IM: A love-hate situation.

[Leukocyte]

i am currently doing my IM core clerkship, and I HATE IT. I hate it, I hate it, and I hate it. Every day I follow around 15 patients, and I am "on-call" q3, and I hate every second of it. I really cannot see myself going through 3 years of IM residency. On the other hand, I am really interested in "studying and treating the heart" (aka Cardiology). The heart, as an organ, just fascinates me.

So, should I close my nose, and shut my eyes, and endure the hell of going through an IM residency, just to do a cardiology fellowship? Is it worth the sacrifice, given that cardiology is very competetive, and that there is no guarantee that I will end up doing cardiology?

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[Kalel]

15 patients with q3 call is a heavy load for an intern to be carrying, and probably overwhelming for most third yr med students (and interns too!). If you are able to handle 15 patients with q 3 call, I think that internship and IM residency won't be as bad as you predict it will be right now because you will have gotten much more into the flow of things. It's not that unusual for students to have a difficult time deciding between a procedural oriented field of IM like cardiology or GI and a surgical subspecialty too. General medicine and primary care medicine isn't for everybody, that's why there are sub-specialties.

 

[Eidolon6]

You aren't going to be a good cardiologist if you don't embrace some of the qualities of internal medicine. Unfortunately, a lot of the specialty is encumbered by the management of chronic, incurable diseases and a lot of the "active" interventions are saved for subspecialists. I didn't have the same early hatred for internal medicine, but as an upper level resident, I know that general medicine is not my bag either. That being said, I have a deeper knowledge than the surgeons considering most diseases encountered in the hospital, I don't rely on a PA to manage my inpatients, and my training has afforded me the option of going into a number of fellowships which maintain a specialist's edge, offer an interventional component, and given me the foundation that I feel is necessary to be a complete physician. The plus side of internal medicine training is that you get an extremely broad picture of disease, much beyond that of the surgical subspecialties, in a relatively short training time, with the benefit that you may springboard into a specialty.

If you really like the heart, but hate doing internal medicine, consider the following:
-Cardiac anaesthesia
-Pathology w/ focus on cardiac path
-cardiothoracic surgery (can you say CABG over and over)
-nuclear medicine w/ focus in cardiac imaging
-suck it up, do internal medicine, embrace some of the good things about it, and become a *real* heart doctor.

If you truly want to study the heart, consider a research track for your PhD, as some programs have a "fast track" for PhDs, requiring that they forfeit a year of internal medicine training so they can do more research in their chosen specialty.

Just my 2 cents.

 

[Joejitsu]

I think there are a boatload of individuals that go into IM with greater aspirations such as cardiology or GI. However, most of them get trapped doing IM for life because they were forced to face the reality of top tier fellowship competitiveness. Or, they had to consider a fellowship they had no interest in just so that they can get out of IM. Just my opinion. But obviously if you really really want to do cardiology then there's only one way about it...suck it up and try not to kill yourself during 3 years of intense boredom. Just remember when you're presenting a 5 page handwritten H&P (4 1/2 pages of which is complete nonsense and useless) that there is a light at the end of the tunnel.

Joe

 

[bariume]

Internal medicine is the only way to get to Cardiology, thats for sure. But not all internal medicine programs are malignant and have you admitting 10 crashing patients while cross-covering and disimpacting demented nursing home patients at the same time. Shop around when you look at residencies and pick one that is going to balance your interest in cardiology with quality of life. You do have to work hard to get to be a cadiologist or gastroenterologist, but there are programs out there that can help you avoid a painful 3 years of internal medicine. A good start is looking at how happy the residents of current housestaff are, and where the seniors end up. Also less months of call is important.

 

[avendesora]

I'm going to go against the crowd here -- if you really do "hate" as in, have trouble getting out of bed, don't want to go to work, can't wait for the end of the day every day while on the rotation... You should NOT go into IM.

