Is IM more limiting than FM if you are not looking to subspecialize?

[jm192]

I would say that knowing what you want to do helps.

If you truly want to do ER--do an ER residency. If you want to do occasional ER--you're ok with most things either way. As IM you won't see peds, and that's part of what you'll see in ER or Urgent care. But we have IM trained docs in the ER's where I work as a hospitalist.

If you know you want to do something occasionally like ER or Urgent Care that sees kids--it probably makes more sense to do FM. You could also do med peds. That said, I'm not sure it's worth the extra training time to do something like urgent care/ER occasionally.

I'm in KY, I've seen job offers from all the major cities. I've seen job offers from Nashville.
I'm sure some of the larger/academic hospitals aren't going to hire FM, but there are options in fairly large cities. I'm sure I'm not going to NYC or Chicago as a hospitalist, but I don't think the limitation is god-awful.

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[LeroyJenkinsMD]

Hospital medicine fellowships for internal medicine graduates who don’t feel comfortable practicing as a hospitalist exist. Good it.

 

[LeroyJenkinsMD]

Hospital medicine fellowships for internal medicine graduates who don’t feel comfortable practicing as a hospitalist exist. Google it.

 

[rokshana]

Hospital medicine fellowships for internal medicine graduates who don’t feel comfortable practicing as a hospitalist exist. Good it.

there are hospital tracks within IM residencies and GIM fellowships for those looking to be academic...if you come out of an IM residency (not Primary care track) having done 2 1/2 years of inpt services, and not comfortable being a hospitalist, then you shouldn't even be an IM doctor.

Dude, let it go...no one here is saying that FM trained docs can't be good Hospitalists, but as has been said here before...by FM docs no less, that FM residencies have, by their nature, greater variation than IM residencies do...its the nature of the beast. IM residencies are by their nature more inpt than out pt...and overall being a Hospitalist is like being a very well paid intern/resident...and this coming from someone who does Hospitalist work...

and you could have just edited the original post...and not actually quote yourself.

 

[Instatewaiter]

I have seen jobs in surburban areas hiring only FM hospitalists as well although this is admittedly less common. FM training is good for rounding on uncomplicated kids, newborn nursery, circumcisions, pregnant women with simple medical complaints, as well as bread and butter adult medicine—CHF, pneumonia, cellulitis, alcohol withdrawal, DKA, and consult specialties when needed as well.

Are you sure you saw this? Or more likely did you make this up? Unless they're admitting only for FM practice or the hospital can't pay enough to hire an IM trained doc, I'm calling BS. You should post the hospital that you saw this at otherwise it's pretty clearly BS.

Knowing that FM has to learn 3 specialties and has a predominantly outpatient bias, who in their right mind who is FM trained would feel comfortable being an adult hospitalist. I did more adult inaptient time during my intern year than the entirety of an FM residency. And then I spent 2 more years in residency.

Having some experience with a hospital with a supposed strong FM program and a supposed weak IM program, the difference between the IM trained people and FM trained people is astounding, at least when inpatient. I can't tell you how much mismanagement I have seen from the FM folks and they are the ones training the current FM residents.

Being a heart failure specialist I can feel comfortable saying the FM people in my area have no idea how to manage heart failure, inpatient or outpatient. The consults- cardiology or chf related are of a different quality than what I get from the IM folks. The knowledge of what to do and how to treat and most importantly when to consult must not be well taught. I often don't get consulted and the patients don't end up on the right medicine and when I do finally get consulted, the guy has been diltiazem'ed into cardiogenic shock .


Major hospitals don't allow FM to be peds hospitalists, IM hospitalists or OB for a reason; unlike in 1922 we actually have people who train in only these specialists and have expertise.

Sorry to be harsh but the reality hurts.

 

[jm192]

I'm FM trained, and I'm comfortable in saying my IM trained counterparts got better hospital training than me. Several are better than me, and that's fine. I can ask for help when I need it.

Some don't work as hard as me or do as good a job as I do. Part of it is how hard do you work/study/etc.

That said, there's no point in having a pissing contest.

Also: Anyone considering fellowships for hospitalists...you're essentially practicing as a hospitalist with a little extra supervision. But they're paying you 1/3 to 1/4 of what you could have made if you were just an attending. I looked at several of them, and was extremely nervous about going into the hospital straight out of FM residency--I've done really well without it. I don't think it's worth the year of income loss.

