Gen Med vs Subspecialty

[PCN]

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I want to start a new thread re: doing gen med vs getting a fellowship. My general impression is that everyone wants to subspecialize, and those who don't either did not train in a good residency or did not do well enough in the residency to get a fellowship they wanted. People say that doing Gen IM is like being the scutmonkey for everyone else and additionally being underpaid.

I feel that I am in a position, where I have done well in medical school to be competitive in many top programs. I am interested in one of the more competitive fellowships. BUT (big but), I also like general medicine. I like being the primary guy, being able to take care of many problems. If I don't do a fellowship, and do gen medicine, I will go into private practice. The hours are not too bad, lifestyle is not bad, you don't have to waste another 3 years of your life doing a fellowship, and my impression is that financially sky is the limit depending on how you run your practice. Now I did a rotation in one of the less competitive subspecialties (not one I am interested in pursuing), and the first year fellows there took call q2 (although home call), and had to stay late hours at the hospital. I thought to myself that after completing three years of IM and finally feeling like you have accomplished something, going back to being virtually an intern again has got to be absolute hell. I am interested, are there any people that are kind of in my shoes, who have done well in school, can potentially set themselves up for a future competitive fellowship, but are also thinking whether the investment of this extra time is really worth it in the long run?

 

[dmc05]

I am in a very similar position. I too am applying for IM and I am interested in one of the competitive fellowships but I also like general medicine as well. I am a competitive applicant just like you and I have interviews at very respectable and reputable institutions, but I am torn as to which route I will pursue once I start residency. Any ideas??

 

[DrKnowItAll]

Hear it from some one who was exactly in your shoes last year and is now an intern at top 10 IM program:

If you are competitive and have good scores, DO NOT GO INTO IM!

Do radiology, Derm, optho, ...

Anything but IM. It is a dumping ground and a waste of time and talent. On top of that, compenations are dropping fast for all IM subspecialties, including GI and Cardiology.

And please don't give me the crap about patient contact long term follow up and what not. It's just a job and in IM you are at the lowest end of the specturm.

 

[PCN]

Thanks for the Reply DrKnowItAll

I understand your point, and have thought about this a lot. I have considered several competative specialties. I will kill myself if I had to do rads for the rest of my life. Derm is also boring. Optho: number 1 or number 2, need I say more. This is not to make fun of the other specialties, but they are just not for me. Additionally, what I realized is that I will have a good shot of getting into a very competative IM residency program rather then settling for an avg rads program (after applying to like 50 programs) for example. I have already applied to IM and did not apply to any other specialty. At this point I am not considering anything else, its only IM and subspecialty or Gen IM.

PCN

Hear it from some one who was exactly in your shoes last year and is now an intern at top 10 IM program:

If you are competitive and have good scores, DO NOT GO INTO IM!

Do radiology, Derm, optho, ...

Anything but IM. It is a dumping ground and a waste of time and talent. On top of that, compenations are dropping fast for all IM subspecialties, including GI and Cardiology.

And please don't give me the crap about patient contact long term follow up and what not. It's just a job and in IM you are at the lowest end of the specturm.

 

[Eidolon6]

Hear it from some one who was exactly in your shoes last year and is now an intern at top 10 IM program:

If you are competitive and have good scores, DO NOT GO INTO IM!

Do radiology, Derm, optho, ...

Anything but IM. It is a dumping ground and a waste of time and talent. On top of that, compenations are dropping fast for all IM subspecialties, including GI and Cardiology.

And please don't give me the crap about patient contact long term follow up and what not. It's just a job and in IM you are at the lowest end of the specturm.

Interns like Know-It-All, are probably the last to give advice in the "what specialty you should go into" department...and frankly it doesn't matter squat if you are at a "top 10 program" or not. Medicine internship is probably the most thankless internships you can do and when I did mine...there was no 80 hr work week or "I can only work a 30 hr shift" rules. Medicine internship was hell. That being said...I did and continue to do some great things...and I wouldn't trade those experiences in.

So as a graduating IM resident from an academic IM program (not top 10....but then again there is not a true "ranking") who is going to a competitive fellowship, I can offer this

1) don't be starstruck by the "top 10" or competitive residency stuff...you will end up like Know It All at a program you hate, loathing your job. You'd be better off finding a place that offers diversity of training and a group of people that will help you make it to where you want to go.

2) general IM has some things to offer...although not great monetary compensation. The traditional outpt/inpt thing is going away and IM is diverging into hospital based and office practice. You will not make a lot of dough, but you may have personal rewards beyond that, that folks like Know It All have forgotten about. There are a lot of dumps and yes you are abused by "the system"...but hey, thats life. You have to be smart though...there are a lot of BAD deals out there...

3) the IM subspecialties are still lucrative...and much of your takehome is dependent upon how much time and lifestyle you want to sacrifice.

4) as for wasting talent...the most talented folks I've seen have been old-school internists, medicine subspecialists and a small handful of surgeons....

5) you've got to do what you like. The money will mean a lot less in 10 years and if you are left doing Lasik procedures all day or reading chest x-rays...you may regret your decisions.

6) shed the idealism...medicine is ugly. People are sick, the problems complex and the treatment options often unsatisfying...but frankly you have to look at it like joining the military (be it as an infantryman)...you are gonna crawl in the mud, dodge bullets and occasionally step on landmines...again...thats the way it is...except on TV.

I have more but for another time. All I can say is...IM is hard...and its not a cop-out like going into anesthesia or radiology. It lacks the money, the glamour and instant gratification...Its real work...but depending on your personality, its work worth doing.

 

[PCN]

I hate it that compensation has become so important in making a decision about a future career. Of course with $150,000+ in loans, and wife's loans, it is just impossible to ignore it. I am not an expert on salaries, however, from what I heard, and from salary.com (in my area code), GI does not avg nearly 250-500K. It is more like 210-300 (25-75th percentile) with 240 being median. A generalist making 140-180K (25-75th percentile) with 160 being median. If we are thinking only about the money, putting the call schedule and the "coolness" of the procedures away, there are a few things to consider. Doing a fellowship will take 3 years. During the three years, one can do gen medicine making $150K/year (avg salary) compared to $50K during the fellowship, and make a profit $300K more then one would being a GI fellow for three years ($450K/3years gen med - $150K/3years as a GI fellow). If you were to invest these $300K and get a 15% return (this maybe a little high) that would be like extra $45K/year. With compound interest in a few years, this extra $300K can make you as much as, and even more then one would as a GI doc. Moreover, while doing a GI fellowship, I would have to put my $150,000+ loans into forbearance, accumulating an even greater amount of money that I will have to payback. This is all without considering, spending my late 20s and early 30s in training, not spending enough time with my wife and my future kids.

I am just thinking out loud about these issues. I am in fact interested in GI, but I am realizing that I have to consider all of these matters before making a decision of doing a fellowship. I am also realizing that in doing gen med, one can have fun, see good pathology, not be overworked, and if you are smart you can run your business to make way more then $150K. What do you guys think?

PCN

I don't think the compensations are dropping at all. Actually, they are increasing for GI at least. For example, the entry salary after GI fellowship is between 250K to 500K in major big cities and areas (except for NYC and LA). All of my friends got multiple job offers during the late 2nd and early 3rd year. You get to choose which job you want even in NYC. Some of them are only working 3 days a week and making over 300K+ a year, no over night call in a major city. I know some jobs requre overnight calls. He loves his job! He gets to do multiple procedures and also do regular medicine stuffs with his patients. Once you become a partner in 2-3 years, the salary easily doubles or quadruples.