FM vs IM: Looking for hopefully a new type of discussion on the topic, and comments on residency differences (with relevant poll)

[deleted849476]

TLDR: sorry for the text wall, if you can't make it all the way through then maybe just discuss your poll choice or pick a question below and answer that. Its just nearly impossible to have these discussions candidly in person with attendings.

Third year student and trying to flesh out my interests in specialties, and when it comes to thinking about FM vs IM I have some questions I feel like have been hard to research. I'm really trying to get at a different angle on the discussion of FM vs IM, especially as it relates to "difficulty" of the residency itself, which might involve tackling kind of (baseless?) stereotypes about the two.

So first, for some background, the doctor I imagined being before med school was one who could be approached by any random person--old, young, pregnant or not--on the street and still have a good/reasonable chance of giving the person solid advice or helping them with their complaint (maybe even throwing a suture for a lac repair on the camping trip, or something dumb like doing a procedure for their in-grown nail). Obviously that's romanticized, but to me it's more FM than IM and subjectively, a bit more "doctory." Anyway, it contrasts a bit with my impression/the IM doc stereotype who (since I've been in med school) seems to be a bit more "hardcore" and perhaps in a way more knowledgable, albeit with lesser breadth of scope than the FM doc. For example, (and I'm honestly not trying to offend or say anything about one being better or worse, just commenting) the FM docs I'm around are more likely to talk about humanistic patient issues, whereas it seems like IM would rather talk about lab values or all the causes of the micro/macrocytic anemia (lol hopefully someone out there knows what I'm talking about about these vibes), BUT THEN, at the end of the day, they are both seemingly treating the generic adult patient the same and (likely?) having the same outcomes, and (maybe?) have the same depth of knowledge on said disease.

But you gotta admit, they give pretty separate vibes, know what I'm sayin'???

So, specific questions:

-Biggest question: is FM residency "easier" than IM intellectually speaking, and if so does that say anything about how prepared graduates are to be great docs? (AKA, if true that IM's harder, does residency rigor = better doctor)? ...In a way I think I'm kind of looking for ways to be content with FM because I do want it, but I feel guilty because I have stereotypes about it compared to other specialties, which I know is pretentious but idk I just can't help it. It seems to me like, "Do you want to do 80hr/week for 3 years, or a bit more of a lifestyle specialty residency for 3 years but either way you get to be a hospitalist"

-They're both 3 years and FM is objectively larger in scope (and from the sounds of it, less "intense" than the common IM residency), so what exactly is being sacrificed in FM? This is my second biggest question. Especially because it seems like IM exists for a reason (adults), peds for a reason (kids), and FM could arguably be described as trying to be both but not as good as each categorical specialty and then throw in some women's health (but again not an OB). Again not trying to be rude, and in a way I'm just shooting straight and looking for answers because I am partial to FM but I want to be informed.

-FM can do inpatient and from my own search, most places in my area hire "FM/IM" for their hospitalists, so is the training similar enough that they are truly equal with inpatient quality? Like if I got hired out of FM residency alongside a new IM grad and we were on an inpatient shift, would there be some noticeable difference between us? And if not, for someone like me who likes the broader scope of FM, why would I even think about IM, because I'm certainly not going for any fellowships.

-So IM is way more commonly described as intense and time consuming during residency, so for someone like me who wants FM scope and to be a hospitalist, why do people say "do IM if you want to be a hospitalist" especially given that FM gets the same jobs (and doesn't appear to be as grueling in residency and is presumptively trained "well enough" for it)? It is becoming increasingly important to me to have time to have my own life even during residency, but again then I feel guilty like I could be "becoming more prepared for inpatient" doing IM even though I think residency would be miserable because of the hours and almost sole focus on adult inpatient. (As an aside, I'd be wanting FM scope in order to transition back to outpatient one day and see women's health and kids, or to pick up UC shifts, or even work in a rural ED or something, or just to be more like my fantasy type of doc I always imagined and not to mention have a better lifestyle in residency if that is really a thing).

-The poll question is just to get a feeler on inpatient after FM residency.

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[VA Hopeful Dr]

TLDR: sorry for the text wall, if you can't make it all the way through then maybe just discuss your poll choice or pick a question below and answer that. Its just nearly impossible to have these discussions candidly in person with attendings.

