Internal Medicine FAQ - Updated

[AJM]

I have updated and revised the FAQ originally written by Kalel. Feel free to PM me with any corrections or additions you might have.


What is an internist?

An internist is primary care physician who treats adults. Internal medicine differs from family practice in that family practioners are trained to treat adults, children, and do obstetrics. Internal medicine residency training is more focused on inpatient medicine and management of complex patients/diseases than is family practice training. Internists are trained in all areas of men’s health and all areas of women’s health with the exception of obstetrics (delivering babies). Internists are board eligible after completing 3 years of an internal medicine residency. Most general internists have outpatient offices where they talk with patients and manage every day diseases such as diabetes, heart disease, depression, high blood pressure etc. For the most part, general internists focus on preventative medicine and referring patients to the appropriate specialists when necessary. Some internists may also choose to manage their private patients whenever they are admitted into a hospital.

What procedures can internists do?

Among other things, internists are trained to place central and peripheral lines, arterial lines, and pulmonary artery catheters. They also do paracenteses, thoracenteses, arthrocenteses, lumbar punctures, skin biopsies, and drainage of simple abscesses. If an internist completes a fellowship and becomes a subspecialist, they will have an even wider range of procedures available to them. Examples of these procedures include things like endoscopy, cardiac catheterization, bronchoscopy, colonoscopy, and kidney and liver biopsies. It's not that unusual to find students having a difficult time between choosing between surgery and some of the medical subspecialties as both can be very procedure oriented. The most procedural medical subspecialties are cardiology, gastroenterology, and pulmonary/critical care. As with any specialty, the more rural of location an internist chooses to practice, the more procedures he or she may be called upon to perform.

What can I do after completing my internal medicine residency?

Approximately 60% of physicians who complete their internal medicine residency go into practice as an internist after they complete their residency, either as a traditional outpatient general internist, or as a hospitalist. About 40% of people who complete their internal medicine residency program go on to subspecialize in internal medicine by completing fellowships. Physicians trained in internal medicine have a lot of options. Besides working in hospitals or physician offices, internists can be found working at campus health centers, drug rehabilitation programs, managed care companies, prisons, nursing homes, drug companies, and major corporations among other places.

What is a hospitalist?

A growing percentage of people trained in internal medicine are beginning to work as hospitalists, a new specialty in which internists work solely in a hospital and only manage patients as inpatients. They can be either employees of the hospital in which they work, or will work for a private practice group that tends to admit a large number of patients to a specific hospital. The hospitalists specialty grew as a response to managed care and an increasing demand that physicians be efficient with their time. While other internists and family practioners manage patients as an outpatient, once patients are admitted, a hospitalist can take over their care and manage their medical needs while they are in the hospital. Some places are beginning to offer hospitalist fellowship training programs, but it is not yet considered necessary to be trained as a hospitalist in order to work as a hospitalist; any internist can be hired and work as a hospitalist. An often-cited criticism of working as a hospitalist is that these physicians are sometimes viewed as glorified residents, as much of the work is similar to that done during IM residency. This is more true at a community hospital which doesn’t have residents rotating through. At teaching hospitals, hospitalists directly supervise the IM residents, and are often the primary teachers and mentors to the house staff. Growing numbers of physicians are choosing to work as hospitalists immediately out of residency for a variety of reasons. One reason is that hospitalists do not have to spend time to build up a patient base – they simply take care of patients coming into the hospital. Similarly, it’s a good position to take as a short-term job, since you don’t have to worry about continuity of care. Many recent IM residency graduates will work as a hospitalist for a year or two in between completion of their residency and start of their fellowship, if they are taking some time off from their training (which is becoming increasingly popular as well).

Threads:
Hospitalists
Hospitalist
What's the view on hospitalists?

For a helpful website, check out www.hospitalmedicine.org

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[AJM]

How competitive is it to get into an internal medicine residency program?

Right now, internal medicine is considered not competitive, as most American medical graduates do not have a difficult time matching in internal medicine residency programs. Approximately 40 % of internal medicine residents are international medical graduates. Of course “top” internal medicine programs remain extremely competitive for students to match at. Students that match at top internal medicine programs often have AOA status, 230+ step I scores, and strong letters of recommendation. Publishing research, having experiences that show leadership skills, and doing audition rotations or having connections at top programs is thought to be helpful as well. It has also been said that many students who match at those top programs have “unique” applications, with exceptional activities on their resumes that show a true dedication towards internal medicine.