 

[IMreshopeful]

Hospital medicine fellowships for internal medicine graduates who don’t feel comfortable practicing as a hospitalist exist. Good it.

Yeah, those are unnecessary fellowships as an IM resident. As said above those and GIM fellowships are not needed to practice. If your IM residency doesn’t prepare you well to be a hospitalist, then the residency should lose its accreditation.

Let it go. It’s a fact that coming out of an IM residency does prepare you in general much better to practice inpatient medicine than coming from an FM residency. I don’t doubt there’s a few good FM hospitalists out there. But their education on subspecialty medicine is incredibly poor and that’s the nature of the beast.

 

[IMreshopeful]

I'm FM trained, and I'm comfortable in saying my IM trained counterparts got better hospital training than me. Several are better than me, and that's fine. I can ask for help when I need it.

Some don't work as hard as me or do as good a job as I do. Part of it is how hard do you work/study/etc.

That said, there's no point in having a pissing contest.

Also: Anyone considering fellowships for hospitalists...you're essentially practicing as a hospitalist with a little extra supervision. But they're paying you 1/3 to 1/4 of what you could have made if you were just an attending. I looked at several of them, and was extremely nervous about going into the hospital straight out of FM residency--I've done really well without it. I don't think it's worth the year of income loss.

I don’t think a pissing contest was meant here - the poster I quoted said that there’s hospitals who preferentially take FM grads which I just don’t think is true.

If you don’t know how to do something and can ask for help when you need it, then you’ll succeed. However, there’s obviously a difference in the caliber of knowledge that’s imparted during training.

My ID colleagues regale me with tales of their bad FM consults. The IM consults are usually - patient comes in with fever and back pain. Diagnosed with osteo of the spine and started on antibiotics. Developed breakthrough fevers. Cultures grew out staph aureus. Echo/TEE shows mitral valve IE without valve destruction. ID is now consulted to aid in outpatient antibiotic infusion plan and follow up. The FM consults tend to be on the order of “patient has fever, what do I do next?” No cultures, no antibiotics, no imaging.

I think the only way you’ll see FM residents get on par training with IM for inpatient medicine is if they’re educated by other IM attendings. It does happen but not commonly in my experience

 

[jm192]

I don’t think a pissing contest was meant here - the poster I quoted said that there’s hospitals who preferentially take FM grads which I just don’t think is true.

If you don’t know how to do something and can ask for help when you need it, then you’ll succeed. However, there’s obviously a difference in the caliber of knowledge that’s imparted during training.

My ID colleagues regale me with tales of their bad FM consults. The IM consults are usually - patient comes in with fever and back pain. Diagnosed with osteo of the spine and started on antibiotics. Developed breakthrough fevers. Cultures grew out staph aureus. Echo/TEE shows mitral valve IE without valve destruction. ID is now consulted to aid in outpatient antibiotic infusion plan and follow up. The FM consults tend to be on the order of “patient has fever, what do I do next?” No cultures, no antibiotics, no imaging.

I think the only way you’ll see FM residents get on par training with IM for inpatient medicine is if they’re educated by other IM attendings. It does happen but not commonly in my experience

I don't think there are hospitals that prefer FM.

I do think IM training does a better job on average than IM training.

That said, "patient has fever what do I do next" feels like an extreme example, and I can see where someone gets in a pissing contest over that. No antibiotics? I'm sure it's happened, but even the biggest idiot can figure out to throw Vanc and Zosyn at Sepsis or FUO. We've got plenty of IM guys in my group that consult for everything, and never do anything for the problem someone is consulted for. I've been an attending at 2 hospitals, and I can tell you there are excellent IM doctors at both. There are also terrible IM doctors at both.

I don't think that means the bad IM docs are poorly trained. But when you say "FM docs consult for fever and do nothing." I've got IM docs that consult for a fib, chest pain, abdominal pain, etc. and do nothing. It's not about where you trained.

 

[VA Hopeful Dr]

Are you sure you saw this? Or more likely did you make this up? Unless they're admitting only for FM practice or the hospital can't pay enough to hire an IM trained doc, I'm calling BS. You should post the hospital that you saw this at otherwise it's pretty clearly BS.

