On my IM rotation, the primary IM team just consults cards, nephro, pulm on almost everyone. I felt like they were just taking the recommendations from those teams and implementing that into the plan, but not actually making their own plan. Where is all the cool detective work done by general internists? I almost feel like if I did IM as a specialty then I would need to do a fellowship so I actually get to do stuff instead of acting like a secretary and coordinating discharges and letting the specialty teams do all the interesting work. Also, EM seems to get most of the story and has a decent idea of what is already going on in the patients, so there isn't much mystery about why the patients are coming in. It is not what I expected from IM.
As many have suggested, this is highly dependent on your practice setting.
Here are a few thoughts that come to mind:
- First off, EM docs are very talented and great multi-taskers, but they definitely miss things--and in a busy hospital without a lot of residents and other helpers in the emergency department, admitted patients tend to get quickly forgotten once they have been accepted by the hospitalist service. As such, you'll find that as an IM doc, you'll end up doing a lot of the initial assessment and treatment decision-making. Also keep in mind that in many community hospitals, especially in remote areas, ERs are frequently staffed by non-EM physicians who may not be quite as thorough or adept at assessment and treatment as you are accustomed to at your teaching hospital.
- On a similar note, specialists at non-teaching hospitals are typically VERY busy with consults, procedures, etc. They will gladly take consults given to them by the IM docs, but without residents and students to see patients at a moment's notice, low-priority consults can go to the bottom of the list and take a while to be seen. In community hospitals, the admitting internist may have more pressure to quickly get the ball rolling on patients for eventual discharge, increasing the incentive to be more of a DIY-er.
- In the non-academic world, physicians are often paid at least somewhat on their productivity--i.e. how many patients they see, tests they run, procedures they perform, etc. A hospitalist in the real world could lose tens of thousands of dollars in pay each year if they literally did nothing on their own and just consulted out all of the work based on every out-of-range lab value and vital sign.
- Academic hospitals do sometimes have more complicated patients, for which it may be beneficial to have a specialist on board. For example, a poorly controlled Type 1 diabetic s/p renal transplant coming in with an acute spike in creatinine after an influenza infection is quite different than a 75 y/o with uncontrolled HTN and chronic Stage 2 renal insufficiency coming in after fainting at church.
- Finally, consult-happiness at academic centers may be in part due to the fact that the in-house IM attendings are more often specialists doing a required 1-2 weeks of inservice work for the year. I know this was the case at both my med school and residency. As an academic specialists gets farther into his or her career, their knowledge of basic IM problems outside of their field can definitely decrease. So I could see why a late-career ID doc, for example, may not feel as comfortable treating a seemingly basic problem as a COPD exacerbation (prompting a pulmonary consult) compared to a community IM hospitalists who sees 40 COPD exacerbations a month--but may feel less comfortable dealing with any complicated infectious problems than the ID doc.
In sum, it depends on the institution. And in general, the more "community" your hospital and the more remote your location (thus having less specialists), the more you will likely do as a practicing, non-specialized internist.
Good luck!
A piece of advice I received was “don’t read the EM note too closely.” The attending was clearly joking, but the moral is not to rely on someone else’s quick HPI and diagnosis.