True, cardiologists are specialists, but they are also internists. If you forget your IM training when you start fellowship, you will be a crappy cardiologist (I've worked with a few in this vein).

I want to do cards, and no WAY could I ever be a primary care doc, but I've found things about all parts of IM that I like.

Sounds like you're under too much of a load to really get an objective picture, though. Maybe try an elective?? Someone mentioned other areas involving the heart (cards anesthesia makes BANK by the way).

Good luck -- you'll figure it out. We all do.

 

[jashanley]

I'm sorry, but I have trouble believing that you as a student are left caring for 15 patients and are on q3 call. What school do you go to?
No student is capable of that feat (no offense to the students) and even interns would be hard pressed to manage those patients well.

I honestly don't believe anything you have said in your passage Leukocyte.

Your "view" on IM is extremely skewed. Why didn't you just say you wanted to do cardiology (not study and treat the heart)? I'm puzzled. I doesn't all add up.

Anyway, most IM programs in the country don't force you to be on call q 3 or carry 15 patients. Most interns don't carry 15 patients, let alone 10, on average. I think at my program the most I had at once was 10 and I was dead tired, and I discharged most of them the next day.
Try to do a sub-I somewhere less "hostile" or "malignant" to get a better idea if you like the specialty.

 

[Bobblehead]

Are you "following" 15 patients in terms of knowing what's generally going on with them? Or are you "following" them by writing the daily progress note, all of the orders, calling consultants and seeing that proper studies are done, discharging them and dicating them? I must say that even on our non-teaching service 15 patients is considered a heavy load, even for a board-certified internist since they get exactly as much help from the ancillary staff as the housestaff does which makes their jobs about twice as hard as ours.

Also FWIW an intern is not permitted to care for more than 12 patients at any given time, period. That's an RRC requirement and programs that have danced around the edges have gotten their hands slapped as of late.

I suggest to see what exactly it is you hate about your clerkship. Internship can be quite similar, except you're expected to know even more details. You will have the advantage of having the consultants and radiology actually call you though instead of the intern/resident/attending. No one really likes their residency, you just have to find enough days you like to get through it.

 

[Leukocyte]

I'm sorry, but I have trouble believing that you as a student are left caring for 15 patients and are on q3 call.

I am not "left alone" to care for 15 patients. I am dicrectly supervised by my Intern, and I follow his schedule (q3 call). I help my intern out by following HIS patients (usually around 12-16), AND often "asked" to "follow" on the patients of OTHER interns who need help (which usully adds an extra 1-3 patients to my usual patient load).

I am rotating at a busy trauma 1 center, and the medical floors are FULL all the time. The number of medical interns is small in proportion to the number of medical beds, which puts the interns under more pressure. No, it is not unusual for an intern to carry more than 12-15 patients. My Intern told me that he once had 24 patients. And as far as reporting the "abuse" to authoroties, well, most of the Interns are FMGs, and are thankfull that they had landed a residency program. So, I do not think they ever thought about complaining, for the risk that they might loose their residency opportunity (which might well be their only opportunity).

Anyways, I thank every one for their input.

 

[doc05]

the bottom line is that Leukocyte isn't really following 15 patients; he is just running scut for his intern.

 

[Leukocyte]

the bottom line is that Leukocyte isn't really following 15 patients; he is just running scut for his intern.

Mmmm. Lets see, I am a medical S-T-U-D-E-N-T, so sure, I am running scut. What else do you think I do? Yeah, I am running scut on ~15 patients + ER admission scut + code scut +........, so what's your point?

I just wanted to address a conflict that I had: IM vs Cardiology. I am frankly not interested in any of the feilds of IM, except Cardiology. And I was wondering if there are others who share my conflict. Is it "wise" to go into IM just to get into cardiology (If you care less about IM)? Is this common/uncommon? Are cardiologists interested in IM in general?

 

[avendesora]

No, it is not unusual for an intern to carry more than 12-15 patients. My Intern told me that he once had 24 patients.