Knowing that FM has to learn 3 specialties and has a predominantly outpatient bias, who in their right mind who is FM trained would feel comfortable being an adult hospitalist. I did more adult inaptient time during my intern year than the entirety of an FM residency. And then I spent 2 more years in residency.

Having some experience with a hospital with a supposed strong FM program and a supposed weak IM program, the difference between the IM trained people and FM trained people is astounding, at least when inpatient. I can't tell you how much mismanagement I have seen from the FM folks and they are the ones training the current FM residents.

Being a heart failure specialist I can feel comfortable saying the FM people in my area have no idea how to manage heart failure, inpatient or outpatient. The consults- cardiology or chf related are of a different quality than what I get from the IM folks. The knowledge of what to do and how to treat and most importantly when to consult must not be well taught. I often don't get consulted and the patients don't end up on the right medicine and when I do finally get consulted, the guy has been diltiazem'ed into cardiogenic shock .


Major hospitals don't allow FM to be peds hospitalists, IM hospitalists or OB for a reason; unlike in 1922 we actually have people who train in only these specialists and have expertise.

Sorry to be harsh but the reality hurts.

Let's not let one troll lead to unnecessary generalizations about other fields.

 

[VA Hopeful Dr]

I think the only way you’ll see FM residents get on par training with IM for inpatient medicine is if they’re educated by other IM attendings. It does happen but not commonly in my experience

My program had 2 attendings for inpatient one of whom was always IM. I think it did make a difference, so I'm with you here.

 

[IMreshopeful]

I don't think there are hospitals that prefer FM.

I do think IM training does a better job on average than IM training.

That said, "patient has fever what do I do next" feels like an extreme example, and I can see where someone gets in a pissing contest over that. No antibiotics? I'm sure it's happened, but even the biggest idiot can figure out to throw Vanc and Zosyn at Sepsis or FUO. We've got plenty of IM guys in my group that consult for everything, and never do anything for the problem someone is consulted for. I've been an attending at 2 hospitals, and I can tell you there are excellent IM doctors at both. There are also terrible IM doctors at both.

I don't think that means the bad IM docs are poorly trained. But when you say "FM docs consult for fever and do nothing." I've got IM docs that consult for a fib, chest pain, abdominal pain, etc. and do nothing. It's not about where you trained.

Of course there’s crappy IM hospitalists that consult everything. However at least where I trained it was a particularly huge dichotomy in the consult quality. This isn’t an uncommon occurrence.

As I mentioned before, if the FM programs want to get better inpatient IM training, probably should get trained by someone with academic IM training. If they build up a retinue of well trained FM attendings inpatient down the line, then sure, I’ll buy that having FM trained attendings is equivalent in the inpatient side.

 

[PotGoblinsales10]

Hey guys, strong discussion here. thanks.

It seems the consensus is that IM is better equipped to handle inpatient medicine because of the nature of their residency focus, and are preferred as hospitalists.

But I haven't heard many good things about FM here (especially from non-FM posters). I understand FM as the preferred primary care specialty since residencies tend to focus on outpatient practice.

What can an IM do if they want to occasionally do some urgent care, ED stuff? (or is IM completely limited with that regard and need to stay in a hospital inpatient setting).

 

[VA Hopeful Dr]

Hey guys, strong discussion here. thanks.

It seems the consensus is that IM is better equipped to handle inpatient medicine because of the nature of their residency focus, and are preferred as hospitalists.

But I haven't heard many good things about FM here (especially from non-FM posters). I understand FM as the preferred primary care specialty since residencies tend to focus on outpatient practice.

What can an IM do if they want to occasionally do some urgent care, ED stuff? (or is IM completely limited with that regard and need to stay in a hospital inpatient setting).

Urgent Cares generally want someone who can see kids as well, so that will limit you a fair bit.

Most EDs want EM-trained doctors, even FM is getting pushed out of those pretty well these days.

 

[IMreshopeful]

Hey guys, strong discussion here. thanks.

It seems the consensus is that IM is better equipped to handle inpatient medicine because of the nature of their residency focus, and are preferred as hospitalists.

But I haven't heard many good things about FM here (especially from non-FM posters). I understand FM as the preferred primary care specialty since residencies tend to focus on outpatient practice.