Third year student and trying to flesh out my interests in specialties, and when it comes to thinking about FM vs IM I have some questions I feel like have been hard to research. I'm really trying to get at a different angle on the discussion of FM vs IM, especially as it relates to "difficulty" of the residency itself, which might involve tackling kind of (baseless?) stereotypes about the two.

So first, for some background, the doctor I imagined being before med school was one who could be approached by any random person--old, young, pregnant or not--on the street and still have a good/reasonable chance of giving the person solid advice or helping them with their complaint (maybe even throwing a suture for a lac repair on the camping trip, or something dumb like doing a procedure for their in-grown nail). Obviously that's romanticized, but to me it's more FM than IM and subjectively, a bit more "doctory." Anyway, it contrasts a bit with my impression/the IM doc stereotype who (since I've been in med school) seems to be a bit more "hardcore" and perhaps in a way more knowledgable, albeit with lesser breadth of scope than the FM doc. For example, (and I'm honestly not trying to offend or say anything about one being better or worse, just commenting) the FM docs I'm around are more likely to talk about humanistic patient issues, whereas it seems like IM would rather talk about lab values or all the causes of the micro/macrocytic anemia (lol hopefully someone out there knows what I'm talking about about these vibes), BUT THEN, at the end of the day, they are both seemingly treating the generic adult patient the same and (likely?) having the same outcomes, and (maybe?) have the same depth of knowledge on said disease.

But you gotta admit, they give pretty separate vibes, know what I'm sayin'???

So, specific questions:

-Biggest question: is FM residency "easier" than IM intellectually speaking, and if so does that say anything about how prepared graduates are to be great docs? (AKA, if true that IM's harder, does residency rigor = better doctor)? ...In a way I think I'm kind of looking for ways to be content with FM because I do want it, but I feel guilty because I have stereotypes about it compared to other specialties, which I know is pretentious but idk I just can't help it. It seems to me like, "Do you want to do 80hr/week for 3 years, or a bit more of a lifestyle specialty residency for 3 years but either way you get to be a hospitalist"

-They're both 3 years and FM is objectively larger in scope (and from the sounds of it, less "intense" than the common IM residency), so what exactly is being sacrificed in FM? This is my second biggest question. Especially because it seems like IM exists for a reason (adults), peds for a reason (kids), and FM could arguably be described as trying to be both but not as good as each categorical specialty and then throw in some women's health (but again not an OB). Again not trying to be rude, and in a way I'm just shooting straight and looking for answers because I am partial to FM but I want to be informed.

-FM can do inpatient and from my own search, most places in my area hire "FM/IM" for their hospitalists, so is the training similar enough that they are truly equal with inpatient quality? Like if I got hired out of FM residency alongside a new IM grad and we were on an inpatient shift, would there be some noticeable difference between us? And if not, for someone like me who likes the broader scope of FM, why would I even think about IM, because I'm certainly not going for any fellowships.

-So IM is way more commonly described as intense and time consuming during residency, so for someone like me who wants FM scope and to be a hospitalist, why do people say "do IM if you want to be a hospitalist" especially given that FM gets the same jobs (and doesn't appear to be as grueling in residency and is presumptively trained "well enough" for it)? It is becoming increasingly important to me to have time to have my own life even during residency, but again then I feel guilty like I could be "becoming more prepared for inpatient" doing IM even though I think residency would be miserable because of the hours and almost sole focus on adult inpatient. (As an aside, I'd be wanting FM scope in order to transition back to outpatient one day and see women's health and kids, or to pick up UC shifts, or even work in a rural ED or something, or just to be more like my fantasy type of doc I always imagined and not to mention have a better lifestyle in residency if that is really a thing).

-The poll question is just to get a feeler on inpatient after FM residency.

- No, I do not believe that FM residency is intellectually speaking easier (I'm FM and my wife is IM) generally speaking. Its the old comparison between depth and breadth. FPs have to learn peds and OB in addition to adult medicine. We also, generally speaking, get a fair but more ortho training than internists. They on the other hand get more subspecialty rotations and usually more inpatient experience. Now the question always becomes how much is good enough. As an FP I feel comfortable doing outpatient adult medicine to the same level as my wife, but there are slight differences in how we practice. She refers to ortho much more quickly than I do for similar things. In contrast, she will do a more thorough work-up before sending to specialists like nephrology or rheumatology. We both refer at about the same level she just sends them with more of the work-up done compared to what I do. I'm pretty comfortable with most peds outpatient as well. I will typically recommend someone take their child to a pediatrician if they're significantly complicated: bad autism, super premature, CP, stuff like that. I would love to do more women's health but as a male doctor in an area with lots of female OB/GYNs my patients prefer being sent out for most of that.