You should know that this is not common or tolerated at most programs. In fact, this is a direct violation of the RRC guidelines for resident work schedules (12 patients at once for interns, 5 admissions per day). Most programs don't abuse their interns like this b/c it is the fast track to going on probation. If this is your major problem, then all you have to do is look elsewhere for residency.

In response: Like I said, yes, there are cardiologists who have forgotten (or choose to ignore) the other facets of IM. IMO, these are not good cardiologists nor good physicians in general. If you want to look at one specific part of the body to the exclusion of all others, perhaps one of the surgical fields would be more appropriate. Not trying to be crass or whatever, but there is definitely a philosophical difference in the approach. Surgery (and specialties) treat one problem at a time and leave the rest for someone else to deal with whereas IM and it's specialties take the patient as a whole and try to integrate many issues. (Please don't flame me on this -- I know LOTS of great, brilliant surgeons. Just trying to illustrate the difference in approach!)

 

[Leukocyte]

Thanks to everyone who posted and/or sent me private messages.

The road ahead of me is getting clearer. Thanks.

 

[lowbudget]

Holy cow. 15 patients q3? Then cross-scutting the other intern? Sounds like an abusive program. Our clerkship caps students at 5 patients (our own patients, we have to "know" them), q4-5, call until 10pm no overnight but no post-call day off and it's tough as it is. My brother at another school covered 3-4 patients.

I had 15 patients on Psych though, but I didn't do anything other than shadow the resident/attending in the inpatient service. It didn't make sense to them that we interview the patient twice... but it was a boring experience and I'm dumber now having done that.

If I were you, I'd cut a deal with the team and ask for 3-5 patients to be yours exclusively and do all the scut work, order entry, calling people, etc. than to follow 15 and "help out". Obviously, the intern has to do the note, but you do the presentation.

(Or... maybe you're doing this already... but just with 15 patients?)

Doing cardiology inpatient service as part of my 3rd year clerkship and it's TOUGH. You gotta know how to manage the comorbidities though because they affect the heart and the better you can manage someone's comorbitities the faster you get them out of your service and avoid the politics of transferring and dumping or calling consultants all of which take time.

 

[banner]

I bet you that the same BS you hate about internal medicine, you'll hate about cardiology. I suggest you think that over. Cardiology has the sickest patients and no shortage of nonsense. And you'll likely be on call as frequently as you are now with many more patients. And believe me, the heart will get really boring after the millionth time you've put a patient on a statin and a beta blocker or ruled out chest pain.

Also be careful of making logically impossible statements because you're afraid to admit the you may have made a mistake - I call this medical student fuzzy logic. For example, "I like thinking about cars, but I really hate driving them. In fact, I can't stand being in them for five minutes. I think I'll be a taxi driver." In medicine you hear analagous claims all the time.

I acknowledge your adoration for the heart, but I think it's time to get practical and cherish the memory of your unattainable and fantasy love.

That being said, cardiology is a wonderful way for the shrewd resident to correct the blunder of going into IM and make a lucrative salary. You could do Nucs or Stress testing if you can stand being an indentured servant for your IM residency plus chief year plus four years fellowship.

 

[Leukocyte]

........Also be careful of making logically impossible statements because you're afraid to admit the you may have made a mistake - I call this medical student fuzzy logic. For example, "I like thinking about cars, but I really hate driving them. In fact, I can't stand being in them for five minutes. I think I'll be a taxi driver." In medicine you hear analagous claims all the time.

I acknowledge your adoration for the heart, but I think it's time to get practical and cherish the memory of your unattainable and fantasy love......

Ok. So the bottom line is: If you do not like/enjoy/tolerate IM AND you ONLY want to do cardiology (you will not consider other IM specialities such ID, GI, ENDO,...). then do not waste your time and money applying to IM programs on ERAS.

Gotcha.

