How much do we really need to worry?

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I’m cool with all of these except Peds and Psych. Also does that include most IM subspecialties?

General IMs w/o in-house Cards or GI fellowships are easy to get into.

If your aspiration is GI or Cards, you need average Step 1 and Step 2 and go to a decent IM residency w/ in house fellowships. Afterward, it's up to your in-house IM residency exams, your ability to play well with others, research, and your Step 1 + Step 2. Those factors are in that order of importance. My source is a current Cards fellow who will bank close to 500K - 1 mil out of fellowship, depending on generated RVUs.