What does an internal medicine residency consist of?

To give you an example of what you will do during a typical internal medicine residency, I have copied the curriculum from the University of Maryland’s Internal Medicine Residency Program here:

”During the three year program, residents spend one-third or more of their time in ambulatory rotations, including a weekly continuity medical clinic, four Ambulatory Block Rotations, the emergency room, walk-in clinics and subspecialty clinics during consultation rotations. Residents spend approximately half their time on inpatient rotations, including general medicine units, subspecialty services (e.g., cardiology, infectious diseases, oncology), intensive care units and the medical consultation service. The rotation schedule is carefully arranged so that each resident has exposure to general medicine, all the subspecialties, clinical floors and intensive care units, while not allowing any one area to dominate. The remainder of their time is spent on clinical or research electives, including two electives in the intern year.”

What combined Internal Medicine programs are there?

It is possible to do an IM/Emergency Medicine, IM/Family Practice, IM/Pediatrics, IM/Preventative Medicine, IM/Physical Medicine and Rehabilitation, and an IM/Psychiatry residency. These combined programs offer dual board certification eligibility with fewer years of residency then internal medicine (3 years) and the corresponding specialty put together (e.g. pediatrics is 3 years, however, most IM/pediatrics residency programs last 4 years, IM/EM residencies last 5 years, etc). There are some benefits and some disadvantages of pursuing a combined program. Many physicians feel that students should pick one specialty and focus on it. The idea behind these combined programs was that students could build practices based on where these programs overlapped. An example of this would be how some IM/Pediatric residents are interested in pursuing a career in adolescent medicine, while others plan to subspecialize and see patients of all ages in that subspecialty in the future. Perhaps a med/peds physician could subspecialize in endocrinology and follow type I diabetics throughout their lifetime. Many IM/EM residents say that they chose this route because they are interested in having a private clinic in addition to working shift work in the emergency room, and they want to fall back on internal medicine if they get burnt out in the ER.

Threads on Combined Residencies:
Med/Peds Interview 2004
Med/Peds Advice?
Emergency Medicine/Internal Medicine Residencies

What subspecialty fellowships are available for IM grads?

There are many subspecialties each with unique characteristics that are available for IM grads to pursue. Because of the large amount of variety among them, they are discussed in a separate “sticky”. Please refer to that thread for more information.

 

[AJM]

Previous SDN Discussion topics (feel free to contribute!):

Recently matched seniors...please give us your stats

Internal Medicine Residency Program Rankings

Another Internal Medicine Residency Program Rankings Thread

Residency Program Rankings

Places you love, places you hate

Rank order lists

IM Program Rankings

Cush Medicine Programs

Board Scores: Are they lying?

Prepping for Intern Year


Other free online Resources (not necessarily endorsed by SDN):

Scutwork.com Internal Medicine program ratings (very useful! please rate your program)

American College of Physicians

www.hospitalmedicine.org

Freida online specialty training Statistics

Listings of most internal medicine fellowship programs

Residency Database Search Page (From the ACP)

AMA find-a-physician (locate where your attendings trained at)

Allied Physician Salaries

ACP online Specialty Brochure

Residency, fellowship, and attending vacancies


My Favorite Books in Internal Medicine

Current Medical Diagnosis and Treatment

Rapid Interpretation of EKG's

Washington Manual of Therapeutics

5 Minute Clinical Consult for your PDA

High Yield Internal Medicine

Blueprints in Medicine

 

[AJM]

How do I succeed during my internal medicine rotation?

Your internal medicine grade, just like all of your clerkship grades, depends on interpersonal issues, politics, luck, and how hard you work. The only variable in that equation that you can have direct control over is how hard you work. The first thing that you want to make sure that you have down is all of the basics. Know how to take a good history, physical exam and present your findings to your attending and team. Realize that different attendings want to hear different things in your presentations; some will want to hear all of your history and physical exam findings, while some will only want to hear brief histories with pertinent positives on exam. If you are unsure of what your attending expects, you can always ask an upper level medical student, intern, or resident who has worked with the attending in the past. If you are not able to find anyone, it’s OK just to ask the attending in the beginning of your presentation how thorough he or she wants you to be. If medicine is your first rotation, you will no doubt experience some difficulty in coming up with a concise assessment and plan in the beginning. Before attending rounds, you should discuss your assessment and plan with the intern or resident who is following the patient with you, and make sure that your assessment and plan mirrors theirs. If it doesn’t, then you should ask what their thought process was for coming up with their different assessment and plan.