 

[kinetic]

...unless you don't like anything else OR unless you are reasonably sure that you will be competitive. In that case, go nuts.

 

[madcadaver]

I am rotating at a busy trauma 1 center, and the medical floors are FULL all the time. The number of medical interns is small in proportion to the number of medical beds, which puts the interns under more pressure. No, it is not unusual for an intern to carry more than 12-15 patients. My Intern told me that he once had 24 patients. And as far as reporting the "abuse" to authoroties, well, most of the Interns are FMGs, and are thankfull that they had landed a residency program. So, I do not think they ever thought about complaining, for the risk that they might loose their residency opportunity (which might well be their only opportunity).

Note to self: don't get sick in Miami.

 

[kinetic]

Just to engage that side-track for a second:

They're probably so busy because the population is about 95% old geezers with multiple comorbid conditions.

 

[Kalel]

Note to self: don't get sick in Miami.

Actually, a few of my attendings have told me horror stories about medical care in Florida. Apparently, it's been hit pretty hard by medicare (with the large senior citizen population) and a lot of docs are practicing poor medicine down there. One of my attendings said that he'd rather be flown to another state while someone was bagging him rather then stay sick in Florida.

 

[kinetic]

One of my attendings said that he'd rather be flown to another state while someone was bagging him rather then stay sick in Florida.

What about if he was in the middle of a DRE? Would he take a bumpy car ride to Georgia?

 

[ny skindoc]

Its unlikely that a few less patients and a bit less on call are going to make you like internal medicine much more than you do now.Do not force yourself to do something you cant stand.Cardiologists need to be good internists as well.The hassels of internal medicine are not for everyone.Be happy you found this out now when you are able to explore other specialties...many discover this too late.

 

[Linie]

So, should I close my nose, and shut my eyes, and endure the hell of going through an IM residency, just to do a cardiology fellowship? Is it worth the sacrifice, given that cardiology is very competetive, and that there is no guarantee that I will end up doing cardiology?QUOTE]
Remember, residency is finite! None of them are easy, but it WILL END, period. And you can find one that's nicer than the brutal one you're seeing now. FYI, carrying more than 12 patients at a time is an ACGME violation. So just make certain that you're not miserable because you fundamentally dislike IM, or that cards really isn't your salvation so you don't find yourself deep into residency realizing that you did the wrong thing.

 

[SuFiBB]

True, cardiologists are specialists, but they are also internists. If you forget your IM training when you start fellowship, you will be a crappy cardiologist (I've worked with a few in this vein).

I want to do cards, and no WAY could I ever be a primary care doc, but I've found things about all parts of IM that I like.

.

I have trouble believing that specialists need good training as being internists. I mean they should only make cardiologists and other specialists do just one year of prelimonary medicine like they do for ophtholomologists. Specialists do not need to be good internists any more than dermatologists do. whatever questions come up about preventive care and illnesses in organ systems aside from cardiology, they just refer the patient back to their primary care physician. Come on, Leukocyte, you think that doing an internal medicine residency that you would hate in order to become a specialist is a rare goal. most people go into internal medicine for aspirations to become a specialist and hate general internal medicine and residency for that matter. they do it as a means to an end. listen if you like cardiology that much then just do the residency even if you hate internal medicine, everyone else does. And avenderosa, not to put you on the spot but do you think that every specialist like ophtho, anesthesia, derm, need to be fully trained in internal medicine. because quite frankly cardiologists do not need 3 years of training in internal medicine to become good cardiologists...it just doesn't hurt

 

[drtofu66]

It is possible, though not easy or common, to fast-track it into fellowship. I know one guy in my intern class left for a Pulm/CCM fellowship after our second year and another guy who was in the class after me who spent his 3rd year of residency in the cardiology lab butchering mice and then he went into his cardiology fellowship afterward (I think his BS was in biomedical engineering and I know that he was a favorite son here where he also went to med school. Obviously that helped).

