rei...come 3rd yr had to decide if wanted to do REI vs Gen endocrine because the path split...REI have to do ob/gyn residency vs gen endo goes through IM residency...decided to go through IM and do endocrine...why? because REI was (and still is) very competitive (it is to OB what GI is to IM), favors AMGs (I'm IMG) and there were only about 60 spots at the time ...while gen endo is less competitive and there are more spots...~ 250 at the time...i did a endocrine rotation at the very beginning of 4th year to see if it was even of interest and then asked myself if i would be ok with being a gen ob/gyn vs gen IM if i didn't get the fellowship...i went IM to Endo, because i just couldn't see myself doing gen ob/gyn (prolly didn't help that ob/gyn was my first rotation as a 3rd year) and i'm happy with my decision ...i actually worked as a hospitalist for a couple of years in-between residency and fellowship and would have been ok with continuing down that path if i hadn't matched in endo.

I think it’s worth noting

USMD match rate 2023

Cards 84%
GI 79%
REI 68%

One of these is not like the other IMO especially when you consider the lifestyle of IM vs Cards/GI and OB vs REI

 

[Meerkatology]

I'll do cardiology and then a nephrology fellowship so that I can argue with myself even more than I do now

u can have fun with the chf patients coming in with creatinine of 2.5

 

[Deecee2DO]

I hate IM and solely doing it to match into my subspecialty of interest (im currently finishing up PGY2). I didnt realize how much core IM rotations in residency like hospital medicine/medicine floors is basically all social work/discharge crap/secretarial duties/calling a million people so your patient can get a good price on a med/setting up post-D/C follow up appts with specialists and PCPs. Its mentally exhausting that clinical medicine doesnt even feel like medicine anymore. Other specialties dont do nearly as much of this BS. lol all I care about is my subspecialty of interest at this point and this has become a much stronger opinion the closer I get to PGY3 and beyond

 

[NewYorkDoctors]

Darrow O'Lykos said:
I'll do cardiology and then a nephrology fellowship so that I can argue with myself even more than I do now

hm the only reason to do this is to become a research in ultrafiltration

the clinical trials have not panned out with aquapheresis yet. the CHF cardiologists were so excited for a period of time at UNLOAD. But HF CARESS shot that down quickly.

if Aquapheresis ever became a thing for CHF patients, you can be sure the government will be swooping in take control like they did with dialysis. lol

 

[osprey099]

I went into IM knowing I was going to do heme-onc later. I played the game and did the brown nosing needed. Had superb letters and our home heme onc PD basically guaranteed me I'd have a spot if I wanted to stay. Even then, I almost decided to become a Hospitalist. Your mind might change in the future..

 

[Meerkatology]

I hate IM and solely doing it to match into my subspecialty of interest (im currently finishing up PGY2). I didnt realize how much core IM rotations in residency like hospital medicine/medicine floors is basically all social work/discharge crap/secretarial duties/calling a million people so your patient can get a good price on a med/setting up post-D/C follow up appts with specialists and PCPs. Its mentally exhausting that clinical medicine doesnt even feel like medicine anymore. Other specialties dont do nearly as much of this BS. lol all I care about is my subspecialty of interest at this point and this has become a much stronger opinion the closer I get to PGY3 and beyond

Im a nocturnist for precisely this reason, i rarely need to worry about any of this stuff