- On average, I believe internists are better prepared to be hospitalists compared to FPs. This doesn't mean that FPs can't make excellent hospitalists because they can. But not all programs are created equal in this respect. If you think this is something you want to do, seek out programs with robust inpatient rotations because not all of them have that. Contrast this with IM programs which are required to have significantly more inpatient months than we are.

- This depends. Some of my inpatient rotations were harder than my wife's. Some were not. Her ICU months on the other hand were way worse than mine, but hers were also the worst of anyone I've ever spoken to so I think she's an outlier in that respect.

 

[NeuroticByN8ure]

My recommendation would be to not overthink the subtle differences between the two specialties and just focus on what you want to do after residency. Is your primary goal to work as a hospitalist full-time? If so, your decision is easy--- you need to go into internal medicine. This is a different discussion from "can you work as a hospitalist from FM training?" If you know going into residency that you want to work as a hospitalist, why would you waste valuable time during your training doing peds rotations, OB rotations, continuity clinic, and training alongside people who are by and large intending to practice outpatient medicine?

I would also get rid of the idea that you may work full-time as a hospitalist and then do outpatient medicine and provide women's health and pediatric care. Even if you had that training during residency, you can't put it on a shelf for 10 years working strictly as a hospitalist and think you're going to be comfortable seeing newborns in the office. Again, this is a different career path than full-spectrum family medicine with both inpatient and outpatient straight out of residency.

This is my perspective being 2 years out of a family medicine residency. I do fulltime outpatient and see mostly adults, but still see some kids and provide gyn care (no OB).

 

[wysdoc]

I don't know if this is still the case, but when my med school roommate matched to a FP residency on the east coast she felt that she was "not taken as seriously" as the IM residents and was actually able to switch to IM. Some areas of the US place more value on FP than others. Her goal was eventually private practice and not intensive care.

 

[NITRAS]

I’m an internist to qualify things. IM has more inpatient months than FM. Inpatient is often seen as “harder” because there usually has to be someone covering the service 24/7. So, there are nights, weekends, call.

There is a lot of variability in programs in how taxing they are, and inpatient exposure in FM programs can vary quite a bit. I work in a group with like 40 hospitalist and 3 are FM. None of them were hired right out of residency. I don’t think IM is more intellectually challenging than FM. The vast majority of patients are straightforward.

 

[deleted849476]

Interesting discussion, thanks everybody.

My recommendation would be to not overthink the subtle differences between the two specialties and just focus on what you want to do after residency. Is your primary goal to work as a hospitalist full-time? If so, your decision is easy--- you need to go into internal medicine. This is a different discussion from "can you work as a hospitalist from FM training?" If you know going into residency that you want to work as a hospitalist, why would you waste valuable time during your training doing peds rotations, OB rotations, continuity clinic, and training alongside people who are by and large intending to practice outpatient medicine?

I would also get rid of the idea that you may work full-time as a hospitalist and then do outpatient medicine and provide women's health and pediatric care. Even if you had that training during residency, you can't put it on a shelf for 10 years working strictly as a hospitalist and think you're going to be comfortable seeing newborns in the office. Again, this is a different career path than full-spectrum family medicine with both inpatient and outpatient straight out of residency.

This is my perspective being 2 years out of a family medicine residency. I do fulltime outpatient and see mostly adults, but still see some kids and provide gyn care (no OB).

Good points here. I guess it makes sense that if I'm not seeing peds/women's health regularly as a hospitalist then why work to get the training for it.

@VA Hopeful Dr Lots of details here I never thought of. I'll definitely take a closer look at inpatient heavy programs.

@NITRAS Really interesting take. If the nights/call/etc is what makes IM seem more intense then I see where it gets the bad rap, but just as a single dude with a lot of time on my hands and willing to do what it takes to also feel like most cases are "straightforward," I'd be willing to do it just to feel that much more comfortable as a hospitalist. Was there a point in residency where you felt pretty comfortable with most of your caseload (like felt like those cases were "easy"), or did it come after residency?