I did come across a few places that had combined IM/Cardiology programs so you wouldn't have to worry about applying for fellowship. You might ask your advisor or Medicine Chief about those if you are set on Cardiology.

When I was in med school I too was dead sure that Cardiology was my calling (I'll bet that 75% of IM residents have thought the same thing at some point) until I realized how tedious it is to cath someone. After a hellish cardiac pavillion month early in my 2nd year of residency I was certain that it wasn't as cool as I thought it would be and quickly revised my life's goals.

 

[avendesora]

And avenderosa, not to put you on the spot but do you think that every specialist like ophtho, anesthesia, derm, need to be fully trained in internal medicine. because quite frankly cardiologists do not need 3 years of training in internal medicine to become good cardiologists...it just doesn't hurt

Actually, no, for these three specialties, I think the one prelim year they do is enough because each of these fields practice in a controlled environment. Every physician should have at least one year of general "nuts and bolts" training to learn how to deal with emergencies and common complications. Or would you like to see a dermatologist who has never had to deal with anaphylaxis before? Also, don't Optho people have to do a surgery prelim year? That would make a lot more sense than a medicine year for them.

I would argue that cardiology and GI and other medicine specialties are different. When you are talking about the heart and vasculature and GI tract or whatever, you are not operating in isolation. Renal disease affects cardiac disease, and your treatment of cardiac disease may affect all other systems in the body, etc, etc. In fields like Optho or Derm, you are operating in relative isolation. Skin biopsies and eye drops do not often worsen hypertension.

Trust me, I have seen enough junk done by cardiologists to screw up other body systems who have HAD 3 years of medicine. I was actually talking to a couple friends the other day, and we decided the perfect system would be one in which you do 2 years of IM, then if you want to specialize you go to your fellowship after year 2. Otherwise you finish normally. I think that would be workable. Also, I have heard numerous people opine that they feel IM should really be 4 years with the explosion of our understanding of pathology and the number of therapies. I mean, 1 year of internship was OK when the only therapy we had was to give fluids and morphine and wait, but things have drastically changed over the last 30 years. I'm not personally in favor of this, but I can see the point.

I'll say it again, if you truly HATE IM, then I think you are fooling yourself about wanting to be a cardiologist or GI. Personally, I tolerate general IM with the goal of mastering it so I can be good in my specialty.

 

[SuFiBB]

Actually, no, for these three specialties, I think the one prelim year they do is enough because each of these fields practice in a controlled environment. Every physician should have at least one year of general "nuts and bolts" training to learn how to deal with emergencies and common complications. Or would you like to see a dermatologist who has never had to deal with anaphylaxis before? Also, don't Optho people have to do a surgery prelim year? That would make a lot more sense than a medicine year for them.

I would argue that cardiology and GI and other medicine specialties are different. When you are talking about the heart and vasculature and GI tract or whatever, you are not operating in isolation. Renal disease affects cardiac disease, and your treatment of cardiac disease may affect all other systems in the body, etc, etc. In fields like Optho or Derm, you are operating in relative isolation. Skin biopsies and eye drops do not often worsen hypertension.

Trust me, I have seen enough junk done by cardiologists to screw up other body systems who have HAD 3 years of medicine. I was actually talking to a couple friends the other day, and we decided the perfect system would be one in which you do 2 years of IM, then if you want to specialize you go to your fellowship after year 2. Otherwise you finish normally. I think that would be workable. Also, I have heard numerous people opine that they feel IM should really be 4 years with the explosion of our understanding of pathology and the number of therapies. I mean, 1 year of internship was OK when the only therapy we had was to give fluids and morphine and wait, but things have drastically changed over the last 30 years. I'm not personally in favor of this, but I can see the point.

I'll say it again, if you truly HATE IM, then I think you are fooling yourself about wanting to be a cardiologist or GI. Personally, I tolerate general IM with the goal of mastering it so I can be good in my specialty.

points well taken