What can an IM do if they want to occasionally do some urgent care, ED stuff? (or is IM completely limited with that regard and need to stay in a hospital inpatient setting).

I know a few IM trained docs who can do shifts at a Patient First where bulk of patients are adults. But I wouldn’t say it’s common.

If you want to do ED work, do an EM residency IMO. In IM we obviously get much better training in adult inpatient medicine and outpatient medicine, but very little training in trauma etc.

 

[LeroyJenkinsMD]

I don’t think a pissing contest was meant here - the poster I quoted said that there’s hospitals who preferentially take FM grads which I just don’t think is true.

If you don’t know how to do something and can ask for help when you need it, then you’ll succeed. However, there’s obviously a difference in the caliber of knowledge that’s imparted during training.

My ID colleagues regale me with tales of their bad FM consults. The IM consults are usually - patient comes in with fever and back pain. Diagnosed with osteo of the spine and started on antibiotics. Developed breakthrough fevers. Cultures grew out staph aureus. Echo/TEE shows mitral valve IE without valve destruction. ID is now consulted to aid in outpatient antibiotic infusion plan and follow up. The FM consults tend to be on the order of “patient has fever, what do I do next?” No cultures, no antibiotics, no imaging.

I think the only way you’ll see FM residents get on par training with IM for inpatient medicine is if they’re educated by other IM attendings. It does happen but not commonly in my experience

This is ridiculous and doesn’t even deserve a defense. You are clearly clueless.

 

[IMreshopeful]

This is ridiculous and doesn’t even deserve a defense. You are clearly clueless.

Do you acknowledge that there is a huge disparity in the training from some centers for inpatient medicine in FM compared to others? Your other colleagues seem to very much agree. I was using my center as an example for just how poor the inpatient experience is there. Pray tell what in that makes me “clueless”?

Either way sounds like I touched a nerve.

 

[LeroyJenkinsMD]

Do you acknowledge that there is a huge disparity in the training from some centers for inpatient medicine in FM compared to others? Your other colleagues seem to very much agree. I was using my center as an example for just how poor the inpatient experience is there. Pray tell what in that makes me “clueless”?

Either way sounds like I touched a nerve.

I acknowledge that there is wide variability in quality of training among every specialty.

If even true, encounters a single FM resident, likely intern, who is burned out and wants to do clinic with his life. Translation: All FM physicians are terrible doctors. What can I say? Your critical thinking skills are limitless. You’ll make an excellent doctor. Just make sure you get IM training.

 

[VA Hopeful Dr]

Do you acknowledge that there is a huge disparity in the training from some centers for inpatient medicine in FM compared to others? Your other colleagues seem to very much agree. I was using my center as an example for just how poor the inpatient experience is there. Pray tell what in that makes me “clueless”?

Either way sounds like I touched a nerve.

You're being trolled

 

[IMreshopeful]

I acknowledge that there is wide variability in quality of training among every specialty.

If even true, encounters a single FM resident, likely intern, who is burned out and wants to do clinic with his life. Translation: All FM physicians are terrible doctors. What can I say? Your critical thinking skills are limitless. You’ll make an excellent doctor. Just make sure you get IM training.

I said the FM inpatient training sucks at my program. Please tell me how that translates to me saying “all FM doctors are terrible”. Perhaps your comprehension is the issue here?
I gave ONE example of a bad consult. I can name about thirty from the FM service. Our IM services occasionally give crap consults but we usually shuttle our cardiac patients to our own inpatient service so we much less get bad consults from them. We also get crap consults from surgery, OB, etc but I hold them to a different standard.
This is besides the point. But as noted above I suspect I’m getting trolled hard

 

[LeroyJenkinsMD]

I said the FM inpatient training sucks at my program. Please tell me how that translates to me saying “all FM doctors are terrible”. Perhaps your comprehension is the issue here?
I gave ONE example of a bad consult. I can name about thirty from the FM service. Our IM services occasionally give crap consults but we usually shuttle our cardiac patients to our own inpatient service so we much less get bad consults from them. We also get crap consults from surgery, OB, etc but I hold them to a different standard.
This is besides the point. But as noted above I suspect I’m getting trolled hard

No trolling. Just needed to hear this post. Thanks.

 

[IMreshopeful]

No trolling. Just needed to hear this post. Thanks.