 

[Lurts]

Many of these points are very residency dependent. Our family med residency has a 24/7 inpatient service that covers two hospitals with open ICUs. We’re a fair bit busier than the IM program that covers one hospital, has a patient cap, and transfers their critical patients.

Edit: and I moonlit as a Hospitalist starting in second year of residency with no issues.

 

[AMEHigh]

I agree that you should try to figure out what you want to do first (I didn’t know exactly what I wanted to do when I started FM, so recognize that could change). And also it is so program dependent.

There are a few FM programs that are 4 years and give you a little more "specialization." One of the smartest and most caring doctors that I know is an FM doc who did a 4 year program and he now does inpatient, ob/deliveries, abortion care, peds, gender affirming care, addiction medicine (is certified) and hiv medicine (is certified). Literally anytime I have a question about anything (mostly prenatal questions) I ask him and he has the answer. Most of the FM doctors I know that don’t live in rural areas that do full spectrum like that either work in academics or work at community health or fqhc type places.

I actually don’t do much primary care these days as I mostly do gyn care/reproductive health stuff but I’m still so thankful for my FM training as I think it overall has made me a better doctor and I’m able to explain things well to my patients/can make them feel more comfortable about what to expect if I have to refer them to a pcp for an A1C of 11 or some other specialist like a dermatologist.

If you have no idea what you might want to do I’d say do FM, and if you want to work as a hospitalist for sure I would say prob better to do IM. Otherwise there are pros and cons to each and different programs have their benefits.

 

[InternistDO]

Most people have already covered most of this but my experience as an IM resident in the Northeast is this:

FM isn't "easier" than IM. There are a lot of FM programs in the NE that have very light inpatient schedules and therefore have an 'easier' schedule than me but they still have to learn a bunch of stuff that I don't (peds/OB/more outpatient procedures). There are FM programs in other areas that have more robust inpatient experiences that probably work harder than I do.

As a general rule, IM will get more inpatient time than FM. Also, all big academic centers will have their inpatient services run by the Department of Medicine, meaning they will almost always be staffed by internists. With this in mind, if you want to do inpatient/hospitalist medicine, you should do IM. Not that there aren't plenty of FPs who do inpatient, just that as an internist basically every hospitalist job will be open to you and as a family doc many will be closed.

FM will get more outpatient exposure in residency, especially with procedures and non "medicine" things like gyn, sports medicine, ENT, derm. As you already know, you won't get any peds or OB training at all in IM. Most IM programs will give you a tiny amount of gyn at best, some will give 0 training. If providing broad scope outpatient medicine is important to you, you should go with FM. Doing IM will require you to put in more work in residency to get outpatient procedures, women health, ortho stuff and you still will be closed out of many urgent care or rural jobs that want you to see kids. On the other hand if you never want to see a child or a vulva again, consider IM.

The other issue with IM is the push towards specialization. If you're at a "good" IM program you may find that 70-80% of your classmates will sub-specialize. If you're looking to be a rural generalist while your classmates are gunning for structural interventional cardiology you might find it a frustrating environment.


It sounds like you want to do FM. I would focus on programs that provide good inpatient training (avoid most of the urban Northeast for this, unfortunately) and broad spectrum care. If you put in the time and effort I have no doubt you'll be comfortable with inpatient medicine by the end of residency, but who knows if you'll even want to do pure inpatient when you graduate. When I started IM I thought I might do pulm/crit and run an ICU, and now I'm doing primary care with HIV and women's health. A good FM program will give you the ability to do any flavor of generalist medicine that you want. I will say that like someone else mentioned, the idea of doing hospitalist for 5-10 years and then switching to general outpatient broad spectrum medicine is likely not realistic. In a field like medicine that moves so quickly, it's very much use it or lose it. If you want to do inpatient and outpatient you should find jobs that let you do both from the beginning.

 

[SXMMD]

Some really good answers here. I'll throw in my 2 cents as an FM hospitalist~2 years out of residency.

It took me a few months to be as comfortable with some of the more complicated patients as my IM colleagues but now there's largely no difference. You'll get the reps, if you're diligent about learning and keeping up it won't be an issue. In some cases the FM background has been an advantage. Recently had a case, dude had poison ivy with overlying cellulitis. I got a good history, started tx for cellulitis and poison ivy. Handoff of patient next day as my shifts were over, IM colleagues were freaking out thinking all sorts of zebras because they hadn't seen poison ivy in clinic that often- they got ID involved, tested for all sorts of wild stuff. Everything is negative the guy got better, largely benign hospital course otherwise. Could probably have treated it outpatient to be honest.