As you get more experienced with working up patients, you should try to look up current literature pertaining to your patients. You can bring copies of whatever literature you find for your medical team to present during rounds. While you may be asked by your resident or attending to present on a certain topic, it is always best to bring in literature and offer to discuss it before you are asked to do so, as it demonstrates much more initiative and interest on your part. Some attendings will want to hear about what you were able to find in current literature, while others will want to round quickly and move on. You can always mention recent papers that you found during your presentation with one-line synopses and gauge how interested your attending and team is in hearing about your findings during rounds. If they do not seem interested in hearing about it, at least you have shown that you are taking initiative in doing research in current medical literature. For your presentations during rounds, you should also try to make sure that you have things that your attending may want to see readily available. This can include things like ECG’s, x-ray films, and CT scans.

You should always volunteer for more work. Try to pick up as many patients as you can, as taking care of medical patients is the best way to learn about medicine. When you do pick up patients, take personal responsibility for their care. Out of your entire medical team, you should know your patients the best. This means knowing whatever recent abnormal lab values have come up on your patient, what consults you are waiting to hear from, and what tests your patient has scheduled during the day. Ask to be the one to call consults so that you will be able to ask them whatever questions your medical team needs answered. When you do call a consult, however, make sure that you know the specific questions that you and your team want the consult to answer. Don’t complain about staying late or having to come in early, you should actually be doing the opposite by staying late if your patient needs to have a procedure done. Always volunteer to do procedures. Remember in a relatively short period of time, it will be you who is called upon to supervise procedures. The more central lines you have placed, the more comfortable you will be supervising someone do one. If your patient is going to have a procedure done by a subspecialist (eg colonoscopy, IR embolization, etc), you should go watch the procedure yourself. That way, you can learn first-hand what is involved in these types of procedures, and you can discuss directly with the people performing the tests or procedures about what they are doing. Most importantly to your team, you will be the first person to know what exactly happened with your patient, and can immediately report back to your team the results of the procedure that was done.

Finally, if your medical school is anything like most medical schools, you should recognize that the senior resident on the medicine team will have a fairly significant say in your grade.

How should I study for my Internal Medicine shelf Exam?

I read through blueprints and high yield internal medicine from cover to cover during my internal medicine rotation. I think that it is important to have a basic understanding of everything to pass the test, but having a basic understanding of everything will not allow you to do well on the test. The shelf exam is very specific, it does not simply ask “what is the pathophysiology of disease X”, but rather it asks questions like “a patient with disease X presents with new onset weakness. What is your next step of management?” You will not be able to answer many of the shelf exam questions even if you have blueprints open right in front of you during the exam. My advice for the shelf exam is to study by looking up things pertaining to all of the patients that you are taking care of. You should be looking up and reading things in a medical text such as Current Medical Diagnosis and Treatment. If you admit a patient with community acquired pneumonia, you should look up what all of the organisms that could cause pneumonia, what findings you would expect radiologically and on physical exam, and what the current treatment recommendations for pneumonia and atypical pneumonia are. I found Current to be the most concise, up to date, and readable book out of Current, Harrison’s, and Cecil’s (the three major internal medicine textbooks that most medical students choose from). You should flip through copies of each at your local bookstore and see which one lends itself best towards your reading and studying style. If your medical school has a subscription, the on-line Up To Date is a valuable resource, and has a great search function. IMO it’s too expensive to purchase on your own, however. After you have finished reading through Blueprints once or twice and completing the questions at the end of that book, you should use a question book to practice on as many questions as you have time for. I found Pretest to be very useful for questions, many of the questions that I encountered on the shelf exam were similar to questions in Pretest. When you encounter an answer to a question that you don't fully understand or are interested in learning more about, you should look up more information about the subject in your medical text (Current) as if you had a patient with the disease in question. While taking the test, you should make sure that you pace yourself during the exam. Most medical schools give students 2 hours to complete the 100 question exam, which ends up being barely sufficient time for students to finish. Realize that the last 10 questions or so on the internal medicine shelf exam and all shelf exam are very long questions with many, many answer choices and these questions will take you longer then the average question in the beginning.

 

[AJM]

When am I supposed to apply for my internal medicine residency?