So you agree with my original point? Definite troll

 

[rokshana]

I said the FM inpatient training sucks at my program. Please tell me how that translates to me saying “all FM doctors are terrible”. Perhaps your comprehension is the issue here?
I gave ONE example of a bad consult. I can name about thirty from the FM service. Our IM services occasionally give crap consults but we usually shuttle our cardiac patients to our own inpatient service so we much less get bad consults from them. We also get crap consults from surgery, OB, etc but I hold them to a different standard.
This is besides the point. But as noted above I suspect I’m getting trolled hard

no not comprehension...chip on his shoulder is as big as a boulder...

 

[LeroyJenkinsMD]

Thanks guys. Have a great day.

 

[deleted245683]

I think there’s a role for it, but I do think that by and large the more specialized we get as a society wrt medicine the less the role of the generalist is.

This is exactly where I found my niche coming out of IM residency. I work only outpatient, but the increased specialization allows me to practice primary care exactly how I want. I understand my training in outpatient medicine was severely limited, but routine preventative health for adults is simple enough, provided you stay frosty. All the "guidelines" are in the EMR and health maintenance for me is checking boxes when the patient actually comes in. My patient panel is well-balanced with young adults with chronic anxiety/neck pain, that really only come in for yearly physicals. The other half are the standard elderly IM outpatients with multiple chronic diseases, but i quickly know if the can be easily managed in my clinic or if they need specialist on board. Everything else goes to the specialist (rash, joint pain, etc.). I specifically chose where I work because in our practice the specialists are there to specifically support the PCPs, to mostly to help offload the crazy demands from our patients. The vast majority of the time, they just need someone with the specialist badge to tell them they're fine and to knock it off. I never do any procedures, or even freeze off warts, because honestly I don't care. They can go next door the next day and see Dermatology and take care of all their other AKs at the same time (also, I do not work at Kaiser). I'm very straightforward and honest with my patients regarding how I work and they love it. We never tread water in my clinic unless they're doing well. They're either improving or seeing someone who I know will get them better. This will greatly depend on the type of group one's at and the available resources, but this is exactly what I sought after residency. I understand I am basically an overpaid mid-level provider, that really just triages specialist vs no specialist. But hey, when i get a referral from a dentist for new HTN, i still pick up the liver cancer that's also there.

 

[gutonc]

This is exactly where I found my niche coming out of IM residency. I work only outpatient, but the increased specialization allows me to practice primary care exactly how I want. I understand my training in outpatient medicine was severely limited, but routine preventative health for adults is simple enough, provided you stay frosty. All the "guidelines" are in the EMR and health maintenance for me is checking boxes when the patient actually comes in. My patient panel is well-balanced with young adults with chronic anxiety/neck pain, that really only come in for yearly physicals. The other half are the standard elderly IM outpatients with multiple chronic diseases, but i quickly know if the can be easily managed in my clinic or if they need specialist on board. Everything else goes to the specialist (rash, joint pain, etc.). I specifically chose where I work because in our practice the specialists are there to specifically support the PCPs, to mostly to help offload the crazy demands from our patients. The vast majority of the time, they just need someone with the specialist badge to tell them they're fine and to knock it off. I never do any procedures, or even freeze off warts, because honestly I don't care. They can go next door the next day and see Dermatology and take care of all their other AKs at the same time (also, I do not work at Kaiser). I'm very straightforward and honest with my patients regarding how I work and they love it. We never tread water in my clinic unless they're doing well. They're either improving or seeing someone who I know will get them better. This will greatly depend on the type of group one's at and the available resources, but this is exactly what I sought after residency. I understand I am basically an overpaid mid-level provider, that really just triages specialist vs no specialist. But hey, when i get a referral from a dentist for new HTN, i still pick up the liver cancer that's also there.

Nothing to say about your post in particular (other than it is quite interesting and thanks for posting), but I wanted to commend you for nearly getting to your 10 year SDN-iversary and this being only your 2nd post.