In short, medicine is what you make of it. You'll get enough in most programs in FM to succeed an the hospital arena. IM is better trained to do it right out of the gates, but you'll catch up quickly if you're diligent. Likewise you're better suited to multiple different types of practices in FM- the diligent IM doc will catch up if they seek to practice in those environments and are on top of things.

Main difference is what you can do outside of your core specialty- fellowship opportunities, practice environments e.g. ER, wound care, OB, peds, palliative care etc vs the plethora of IM subspecialty fellowships.

 

[Drrrrrr. Celty]

Internist here.

I think it's good to recognize what your individual program is actually going to sell to you. A FM program with a robust inpatient training is going to offer you a very comprehensive understanding of how to be a hospitalist. That being said I think there's more to medicine than just understanding how to function as a hospitalist which is why I think the question is loaded. There's a broader philosophical question of what actually interests you in medicine and whether or not that means you're going to be more prone towards subspecialization.

And mind you I'm going to say this as a person who came from a strict IM background and is subspecializing. But Medicine is nuanced and complicated and we cheapen a lot of disease by pretending it follows very easy pathophysiology without understanding the diversity of our patients. And this in my opinion is where the 'idealized internist' arrives. The guy who will be able to pull in the big picture and figure out that their classic hfpef patient actually has an ILD or cardiac sarcoidosis or cushings disease or etc. And I can honestly say this is extremely interesting and it's why internal medicine spends a lot of time thinking about some seemingly petty **** like hyponatremia or inverse A:G ratios. Because you don't want to miss an interesting patient when they arrive after being mismanaged or misdiagnosed.

A lot of hospitalists Frankenstein medicine. This is regardless of IM or FM background as well. They do things based on what is likely going to work, without really knowing enough about what's going on. However I would argue that every subspecialty rotation I covered pushed further away from frankensteining my medicine and more towards being more scientific, more comprehensive, and more deliberate about why I am doing what I do. I don't think is common in most FM programs I've seen including my former residency's FM program or my FM rotations during medical school.

Next is open ICU v.s closed ICU and procedures. IM trains you to do procedures inpatient. I have enough experience in POCUS, lines, intubation, and as such can be easily credentialed to do them. So in an open ICU hospital where you are expected to be qualified it may be an issue.

And finally is subspecialization. This is actually where the issue kind of heats up. IM training is not to become a hospitalist. It's to be a good internist. This is because you need to be a good internists go on to become good subspecialist. FM is locked out of IM specific fellowships.


Short answer: You can absolutely be a hospitalist as a FM graduate from a program with a good inpatient training. The question is whether you're going to be content off the bat without having had a varied subspecialty experience that expanded your familiarity with diseases and skills of how to handle them yourself.

Some really good answers here. I'll throw in my 2 cents as an FM hospitalist~2 years out of residency.

It took me a few months to be as comfortable with some of the more complicated patients as my IM colleagues but now there's largely no difference. You'll get the reps, if you're diligent about learning and keeping up it won't be an issue. In some cases the FM background has been an advantage. Recently had a case, dude had poison ivy with overlying cellulitis. I got a good history, started tx for cellulitis and poison ivy. Handoff of patient next day as my shifts were over, IM colleagues were freaking out thinking all sorts of zebras because they hadn't seen poison ivy in clinic that often- they got ID involved, tested for all sorts of wild stuff. Everything is negative the guy got better, largely benign hospital course otherwise. Could probably have treated it outpatient to be honest.

In short, medicine is what you make of it. You'll get enough in most programs in FM to succeed an the hospital arena. IM is better trained to do it right out of the gates, but you'll catch up quickly if you're diligent. Likewise you're better suited to multiple different types of practices in FM- the diligent IM doc will catch up if they seek to practice in those environments and are on top of things.

Main difference is what you can do outside of your core specialty- fellowship opportunities, practice environments e.g. ER, wound care, OB, peds, palliative care etc vs the plethora of IM subspecialty fellowships.

Alternatively the converse is true. I remember a week I started a hospitalist rotation where we got sorted a bunch of patients admitted by a nocturnist and it was a bunch of nonsense. However this again kind of rolls around to my general ire of inpatient hospitalist medicine. The hospital is Frankenstein's bride.