Most medical students apply for residency during the beginning of their fourth year. Here is the timeline that medical students participating in the National Residency Matching Program (NRMP)/ Electronic Residency Applicant Service (ERAS) are expected to follow this year:

For 2006 graduates:
July 1, 2005: MyERAS website opens to applicants
August 15, 2005: Applicant Registration Opens at the NRMP
September 1, 2005: ERAS allows applicants to submit their application
November 1, 2005: The Dean’s Letter/MSPE’s are released
November-January: Interviewing takes place
December 1, 2005: Registration Deadline
January 15, 2006: Rank Order List System Opens
February 22, 2006: Rank Order List System Closes at 9pm Eastern Time
March 16, 2006: Match Day!

For more information, visit the NRMP Homepage and ERAS Homepage

What about letters of recommendation?

Most internal medicine residency programs require students to submit three letters of recommendation, with one letter coming from your internal medicine department chair irrespective of whether or not he or she actually knew you. Your other two letters should be from attendings who know you well and who you know can write you strong letters of recommendation in support of your application. One of the two should come from an attending in the department of medicine (this can include subspecialists). Most recommend that you try to obtain a letter from the attending that you do your sub-internship in medicine at the beginning of fourth year, as these attendings will see how strong you will be as a resident. It’s not always possible to get this attending to write you a letter for a variety of reasons, in which case a letter from one of your third year medicine attendings or a fourth year medicine elective attending should suffice. If you take your medicine rotation early during your third year and get along with your medicine attending then, it?s OK to ask that attending to write you a draft for a letter of recommendation and save it on their computer so that they will not forget about you. Your other letter can be from any physician, whether it be a psychiatrist, a pediatrician, or surgeon, who you know will write you a strong letter of recommendation. A big advantage of asking third year attendings to write your letters is that you will already have seen what they wrote about you in your evaluation, and therefore are less likely to be surprised with your letter of recommendation. You should begin collecting your letters at the beginning of fourth year.

What about my CV and Personal Statement?

You should probably have your CV and personal statement completed or close to completion by the end of your third year. The reason for this is because you will want to give a copy of your CV and personal statement to everyone who writes you a letter of recommendation so that there can be continuity throughout your application. It doesn’t look good if your write your personal statement about how you want to pursue a subspecialty while one of your letter writers turns in a letter about how dedicated you are to becoming a general internist. Similarly, by giving your letter writers a CV, you can ask them for advice for what programs they think that you will be competitive for and what programs they think are good. I personally believe that residents are the best source of information about individual programs, not attendings, since they are more likely to have recent direct contact whereas attendings may be basing their comments on what they hear other attendings saying about programs, but you can never have too many opinions.

Should I apply for primary care or categorical internal medicine programs? What's the difference?

Primary care programs are geared towards training internists to only be general internists, and categorical programs are geared towards training internists to go onto further fellowship training or become general internists. In general, PC programs are less competitive then categorical programs, particularly the community vs university programs. The biggest advantage of doing a categorical program is that you are more competitive when competing for fellowship programs. This does not mean that you can't get into a fellowship after doing a PC program, but you will be hard pressed to get into a competitive fellowship like cards or GI after a PC program (although the top university PC programs still are able to match residents into competitive specialties). If you go to a community based PC internal medicine program, you probably will not be able to get into a cards or gi fellowship. The biggest advantage of a PC program is less in-patient time and more out-patient training. If your goal is to be a primary goal is to be an out-patient physician, a PC program would be appropriate. If you’re not sure, then I'd recommend a categorical program.

If you are sure that you want to be a general internist, when deciding which PC program to apply for, realize that "prestige" is not as important if you just want to do straight out-patient IM, and you actually may be better served by going out to a high quality community program, perhaps a rural program, that teaches you a lot of out-patient procedures and complex out-patient management that would normally be picked up by specialists at any university program. Examples of procedures that out-patient internists may do in rural communities but may not be trained to do in categorical programs include things like sigmoidoscopies, running stress tests, and doing minor surgical procedures.

 

[AJM]

What can I do now if I am interested in learning more about internal medicine?

For Pre-Medical Students: Using the internet to read up on internal medicine and its subspecialties can be a good way to get started in learning more. I would also recommend that you pursue shadowing opportunities, as it is important to get comfortable seeing how doctors and their patients interact fairly early in the game. Realize that these shadowing experiences do not have to amount to anything substantial, but rather they can just be following around a physician in his clinic one day and perhaps watching a procedure or two that you are interested in watching. Don’t try to convince adcoms that you are dead-set on going into internal medicine as they realize that most medical students change their mind about what field they want to go into during medical school, but you can show an active interest in the specialty by the way that you talk about it and showing that you have done your research.