 

[IMreshopeful]

This is exactly where I found my niche coming out of IM residency. I work only outpatient, but the increased specialization allows me to practice primary care exactly how I want. I understand my training in outpatient medicine was severely limited, but routine preventative health for adults is simple enough, provided you stay frosty. All the "guidelines" are in the EMR and health maintenance for me is checking boxes when the patient actually comes in. My patient panel is well-balanced with young adults with chronic anxiety/neck pain, that really only come in for yearly physicals. The other half are the standard elderly IM outpatients with multiple chronic diseases, but i quickly know if the can be easily managed in my clinic or if they need specialist on board. Everything else goes to the specialist (rash, joint pain, etc.). I specifically chose where I work because in our practice the specialists are there to specifically support the PCPs, to mostly to help offload the crazy demands from our patients. The vast majority of the time, they just need someone with the specialist badge to tell them they're fine and to knock it off. I never do any procedures, or even freeze off warts, because honestly I don't care. They can go next door the next day and see Dermatology and take care of all their other AKs at the same time (also, I do not work at Kaiser). I'm very straightforward and honest with my patients regarding how I work and they love it. We never tread water in my clinic unless they're doing well. They're either improving or seeing someone who I know will get them better. This will greatly depend on the type of group one's at and the available resources, but this is exactly what I sought after residency. I understand I am basically an overpaid mid-level provider, that really just triages specialist vs no specialist. But hey, when i get a referral from a dentist for new HTN, i still pick up the liver cancer that's also there.

Yeah and that’s fine - obviously you can’t know everything as a generalist. I think there should be SOME things that can be managed by a PCP - for example I get pretty annoyed when the medicine teams consult me for run of the mill afib or CHF - that’s 100% within their domain - but that’s basically mostly because I’m at a teaching hospital right now. I know in practice I will get consulted up the wazoo for simple things - and with that expectation I’m totally fine.

 

[PlutoBoy]

Yeah and that’s fine - obviously you can’t know everything as a generalist. I think there should be SOME things that can be managed by a PCP - for example I get pretty annoyed when the medicine teams consult me for run of the mill afib or CHF - that’s 100% within their domain - but that’s basically mostly because I’m at a teaching hospital right now. I know in practice I will get consulted up the wazoo for simple things - and with that expectation I’m totally fine.

Wait for the consult for first degree AV block

 

[IMreshopeful]

Wait for the consult for first degree AV block

I didn’t say it wouldn’t be a struggle hahaha
I also already get that from some specialty teams

 

[Instatewaiter]

Wait for the consult for first degree AV block

I will recommend monitoring alone. Thank you for this interesting consult and the opportunity to generate a few RVUs with literally no work or thought. In addition to monitoring, I will recommend calling your medical school and asking for a tuition refund.

 

[deleted245683]

Nothing to say about your post in particular (other than it is quite interesting and thanks for posting), but I wanted to commend you for nearly getting to your 10 year SDN-iversary and this being only your 2nd post.

Thank you, gutonc! I know it is very belated, but thank you for your years of wisdom. I'm sure you've helped many more people over the years than you even know!

 

[deleted245683]

Yeah and that’s fine - obviously you can’t know everything as a generalist. I think there should be SOME things that can be managed by a PCP - for example I get pretty annoyed when the medicine teams consult me for run of the mill afib or CHF - that’s 100% within their domain - but that’s basically mostly because I’m at a teaching hospital right now. I know in practice I will get consulted up the wazoo for simple things - and with that expectation I’m totally fine.

Completely agree. I have fond memories of those annoying cards consults from residency. Although I'm still pretty new to outpatient IM, I still view myself mostly as an "outpatient hospitalist." I don't think twice before punting referrals immediately to Derm, Ortho, Podiatry or Physiatry. Completely different when the issues fall under internal medicine. Those definitely get the ol' college try before embarrassing myself in front of the Cardiologists/Endocrinologists/Rheumatologists

 

[Money Moniker]

So...why do we need physicians to work in primary care again? Seems like any idiot with a online certificate could do the job as described in this thread.

 

[doctorbeastmode]

Nothing to say about your post in particular (other than it is quite interesting and thanks for posting), but I wanted to commend you for nearly getting to your 10 year SDN-iversary and this being only your 2nd post.

Love gutonc. Savage.

 

[doctorbeastmode]

Also, came back after a few months to see this thread still at the top. OMG why? The OP is totally going to do allergy or ID. Also, they’re like a 1st year Med student or something. Classic SDN post gone completely rogue.

FYI I put this on my calendar - planning to necro-bump this mess three years from now so I can have a real life ground hogs day experience. Live, die, repeat.