For Pre-Clinical Medical Students: I would highly recommend all students interested in internal medicine join the American College of Physicians and sign up to receive their newsletter as I have found those to be very helpful. U.S. Medical students can join the American College of Physicians for free through their website. Most medical schools have an internal medicine interest group that I would also recommend that students join, as well as finding an internal medicine or internal medicine sub-specialists mentor at your school. When you select your mentor, make sure that you find someone who is genuinely interested in getting to know you and meeting with you regularly to help guide you through medical school. I would also recommend doing research in any one of the internal medicine subspecialties during your first year summer as this will help your resume in general regardless of what field you decide to go into. Using your free weekends to shadow physicians in the different sub-specialties can be useful as well, as it helps to know what general direction you want to go in your career early (whether you want to subspecialize, or whether or not you’d be happy as a general internist). Of course, even if you do make up your mind, never be too inflexible to change, as it is almost never too late to change.

For third year medical students: Besides doing audition rotations at universities that you are interested in, you may want to consider doing rotations in the subspecialties that you are considering pursuing as there often is not enough elective time during your internship year to try all the subspecialties that you are considering. Remember that most people apply in the beginning of their 2nd year in order to go directly into your fellowship after residency, when you have to begin organizing strong letters of recommendation, so I?ve always thought that it is a good idea to roughly decide which fellowship you want to pursue, if any, before the end of medical school. Besides doing those electives, other good electives for people going into internal medicine can include radiology, infectious diseases, cardiology, sub-internship in general medicine, medical intensive care unit sub-internship, and dermatology. Those electives represent my own preferences though, and you should ultimately use your fourth year to do the things that you enjoy or to train in areas in which you feel deficient.

For all students (accepted pre-medical and medical):
I would personally recommend purchasing one of the following books: Iserson's Getting into a Residency, or First Aid for the Match . I believe that most medical schools do not adequately answer student’s questions regarding what they need to do to prepare for their career, and I have found that obtaining career advice from one faculty source is often not adequate. If you do decide to purchase either of these books, please click on the book titles or purchase them through SDN to support this website!

How many people are in IM residencies and fellowships, and who are they?**

In the year 2002:

US RESIDENCIES (all specialties):
No. of programs: 8,064
Total no. of residents: 98,258
40.0%(39,279) female
67.8% (66,646) USMG
26.2% (25,783) IMG
0.4% (418) Canadian
5.4% (5,327) DO

For the year 2003/2004*:

Internal Medicine
No. of programs: 390
Total no. of residents: 23,749
42% female
54% USMG
41% IMG
5% DO

Combined IM Programs, 2002**:

IM/Emergency Medicine:
No. of programs: 9
Total no. of residents: 81
21.0% female
91.4% USMG
4.9% IMG
3.7% DO

IM/Family practice:
No. of programs: 5
Total no. of residents: 9
66.7% female
66.7% USMG
22.2% IMG
11.1% DO

IM/Neurology:
No. of programs: 11
Total no. of residents: 25
28.0% female
64.0% USMG
32.0% IMG
4.0% DO

IM/Pediatrics:
No. of programs: 107
Total no. of residents: 1,507
49.3% female
85.1% USMG
10.4% IMG
4.3% DO

IM/Physical medicine and rehabilitation
No. of programs: 8
Total no. of residents: 10
20.0% female
60.0% USMG
40% IMG
0% DO

IM/Preventive medicine:
No. of programs: 8
Total no. of residents: 29
51.7% female
27.6% USMG
65.5% IMG
6.9% DO

IM/Psychiatry:
No. of programs: 20
Total no. of residents: 111
49% female
68.5% USMG
28.8% IMG
2.7% DO


*Source: American Board of Internal Medicine

**Source: The Journal of the American Medical Association, Volume 290, No. 9. September 3, 2003. pp. 1119-1268

 

[AJM]

What makes a competetive applicant in IM? Do grades matter more than USMLE scores?

Due to the controversial nature of this question and the fact that different programs look for different attributes among applicants, multiple SDN user's opinions were solicited. Here are a few examples:

From SDN user: SoCalDreamin'
”My conclusions regarding strength of application are as follows:

1.) An outstanding Step I score and/or AOA is the ticket for the ultra-competitive specialties, and we all know what they are.

2.) For Medicine, two factors bear more weight that an outstanding Step I score and/or AOA; such factors include:

a.) Strength/rank/reputation of your medical school
b.) Getting letters of recommendation from nationally renowned physicians

However, these statements in no way imply that one should not try hard to obtain a good Step I score and a high class rank. These two factors might get you that top interview, even if your medical school's rank or the prestige of letter writers is not super-stellar. With this information in mind, let's consider the following 2 applicants:

On the one hand, we have med student X with the following statistics:

* Step 1 = 245
* AOA
* Attends a medical school that is not ranked in terms of NIH research funding or in US News & World Report
* Has letters of rec from 3 faculty members that are not well-published

On the other hand, we have med student Y with the following statistics:

* Step 1 = 225
* No AOA
* Attends a medical school that is ranked in terms of NIH research funding or in US News & World Report (e.g. Stanford, UCSF, HMS, UT Southwestern)
* Has a letter or rec from Dr. Topol of the Cleveland Clinic that is based on a cardiology elective he did there at the beginning of his fourth year

Of these two candidates, whom do you think will be more likely to land interviews at MGH and Brigham & Women's? If you said med student Y, then you are correct.

Luckily for me, I am not hung up on silly things such as rankings and academic reputation, so none of the above information mattered to me when it came down to deciding where I wanted to go for residency. Much larger factors weighed on my mind, such as work environment and house staff support, and most importantly, if I was going to be happy at a particular program. Things worked out just the way I wanted them to, and I couldn't be any happier.”

From SDN user: SuFiBB
”from my experience from going through the whole application ordeal, some programs indicated that they place significant emphasis on the IM department chairman's letter which reflects your performance in your sub-I because most of what you do in your internship is similar to your sub-I rotation. whatever you do, do as well as you can for your sub-I to form the basis for a good chairman's letter. read before, learn the pocket intern survivor's guide, take a few electives beforehand, learn cross-cover emergency stuff, learn how to write orders such as admit orders, and prepare & memorize each presentation you give about a patient during rounds to your attending.”

From SDN user: Renovar
”I would have to say that looking at my experience and my classmates', the biggest break point for competitive IM, at least for interview purposes, is going to be:

1. AOA vs non AOA

and

2. The "eliteness" of your med school - top 10 vs Top25 or so vs the rest

Step 1 score is massively overrated for IM. I agree, higher is ALWAYS better, but there is a point where any higher wont do you any more good - and this point is surprisingly low. I'd boldly say that anything above mid-230's (mid-high 90's on 2 point) should keep all doors open, and it will be up to your other stats to get you interviews.

I ran into this dude on my interview trail from HMS, openly stated that he is below average in his class and got below average Step 1, and still got interviews at everywhere he applies (places like Stanford, UCSF, JHU, HMS hospitals, etc). That just goes about saying how much advantange an elite med school carries you in this process.”

From SDN user Kalel:
“I agree with many of the things stated above. In IM, I think that step I is mainly used as a cutoff. However, after seeing a few of my classmates who I know had below avg step I scores but seemingly strong clinical skills not match where they wanted to go (but got interviews at), I wonder how much of a factor it really is used to evaluate your app in IM. In general, AOA and avg step I will probably get you farther in IM then 260 step I and poor clinical evaluations. I don’t know how much of their below average step I score played into where they matched, but I did notice that my classmates who scored above average on step I were able to match into one of their top 2-3 choices. A confounder in this observation is that those who did not do as well on step I probably do not do as well on their shelves, which can adversely affect their clinical grades as well. I strongly agree with the assertion that a school’s reputation plays a huge role in where one will be able to get interviews at. I know of a student at a top 5 medical school who had below average step I and clinical grades but who was able to secure a good number of interviews at top-ranked schools which were not interviewing many of my classmates who had better step I scores and grades but who came from my state school. I still don’t think that it’s worth a lot of extra money to go to a top 20 school just so that you can get into a top 20 IM residency because many students from unranked schools are still able to secure top IM residencies (they just have to be a little bit more competitive), and there are many “unranked” IM residencies that are still excellent training programs and have very high placements ratios in all competitive fellowships. Ultimately, if you are good, I think that you will be able to get whatever specialty you want to in IM coming from whatever school you are coming from in the US.”